V9-01: Evolution of Hilar Vascular Control Techniques During Laparoscopic Donor Nephrectomy at Indiana University

Video

Introductions and Objectives
There are many techniques described for the control of hilar vessels during laparoscopic donor nephrectomy. When choosing a particular technique, certain factors must be considered: graft vessel length, device failure rate, vascular control complications, and duration of warm ischemic time. In this video, we aim to describe the evolution of techniques used in the control of renal hilum since the first laparoscopic donor nephrectomy was performed in the late 1990s at Indiana University. Our goal has been to optimize our techniques to ensure quality care.

Methods
Digital video records of laparoscopic donor nephrectomy were reviewed. Four cases were selected which exemplified each technique. The following devices have been used for hilar vasculature control: EndoGIA linear stapler, polymer locking clips (Hem-o-lok), and EndoTA linear stapler.

Results
We started with using the EndoGIA linear stapler on the artery and vein separately. This led to the loss of graft vessel length because staples were applied on the graft side, which had to be trimmed off during bench dissection. We switched to the Weck Hem-o-lock clips on the artery, which we found reduced loss of graft vessel length. This was followed by the EndoTA on the vein. However, in 2006, Hem-o-lok clips were contraindicated in laparoscopic donor nephrectomy after reports of injuries and rare deaths, all occurring during laparoscopic donor nephrectomies. We switched to the EndoTA linear stapler for both artery and vein, dividing the vessels just distal to the staple line. Occasionally, bleeding was encountered from the arterial staple line, as shown in the fourth case. This could be controlled with additional clips applied to the staple line. The last case shows our current technique, using only the EndoTA stapler for the artery and vein. We then have the option of using a Hem-o-lok clip proximal to the arterial staple line if hemostasis is not satisfactory.

Conclusions
The use of the EndoTA linear stapler with the option of adding a proximal Hem-o-lok clip is safe, reduces warm ischemia time and preserves graft vessel length.

Funding: none