Vessel Length Following Laparoscopic Donor Nephrectomy: Impact of Vascular Ligation Technique on Allograft Vessel Length

Feasibility and safety of renal artery closure with advanced bipolar energy device during nephrectomy

Introduction:

Many devices are available to control the renal pedicle during nephrectomy but the gold standard is still a matter of debate. Nanotechnology has evolved to include vessel-sealing systems; companies guarantee an efficacy for vessels until 7 mm. The aim of our study is to evaluate feasibility and safety of closure of the renal artery with radiofrequency energy during nephrectomy.

Methods:

We retrospectively evaluated consecutive patients undergoing nephrectomy between November 2016 and July 2020. Inclusion criteria were: renal artery diameter <7 mm and no significant arterial wall calcification. The EnSeal device was used in all cases for dissection, hemostasis and to secure the renal artery when feasible.

Results:

Overall 101 patients underwent nephrectomy, in 68 cases the radiofrequency alone was used to close the renal artery; in 45 patients during a laparoscopic procedure and in 23 during an open surgery. Conversion to open surgery was never necessary. No patients had major hemorrhagic complications. Mean operative time was 75 min, mean intraoperative blood loss was 85 ml. Overall 11 patients had postoperative complications, according to Clavien-Dindo: five grade I, three grade II, three grade III.

Discussion:

In our experience the closure of the renal artery with a radiofrequency energy device is a feasible and safe procedure. It allows a safe manipulation of the renal hilum, free from clips, which could limit surgeons’ maneuvers and be dislocated. We believe that a deep knowledge of the available technologies is fundamental for the surgeon and guarantees the best achievable results.

Staplers or clips?: A systematic review and meta-analysis of vessel controlling devices for renal pedicle ligation in laparoscopic live donor nephrectomy

BACKGROUND

Controlling of the renal vessels is a critical step in live donor nephrectomy (LDN). Currently, mainly 2 devices, Hem-o-Lok clips and staplers, are utilized to control vessels during LDN. Both of them have advantages and disadvantages.

METHODS

This systematic review and meta-analysis was aimed to compare the safety and the efficacy of the 2 devices and to identify the better one in LDN. A systematic search for related publications in the databases of PubMed, Medline, Embase, the Cochrane Library, and Web of Science through February 2018 was performed. Eight studies were selected and evaluated with the Newcastle-Ottawa Scale (NOS).

RESULTS

The meta-analysis result showed that utilization of Hem-o-Lok clips resulted in greater amount of estimated blood loss (mean differences [MD]: 40.10; 95% confidence interval [CI] 4.37-75.84) and longer time of warm ischemia (WIT) (MD: 55.61; 95% CI 36.79-74.43) than using staplers. Residual vascular length of grafts in clip group was longer than that in stapler group (MD: 2.51; 95% CI 0.78-4.24). However, the differences in primary outcomes such as device failure rate, death rate, and severe hemorrhage rate, were not significant between these 2 groups. In addition, utilization of Hem-o-Lok clips costed approximate $400 lower than staplers per patient.

CONCLUSION

This study revealed that Hem-o-Lok clips and staplers have the similar function in LDN renal ligation, regarding the device failure rate, death rate, and severe hemorrhage rate. However, the surgeons would benefit from the clips in terms of the residue length of vessels, these outstanding features provide operation convenience and flexibility, such as right-sided donor nephrectomies, early vascular bifurcation, and rare vascular variation. In addition, the clips have potential economic advantages. In some developing countries, it would reduce the healthcare expenditure.

Hilar control during laparoscopic donor nephrectomy: Practice patterns in Canada

INTRODUCTION

In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN.

METHODS

An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried.

RESULTS

Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 12 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death.

CONCLUSIONS

Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy: a single-center experience

OBJECTIVES

To report a single-center experience and technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy (HARLDN).

METHODS

A total of 78 living donors underwent HARLDN from June 2004 to November 2009. We used a three-port, finger-dissecting, routine retroperitoneal approach. After almost complete mobilization of the kidney, the renal pedicle was dissected to expose the renal vessels. The ureter was dissected and divided at the level of the iliac vessels. An approximately 7-cm Gibson incision was made as the hand-assisted port. The surgeon's hand was introduced through this incision directly. With hand assistance, the renal artery was clipped using two Hem-o-lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. Then the kidney was rapidly removed through the incision by hand.

RESULTS

HARLDN was effectively and safely completed in 78 (100%) donors. No conversion to an open operation was necessary. The mean operative time and mean warm ischemic time were 121 minutes (range, 90-134) and 146 seconds (range, 112-247) respectively. The mean blood loss was 61 mL (range, 32-85). Clavien 1 complications including subcutaneous emphysema in 5.1% (4/78). The mean visual analog scales on postoperative days 1 to 5 were: 2.5, 1.2, 0.8, 0.5, and 0.1, respectively. The mean time to resume oral diet was 1.5 days. The mean hospital stay was 4.5 days (range, 4-5). The mean level of postoperative serum creatinines of the donors at 7 days and 1 month thereafter were 1.06 mg/dL (range, 0.74-1.43) and 1.15 mg/dL (range, 0.79-1.61) mg/dL, respectively. The mean level of postoperative serum creatinines of the recipients at 7 days and 1 month were 1.40 mg/dL (range 0.81-1.67) and 1.52 mg/dL (range, 0.76-1.83), respectively. The mean incision length was 6.5 cm (range, 6.0-7.2).

CONCLUSIONS

The modified HARLDN combines the purely laparoscopic technique with quicker, safer organ retrieval by the open access.