BERKELEY, CA (UroToday.com) - This is a sobering report that notes 352 reported problems using a variety of hemostatic devices to secure the renal hilum during laparoscopic nephrectomy between 1992-2006. While the majority of complications were noted using a stapling device vs. titanium or locking clips, the denominator remains an unknown and hence no conclusions can be drawn as to which is the safest method to secure the renal vessels. However, the authors note that in the package insert, it is clearly stated that titanium or locking clips “must not be used on the renal artery” or “is contraindicated in the control of the renal artery during laparoscopic donor nephrectomy”, respectively. This leaves only the stapler as an approved device for securing the renal vessels in all renal cases. Among available staplers, the authors note that the TA stapling device may be safer as occlusion with the staples occurs first and then the surgeon, if satisfied, can cut the vessel above the staple line; this is in contradistinction to the EndoGIA or Endopath in which the vessel is stapled and cut prior to disengaging the instrument.

With regard to the safe use of the stapler, the authors provide several sage points to which I would add:

1. don’t fire the device over previously placed clips or staples
2. after securing the device on the tissue, be certain that the entire area that should be cut rests safely in the jaws of the stapler behind the cut line
3. after securing the device on the tissue, wait for 10 seconds before firing the device to allow for complete compression of the tissue to be stapled
4. be certain to firmly squeeze the handles to obtain a complete incision
5. if the instrument “locks up” and can not be released from the tissue, do not forcibly try to open the jaws. Instead dissect below the device and consider securing with another stapler or converting to open to obtain control of the vessel proximal to the malfunctioning stapler

R. S. His, D. T. Saint-Elie, G. J. Zimmerman, and D. D. Baldwin

Urology. 70(5): 888-892, November 2007
doi:10.1016/j.urology.2007.06.1116

PubMed Abstract
PMID: 17919695

Written by Ralph V. Clayman, MD, a Contributing Editor with UroToday.

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