Page 43 - World Association of Laparoscopic Surgeons - Journal

WJOLS

Techniques to Secure Renal Hilum in Laparoscopic Donor Nephrectomy

staples and has been shown to preserve vessel length lethal and cannot be neglected. As the live kidney donation
compared with the Endo-GIA and Endopath devices. 20 is a gift of life, it is our responsibility to ensure the donor
safety.
DISCUSSION
REFERENCES
Laparoscopic donor nephrectomy is the preferred mode of
renal procurement and it demands more surgical skill 1. FDA safety communications available in web http://
www.fda.gov/Safety/MedWatch/SafetyInformation/Safety
compared to conventional laparoscopic nephrectomy. The
AlertsforHumanMedicalProducts/ucm254363.htm.
need for adequate length of renal artery on the left side force
2. US FDA MAUDE database www.accessdata.fda.gov
to reduce the renal artery stump. The need for securing 3. Maartense S, Heintjes RJ, Idu M, Bemelman FJ, Bemelman WA.
gonadal, adrenal and lumbar veins make the situation Renal artery clip dislodgement during hand-assisted laparoscopic
difficult. The shorter right renal vein poses risk on the right- living donor nephrectomy. Surg Endosc Nov 2003;17(11):1851.
4. Elliott SP, Joel AB, Meng MV, Stoller ML. Bursting strength
sided nephrectomy. Moreover, the surgeon is in a hurry
with various methods of renal artery ligation and potential
during the clue time to reduce the warm ischemia time.
mechanisms of failure. J Endourol Apr 2005;19(3):307-11.
Nonlocking clips, locking polymer clips and staples and 5. Jellison FC, Baldwin DD, Berger KA, Maynes LJ, Desai PJ.
ligatures were used, all with safety, but none is 100% safe. Comparison of nonabsorbable polymer ligating and standard
Stapling devices poses potential for missing, malformed titanium clips with and without a vascular cuff. J Endourol Sep
2005;19(7):889-93.
staple lines, and failure to release. In renal arteries with
6. Baldwin DD, Desai PJ, Baron PW, Berger KA, Maynes LJ,
early branching, surgeons feel it challenging to get multiple Robson CH, et al. Control of the renal artery and vein with the
renal arteries with graft rather than to get the proximal end nonabsorbable polymer ligating clip in hand-assisted laparos-
with single stem. Stapler and NPL are costlier 12 and copic donor nephrectomy. Transplantation 15 Aug, 2005;80(3):
6 times respectively when compared with titanium clips. 310-13.
7. Casale P, Pomara G, Simone M, Casarosa C, Fontana L,
NPL clips increase the graft length, locking mechanism
Francesca F. Hem-o-lok clips to control both the artery and the
increases security. Chances of dislocation are more with vein during laparoscopic nephrectomy: Personal experience and
intraoperative conversion and postoperative exploration. review of the literature. J Endourol Aug 2007;21(8):915-18.
Titanium clips poses the risks of scissoring, malformation, 8. Ponsky Lee, Cherullo Edward, Moinzadeh Alireza, Desai Mihir,
Kaouk Jihad, Haber Georges-Pascal, et al. The Hem-o-lok clip
jamming and dislodgement.
is safe for laparoscopic nephrectomy: A multi-institutional
Surgeon should be familiar to all the potential problems
review. Urology Apr 2008;71(4):593-96.
that arises with securing of the renal artery and should 9. Izaki H, Fukumori T, Takahashi M, Nakatsuji H, Oka N,
anticipate the device malfunctions. Reminding some of the Taue R, et al. Clinical research of renal vein control using
precautions already known to all may be of use. Take Hem-o-lok clips in laparoscopic nephrectomy. Int J Urol Aug
2006;13(8):1147-49.
precaution in all steps of vessel dissection, the vessel should
10. Yip SK, Tan YH, Cheng C, Sim HG, Lee YM, Chee C. Routine
be nicely dissected off all fatty tissue before applying the
vascular control using the Hem-o-lok clip in laparoscopic
device. When using clips, a minimum number of two clips nephrectomy: Animal study and clinical application. J Endourol
should be applied on the donor side, with adequate gap Feb 2004;18(1):77-81.
between them to form a perfect dumbbell. Apply the clip at 11. Chibber PJ, Shah HN. Are titanium clips for control of the renal
hilar vessels as unsafe as generally presumed? Surg Laparosc
right angles to the vessel. Obliquely applied clips are
Endosc Percutan Tech Aug 2006;16(4):276-80.
insecure. Clearly visualize all around the clip. There should 12. Kapoor R, Singh KJ, Suri A, Dubey D, Mandhani A,
be adequate vascular cuff beyond the clip (1-2 mm). Avoid Srivastava A, et al. Hem-o-lok clips for vascular control during
electrocoagulation in the vicinity of clips to prevent laparoscopic ablative nephrectomy: A single-center experience.
J Endourol Mar 2006;20(3):202-04.
conductive tissue necrosis and subsequent clip dislocation.
13. Hsi Ryan SÂ, Ojogho Okechukwu NÂ, Baldwin D Duane Â.
When using NPL clips, other augmenting modalities like
Analysis of techniques to secure the renal hilum during
the use of pretied loop suture, and use of a titanium clip laparoscopic donor nephrectomy: Review of the FDA database.
distal to the NPL clip can also be considered. Use of suture Urology July 2009;74(1):142-47.
ligature with inracorporeal or extracorporeal knotting is 14. Simforoosh Nasser, Aminsharifi Alireza, Z Saeed,
Javaherforooshzadeh Ahmad. How to improve the safety of
always safe there in the hands of a laparoscopic surgeon.
polymer clips for vascular control during laparoscopic
donor nephrectomy? Journal of Endourology Nov 2007;21(11):
CONCLUSION 1319-22.
15. Bittner James G IV, Sajadi Kamran, Brown James A.
The various securing devices for renal artery in laparoscopic
Comparison of the renal artery occlusion techniques in hand-
donor nephrectomy are generally safe, but not exempt from assisted laparoscopic living donor nephrectomy. Journal of
infrequent malfunctions and complications which can be Endourology June 2009;23(6):933-37.

World Journal of Laparoscopic Surgery, January-April 2012;5(1):21-26 25