Comparative analysis of pedicular vascular control techniques during laparoscopic nephrectomy: en bloc stapling or separate ligation?

Goldfinger bypassing and en bloc stapling without dissection of renal vessels during laparoscopic nephrectomy

OBJECTIVE

To test the employment of the Goldfinger Dissector (GD) to bypass and en bloc stapling of renal hilus without vascular dissection. Thus far no study has experimented the use of this integrated technique.

PATIENTS AND METHODS

From July 2002 to October 2020, clinical data were collected from 288 patients who underwent transperitoneal laparoscopic nephrectomies. They were divided into two groups: using GD with en bloc stapling (n = 174, group I) or the separation and ligation method (n = 114, group II) using the same Endo GIA Universal (Vascular) Stapler. Comparative analysis was carried out between the two groups, examining blood loss, operative time, intra and postoperative complications and hospital stay.

RESULTS

The mean age was 58.3 and 55.1 years in group I and II, respectively. Ratio of 90/84 and 55/59 males/females was found in group I and II, respectively.Blood loss was 65.5 ml and 188.9 ml, operative time was 156.5 and 189.2 minutes, wound infection occurred in three patients in each group (1.7% and 2.6%), ileus in 4 (2.3%) and 1 (0.87%), atrial fibrillation in 1 (0.57%) and 0%, incisional hernia in 0 (0%) and 2 (1.75%), deep vein thrombosis (DVT) in 0 (0%) and 1 (0.87%), conversion to open surgery in 2 (1.15%) and 5 (4.39%), mean hospital stay 3.5 days and 4 days in group I and II, respectively.

CONCLUSIONS

Routine use of the GD and en bloc stapling of the renal pedicle in laparoscopic nephrectomy is safe and useful. This technique can decrease blood loss, operative time, and have some benefit in conversion to open surgery.

A comparison of renal vascular control techniques during laparoscopic nephrectomy

Background:

We compared outcomes of en bloc stapler ligation of the renal hilum with separate Hem-o-lok polymer clip ligation of the renal vessels during laparoscopic nephrectomy (LN).

Materials and Methods:

Clinical data of patients who underwent LN for renal surgery from January 2009 to December 2015 were collected. Operation time, estimated blood loss, device malfunction rate, open conversion rate, complications and arteriovenous fistula (AVF) formation were evaluated.

Results:

En bloc stapler ligation and separate clip ligation were performed in 64 and 66 patients, respectively. The mean operative time was 106.8 ± 20.8 min (range: 70–165) in the en bloc stapler ligation group compared with 112.5 ± 24.1 min (range: 70–180) in the separate clip ligation group (P = 0.147). The mean estimated blood loss was 141.4 ± 124.1 ml (range: 25–600) in the en bloc stapler ligation group compared with 147.6 ± 112.4 ml (range: 25–450) in the separate clip ligation group (P = 0.767). The open conversion was required in 7/64 (10.9%) and 2/66 (3.0%) patients in the en bloc stapler ligation and separate clip ligation groups, respectively (P = 0.093). Stapler device malfunction occurred in 6 patients (9.3%). There were no statistically significant differences in overall complications (P = 0.726), minor (Grade 1–2) complications (P = 0.698) and major (Grade 3–5) complications (P = 0.716). No patient was diagnosed with AVF formation during overall median 33-month (interquartile range: 30, range: 24–96) follow-up.

Conclusions:

En bloc stapler ligation of the renal hilum during nephrectomy is an effective and safe technique. Although there is no reported AVF formation with en bloc stapler ligation of the renal hilum, longer follow-up is necessary.

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.

Safety and Efficacy of En Bloc Renal Hilar Vascular Staple Ligation: A Meta-Analysis

PURPOSE

We reviewed the literature on the safety of en bloc ligation. We also performed a meta-analysis of the effect of using this technique with vascular staplers on perioperative factors compared to conventional renal pedicle dissection and isolated staple ligation of the renal artery and vein.

MATERIALS AND METHODS

A literature search was performed to include all primary studies related to the safety of en bloc ligation of the renal hilum. After exclusion criteria were applied 9 studies were identified for review, of which 4 included a control group and were used in the meta-analysis. The primary end point was the incidence of arteriovenous fistula. Secondary end points were procedure duration, blood loss and the number of perioperative complications.

RESULTS

None of the total population of 595 patients in whom en bloc ligation was performed for nephrectomy were diagnosed with arteriovenous fistula formation at an average postoperative followup of 26.5 months. When comparing en bloc and isolated ligation of the renal artery and vein, the meta-analysis showed a significant improvement in procedure duration for en bloc nephrectomy. There was no difference in estimated blood loss or the number of complications.

CONCLUSION

En bloc ligation appears to be as safe as and potentially more beneficial in terms of perioperative factors than conventional renal pedicle dissection and isolated vascular ligation.