(cid:56)(cid:74)(cid:74)(cid:5)(cid:73)(cid:78)(cid:88)(cid:72)(cid:90)(cid:88)(cid:88)(cid:78)(cid:84)(cid:83)(cid:88)(cid:17)(cid:5)(cid:88)(cid:89)(cid:70)(cid:89)(cid:88)(cid:17)(cid:5)(cid:70)(cid:83)(cid:73)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:5)(cid:85)(cid:87)(cid:84)(cid:75)(cid:78)(cid:81)(cid:74)(cid:88)(cid:5)(cid:75)(cid:84)(cid:87)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:5)(cid:70)(cid:89)(cid:31)(cid:5)(cid:77)(cid:89)(cid:89)(cid:85)(cid:88)(cid:31)(cid:20)(cid:20)(cid:92)(cid:92)(cid:92)(cid:19)(cid:87)(cid:74)(cid:88)(cid:74)(cid:70)(cid:87)(cid:72)(cid:77)(cid:76)(cid:70)(cid:89)(cid:74)(cid:19)(cid:83)(cid:74)(cid:89)(cid:20)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:20)(cid:27)(cid:30)(cid:21)(cid:26)(cid:22)(cid:21)(cid:26)
`
`(cid:47)(cid:68)(cid:83)(cid:68)(cid:85)(cid:82)(cid:86)(cid:70)(cid:82)(cid:83)(cid:76)(cid:70)(cid:3)(cid:57)(cid:68)(cid:86)(cid:70)(cid:88)(cid:79)(cid:68)(cid:85)(cid:3)(cid:38)(cid:82)(cid:81)(cid:87)(cid:85)(cid:82)(cid:79)(cid:3)(cid:55)(cid:72)(cid:70)(cid:75)(cid:81)(cid:76)(cid:84)(cid:88)(cid:72)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:39)(cid:82)(cid:81)(cid:82)(cid:85)(cid:3)(cid:49)(cid:72)(cid:83)(cid:75)(cid:85)(cid:72)(cid:70)(cid:87)(cid:82)(cid:80)(cid:92)(cid:29)(cid:3)(cid:40)(cid:73)(cid:73)(cid:72)(cid:70)(cid:87)(cid:86)(cid:3)(cid:82)(cid:81)
`(cid:57)(cid:72)(cid:86)(cid:86)(cid:72)(cid:79)(cid:3)(cid:47)(cid:72)(cid:81)(cid:74)(cid:87)(cid:75)
`
`(cid:38)(cid:87)(cid:89)(cid:78)(cid:72)(cid:81)(cid:74)(cid:100)(cid:100)(cid:78)(cid:83)(cid:100)(cid:100)(cid:47)(cid:56)(cid:49)(cid:56)(cid:31)(cid:5)(cid:47)(cid:84)(cid:90)(cid:87)(cid:83)(cid:70)(cid:81)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:74)(cid:5)(cid:56)(cid:84)(cid:72)(cid:78)(cid:74)(cid:89)(cid:94)(cid:5)(cid:84)(cid:75)(cid:5)(cid:49)(cid:70)(cid:85)(cid:70)(cid:87)(cid:84)(cid:74)(cid:83)(cid:73)(cid:84)(cid:88)(cid:72)(cid:84)(cid:85)(cid:78)(cid:72)(cid:5)(cid:56)(cid:90)(cid:87)(cid:76)(cid:74)(cid:84)(cid:83)(cid:88)(cid:5)(cid:20)(cid:5)(cid:56)(cid:84)(cid:72)(cid:78)(cid:74)(cid:89)(cid:94)(cid:5)(cid:84)(cid:75)(cid:5)(cid:49)(cid:70)(cid:85)(cid:70)(cid:87)(cid:84)(cid:74)(cid:83)(cid:73)(cid:84)(cid:88)(cid:72)(cid:84)(cid:85)(cid:78)(cid:72)(cid:5)(cid:56)(cid:90)(cid:87)(cid:76)(cid:74)(cid:84)(cid:83)(cid:88)(cid:5)(cid:123)(cid:5)(cid:43)(cid:74)(cid:71)(cid:87)(cid:90)(cid:70)(cid:87)(cid:94)(cid:5)(cid:23)(cid:21)(cid:21)(cid:27)
`
`(cid:56)(cid:84)(cid:90)(cid:87)(cid:72)(cid:74)(cid:31)(cid:5)(cid:53)(cid:90)(cid:71)(cid:50)(cid:74)(cid:73)
`
`(cid:40)(cid:46)(cid:57)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)
`(cid:30)
`
`(cid:24)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:88)(cid:17)(cid:5)(cid:78)(cid:83)(cid:72)(cid:81)(cid:90)(cid:73)(cid:78)(cid:83)(cid:76)(cid:31)
`
`(cid:40)(cid:77)(cid:70)(cid:83)(cid:73)(cid:87)(cid:90)(cid:5)(cid:53)(cid:5)(cid:56)(cid:90)(cid:83)(cid:73)(cid:70)(cid:87)(cid:70)(cid:82)
`(cid:46)(cid:83)(cid:73)(cid:78)(cid:70)(cid:83)(cid:70)(cid:5)(cid:58)(cid:83)(cid:78)(cid:91)(cid:74)(cid:87)(cid:88)(cid:78)(cid:89)(cid:94)(cid:5)(cid:56)(cid:72)(cid:77)(cid:84)(cid:84)(cid:81)(cid:5)(cid:84)(cid:75)(cid:5)(cid:50)(cid:74)(cid:73)(cid:78)(cid:72)(cid:78)(cid:83)(cid:74)
`
`(cid:23)(cid:29)(cid:21)(cid:5)(cid:53)(cid:58)(cid:39)(cid:49)(cid:46)(cid:40)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)(cid:25)(cid:17)(cid:29)(cid:30)(cid:26)(cid:5)(cid:40)(cid:46)(cid:57)(cid:38)(cid:57)(cid:46)(cid:52)(cid:51)(cid:56)(cid:100)(cid:100)(cid:100)
`
`(cid:56)(cid:42)(cid:42)(cid:5)(cid:53)(cid:55)(cid:52)(cid:43)(cid:46)(cid:49)(cid:42)
`
`(cid:55)(cid:42)(cid:38)(cid:41)(cid:56)
`(cid:24)(cid:22)(cid:30)
`
`(cid:56)(cid:84)(cid:82)(cid:74)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:74)(cid:5)(cid:70)(cid:90)(cid:89)(cid:77)(cid:84)(cid:87)(cid:88)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:90)(cid:71)(cid:81)(cid:78)(cid:72)(cid:70)(cid:89)(cid:78)(cid:84)(cid:83)(cid:5)(cid:70)(cid:87)(cid:74)(cid:5)(cid:70)(cid:81)(cid:88)(cid:84)(cid:5)(cid:92)(cid:84)(cid:87)(cid:80)(cid:78)(cid:83)(cid:76)(cid:5)(cid:84)(cid:83)(cid:5)(cid:89)(cid:77)(cid:74)(cid:88)(cid:74)(cid:5)(cid:87)(cid:74)(cid:81)(cid:70)(cid:89)(cid:74)(cid:73)(cid:5)(cid:85)(cid:87)(cid:84)(cid:79)(cid:74)(cid:72)(cid:89)(cid:88)(cid:31)
`
`(cid:41)(cid:84)(cid:74)(cid:88)(cid:5)(cid:55)(cid:84)(cid:71)(cid:84)(cid:89)(cid:78)(cid:72)(cid:5)(cid:38)(cid:88)(cid:88)(cid:78)(cid:88)(cid:89)(cid:70)(cid:83)(cid:72)(cid:74)(cid:5)(cid:40)(cid:84)(cid:83)(cid:75)(cid:74)(cid:87)(cid:5)(cid:70)(cid:83)(cid:5)(cid:42)(cid:72)(cid:84)(cid:83)(cid:84)(cid:82)(cid:78)(cid:72)(cid:5)(cid:39)(cid:74)(cid:83)(cid:74)(cid:75)(cid:78)(cid:89)(cid:5)(cid:73)(cid:90)(cid:87)(cid:78)(cid:83)(cid:76)(cid:5)(cid:49)(cid:70)(cid:85)(cid:70)(cid:87)(cid:84)(cid:88)(cid:72)(cid:84)(cid:85)(cid:78)(cid:72)(cid:5)(cid:55)(cid:70)(cid:73)(cid:78)(cid:72)(cid:70)(cid:81)(cid:5)(cid:51)(cid:74)(cid:85)(cid:77)(cid:87)(cid:74)(cid:72)(cid:89)(cid:84)(cid:82)(cid:94)(cid:36)(cid:5)(cid:59)(cid:78)(cid:74)(cid:92)(cid:5)(cid:85)(cid:87)(cid:84)(cid:79)(cid:74)(cid:72)(cid:89)
`
`(cid:38)(cid:81)(cid:81)(cid:5)(cid:72)(cid:84)(cid:83)(cid:89)(cid:74)(cid:83)(cid:89)(cid:5)(cid:75)(cid:84)(cid:81)(cid:81)(cid:84)(cid:92)(cid:78)(cid:83)(cid:76)(cid:5)(cid:89)(cid:77)(cid:78)(cid:88)(cid:5)(cid:85)(cid:70)(cid:76)(cid:74)(cid:5)(cid:92)(cid:70)(cid:88)(cid:5)(cid:90)(cid:85)(cid:81)(cid:84)(cid:70)(cid:73)(cid:74)(cid:73)(cid:5)(cid:71)(cid:94)(cid:5)(cid:40)(cid:77)(cid:70)(cid:83)(cid:73)(cid:87)(cid:90)(cid:5)(cid:53)(cid:5)(cid:56)(cid:90)(cid:83)(cid:73)(cid:70)(cid:87)(cid:70)(cid:82)(cid:5)(cid:84)(cid:83)(cid:5)(cid:21)(cid:24)(cid:5)(cid:38)(cid:85)(cid:87)(cid:78)(cid:81)(cid:5)(cid:23)(cid:21)(cid:22)(cid:25)(cid:19)
`
`(cid:57)(cid:77)(cid:74)(cid:5)(cid:90)(cid:88)(cid:74)(cid:87)(cid:5)(cid:77)(cid:70)(cid:88)(cid:5)(cid:87)(cid:74)(cid:86)(cid:90)(cid:74)(cid:88)(cid:89)(cid:74)(cid:73)(cid:5)(cid:74)(cid:83)(cid:77)(cid:70)(cid:83)(cid:72)(cid:74)(cid:82)(cid:74)(cid:83)(cid:89)(cid:5)(cid:84)(cid:75)(cid:5)(cid:89)(cid:77)(cid:74)(cid:5)(cid:73)(cid:84)(cid:92)(cid:83)(cid:81)(cid:84)(cid:70)(cid:73)(cid:74)(cid:73)(cid:5)(cid:75)(cid:78)(cid:81)(cid:74)(cid:19)
`
`1
`
`IS 1020
`Intuitive Surgical v. Ethicon
`IPR2019-00880
`
`

`

`SCIENTIFIC PAPER
`
`Laparoscopic Vascular Control Techniques in Donor
`Nephrectomy: Effects on Vessel Length
`
`Jonathan E. Bernie, Chandru P. Sundaram, MD, Amy I. Guise
`
`ABSTRACT
`
`INTRODUCTION
`
`Background: Various techniques for vascular control
`have been used during urologic laparoscopic procedures.
`The importance of optimizing the vessel length and se-
`curing reliable vascular control are critical for procedures
`like laparoscopic donor nephrectomy. We aimed to de-
`termine the length of vessel
`lost by using 4 common
`techniques of vascular control in a fresh human cadaveric
`vascular model.
`
`Methods: The techniques include application of 2 non-
`absorbable polymer-ligating clips (10-mm Hem-o-Lok
`MLX Weck Closure Systems, Research Triangle Park, NC),
`Endo-GIA II stapler (30-mm length, 2.5-mm staples, Auto
`Suture, US Surgical, Norwalk, CT), Endopath ETS35 sta-
`pler (35mm length, 2.5mm staples, Ethicon Endo-Sur-
`gery), and the Endo Ta-30 stapler (30-mm length, 2.5-mm
`staples, Auto Suture, US Surgical, Norwalk, CT).
`
`Results: The Endo-TA-30 stapler and the polymer clips
`resulted in significantly less compromise of the vessel
`length, when compared with the other methods of vascu-
`lar control.
`
`Conclusions: The Endo-TA-30 stapler and the polymer
`clips can be applied during laparoscopic procedures
`where optimizing vascular length is important.
`
`Key Words: Stapler, Vascular, Laparoscopy, Donor, Ne-
`phrectomy.
`
`Department of Urology, Indiana University School of Medicine, Indianapolis, In-
`diana, USA (all authors).
`
`Address reprint requests to: Chandru P. Sundaram, MD, Associate Professor, De-
`partment of Urology, Indiana University School of Medicine, 535 N Barnhill Dr,
`Suite 420, Indianapolis, IN 46202-5289, USA. Telephone: 317 278 3098, Fax: 317 274
`0174, E-mail: sundaram@iupui.edu
`
`© 2006 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
`the Society of Laparoendoscopic Surgeons, Inc.
`
`Stapling devices have been used for intestinal, pulmonary,
`and vascular applications.1–5 Laparoscopic donor ne-
`phrectomy has been used since 1995 and has become the
`preferred procedure for live renal transplantation at many
`centers in the world. The benefits of laparoscopic surgery
`over open procedures include more rapid recovery, di-
`minished analgesic requirements, improved cosmesis, and
`equivalent graft function.6 –11 One disadvantage of the
`laparoscopic approach, albeit rare, is failure of the lapa-
`roscopic staplers, which can result in significant bleeding.
`Additionally, vascular ligation may result in some loss of
`blood vessel length when compared with that in open
`techniques. This may become increasingly important with
`the increasing rates of donation and subsequent use of
`right-sided donors.11,12 We aimed to investigate the
`amount of vessel length lost with various common tech-
`niques of vascular control in a human cadaveric vascular
`model.
`
`METHODS
`
`The inferior vena cava, iliac veins, renal veins, aorta, and
`iliac arteries were harvested from 3 fresh human cadavers
`through a midline incision. The vessels were then pre-
`pared, secured to a board with pins, and 4 common
`techniques of vascular division were used:
`
`(1) 2 nonabsorbable polymer ligating clips (10-mm Hem-
`o-Lok MLX Weck Closure Systems, Research Triangle,
`NC);
`
`(2) Endo-GIA II stapler (30-mm length, 2.5-mm staples,
`Auto Suture, US Surgical, Norwalk, CT);
`
`(3) Endopath ETS35 stapler (35-mm length, 2.5-mm sta-
`ples, Ethicon Endo-Surgery) and;
`
`(4) Endo Ta-30 stapler (30-mm length, 2.5-mm staples,
`Auto Suture, US Surgical, Norwalk, CT).
`
`We attempted to determine the length of blood vessel lost
`with each method of vascular division. The Endo-GIA
`stapler fires 6 rows of staggered staples, and cuts between
`rows 3 and 4. We trimmed the stapled end to measure the
`amount of vessel lost. The Endo Ta-30 stapler deploys 3
`
`JSLS (2006)10:141–144
`2
`
`141
`
`

`

`Laparoscopic Vascular Control Techniques in Donor Nephrectomy: Effects on Vessel Length, Bernie JE et al.
`
`rows of staggered staples, but does not cut. With this
`stapler, we sharply divided the “graft” side of the vessel
`and left the 3 rows of staples with the “patient” side to
`measure the vessel length. Two 10-mm Hem-o-Lok clips
`were placed as close together as possible on the “patient”
`side of the vessel and the vessel then sharply transected
`by the second clip, leaving a 1-mm cuff of tissue. Each
`technique was applied, and the length recorded by the
`same investigator using calipers. Fifteen attempts were
`made using each method.
`
`Statistical analyses were performed using ANOVA to com-
`pare the vessel-length data among the 4 kinds of staples,
`followed by a post-hoc pair-wise comparison between
`groups. A Box-Cox transformation was performed for the
`length data to comply with the normal distribution as-
`sumption. Length differences were based on squared
`lengths.
`
`RESULTS
`Using the Endo-TA-30, the length lost was 0.50⫾0.13 cm,
`which was significantly shorter (P⬍0.001) than that with
`the 2 Hem-o-Lok clips, where the average vessel length
`lost was 0.77⫾0.05cm. The use of 2 Hem-o-Lok clips was
`associated with significantly smaller vessel loss (P⬍0.001)
`when compared with loss with the Endo-GIA II
`(1.01⫾0.07 cm) (Figures 1 and 2). Vascular division
`using the Endo-GIA resulted in significantly less
`(P⬍0.003) vessel loss when compared with loss with the
`Endopath ETS35 (1.08⫾0.05 cm) (Table 1). No significant
`
`Figure 1. Nonabsorbable polymer ligating clips (10-mm Hem-
`o-Lok MLX Weck Closure Systems), Endo Ta-30 stapler (30-mm
`length, 2.5-mm staples, Auto Suture), and Endo-GIA II stapler
`(35-mm length, 2.5-mm staples, Auto Suture). From top to bot-
`tom.
`
`Figure 2. Stapler heads of Endo GIA II and Endo-TA-30 staplers,
`and 10-mm polymer ligating clips. From left to right.
`
`difference existed in the loss of vascular lengths between
`the arteries and veins.
`
`DISCUSSION
`
`Laparoscopic donor nephrectomy has duplicated the suc-
`cess of open surgery, while minimizing patient morbidity
`and analgesic requirement. With continued and increased
`use of laparoscopy for donor nephrectomy, safety for the
`donor and adequate graft quality are critical. One impor-
`tant requirement is obtaining adequate vessel length. This
`is especially true for right-sided donors where the vein
`tends to be shorter and in patients with multiple arteries.13
`Suture ligation is the standard method of vascular control
`during open donor nephrectomy. However, this cannot
`be expeditiously done via the laparoscopic approach.
`Practical issues with the vascular staplers are important to
`understand. Staplers, while generally reliable, can mal-
`function. Deng et al14 reported 55 cases from the Food and
`Drug Administration database of endovascular gastroin-
`testinal stapling device complications. Twenty-two events
`occurred during laparoscopic donor nephrectomy but did
`not result in graft dysfunction or loss. Chan et al15 reported
`a series of 10 cases of endovascular stapler malfunction
`during 565 laparoscopic radical nephrectomies using the
`Endo-GIA. Although the failure rate was only 1.7%, this is
`a salient concern for those performing laparoscopic donor
`nephrectomy using staplers. The Endo TA stapler is po-
`tentially safer than the other 2 staplers that divide the
`vessels between 3 rows of staples on each side. The
`
`142
`
`JSLS (2006)10:141–144
`3
`
`

`

`Table 1.
`Vascular Ligation and Blood Vessel Length Lost
`
`Ligation Technique
`
`#Trials
`
`Endo-TA-30
`2 Hem-o-Lok clips
`Endo-GIA II
`Endopath ETS35
`
`15
`15
`15
`15
`
`Mean Length
`(cm)
`
`0.50 (0.23 to 0.67)
`0.77 (0.69 to 0.85)
`1.01 (0.92 to 1.14)
`1.08 (0.96 to 1.15)
`
`Standard
`Deviation
`
`0.13
`0.05
`0.07
`0.05
`
`P Value
`
`⬍0.001
`⬍0.001
`⬍0.003
`—
`
`Endopath ETS35 stapler does not open easily when max-
`imally articulated. The Endo-GIA, while reliable and artic-
`ulating, requires 2 hands to operate. The Endo-TA does
`not articulate. This could result in some vessel length loss
`if the stapler is not placed flush with the vessel. This could
`be a significant drawback if an appropriately placed trocar
`is not used during a laparoscopic donor nephrectomy.
`The future development of the TA stapler with articulation
`could overcome this problem. We use the most medial
`trocar for the Endo TA to achieve the best possible angle
`with the origin of the renal artery. The smaller length of
`the clip compared with the Hemo-o-Lok TA stapler allows
`the clip to be accurately applied on the artery close to its
`origin from the aorta, even when the trocar is not ideally
`placed. If 2 polymer clips are used, the warm ischemia
`time could be increased due to the need to reload clips.
`Having a second clip applier could minimize this. We
`currently use Hem-o-Lok clips or the Endo-TA stapler for
`the vessels, depending on the vascular anatomy and rela-
`tionship of the vessels to the trocars.
`
`Meng et al16 described their experience with laparoscopic
`donor nephrectomy in 97 patients. The initial 15 patients
`had both vessels transected with the Endo-GIA stapler.
`One of these patients required open conversion due to
`significant bleeding at the renal arterial staple line. In the
`remaining 82 patients, 1 polymer clip and 1 titanium clip
`were placed on the artery, while the Endo-TA stapler was
`used on the vein. Janetschek et al17 described,
`in 20
`patients undergoing radical nephrectomy, a technique
`that provides safety with vascular control while avoiding
`the use of stapling devices. In this series, after the renal
`artery is divided, a suture is passed around the renal vein,
`tied down extracorporeally to shrink the renal vein, a
`polymer clip placed, and the vessel divided. The assertion
`here was that this method provides for safe and secure
`vascular ligation, while obviating the cost (Table 2) of a
`stapler and potential for stapler failure. Recent studies
`have demonstrated the safety of polymer clips, and no
`reports exist of polymer clips dislodging postoperative-
`
`Table 2.
`List Prices of Staplers and Reloads
`
`Device
`
`List Price
`
`US Surgical Endo-GIA ⫹ cartridge
`US Surgical Endo-GIA reload
`US Surgical Endo TA-30⫹ cartridge
`US Surgical Endo TA-30 reload
`Ethicon ATW35 Stapler
`Ethicon TR35W Reload
`Weck 10-mm Clip applier
`Weck 10-mm Hem-o-Lok Cartridge (6 clips)
`Weck 5-mm Clip applier
`Weck 5-mm Hem-o-Lok Cartridge (6 clips)
`
`$499
`$258
`$375
`$176
`$184
`$80
`$1395
`$21
`$1195
`$27
`
`ly.18,19 The clip may become dislodged if not applied
`correctly. We have observed this during surgery where the
`second clip is dislodged when the vessel is divided flush
`with the clip. It is therefore important to leave a sleeve of
`vessel distal to the second clip. When the clip is used, the
`artery must be circumferentially dissected to ensure that
`perivascular tissue does not impede secure locking of the
`clip. Though the initial cost of the reusable (Weck) clip
`applier is high, the cost of the applier and clips averaged
`over 50 cases is only $49 per patient. Considerable savings
`are realized if clips are used instead of staplers. The
`inadvertent entrapment of previously placed clips on ad-
`jacent vessels, within the jaws of the staplers can result in
`stapler malfunction. At our institution, we minimize sta-
`pler failure by using bipolar coagulation for control of the
`tributaries of the renal vein, which avoids placing clips
`near the renal hilum.
`
`Although statistical significance was determined between
`all methods of vascular division, the clinical significance
`may be minimal in the vast majority of patients as the
`mean difference in length lost between the Endo-TA and
`
`JSLS (2006)10:141–144
`4
`
`143
`
`

`

`Laparoscopic Vascular Control Techniques in Donor Nephrectomy: Effects on Vessel Length, Bernie JE et al.
`
`10. Ruiz-Deya G, Cheng S, Palmer E. Open donor, laparoscopic
`donor and hand assisted laparoscopic donor nephrectomy: a
`comparison of outcomes. J Urol. 2001;166:1270 –1273.
`
`11. Mandal AK, Cohen C, Montgomery RA. Should the indica-
`tions for laparoscopic live donor nephrectomy of the right kid-
`ney be the same as for the open procedure? Anomalous left renal
`vasculature is not a contraindication to laparoscopic left donor
`nephrectomy. Transplantation. 2000;71:660 – 664.
`
`12. Schweitzer EJ, Wilson J, Jacobs S. Increased rates of dona-
`tion with laparoscopic donor nephrectomy. Ann Surg. 2000;3:
`392– 400.
`
`13. Buell JF, Edye M, Johnson M. Are concerns over right lapa-
`roscopic donor nephrectomy warranted? Ann Surg. 2001;233:
`645– 651.
`
`14. Deng DY, Meng MV, Nguyen HT. Laparoscopic linear cut-
`ting stapler failure. Urology. 2002;60:49 –53.
`
`15. Chan D, Bishoff JT, Ratner L. Endovascular gastrointestinal
`stapler device malfunction during laparoscopic nephrectomy:
`early recognition and management. J Urol. 2000;164:319 –321.
`
`16. Meng MV, Freise CE, Kang SM. Techniques to optimize
`vascular control during laparoscopic donor nephrectomy. Urol-
`ogy. 2003;61(1):93–98.
`
`17. Janetschek G, Bagheri F, Abdelmaksoud A. Ligation of the
`renal vein during laparoscopic nephrectomy: an effective and
`reliable method to replace vascular staplers. J Urol. 170(4 pt
`1):1295–1297, 2003.
`
`18. Joseph J, Leung YY, Eichel L. Comparison of the Ti-knot
`Device and Hem-o-lok Clips with other devices commonly used
`for laparoscopic renal-artery ligation. J Endourol. 2004;18(2):
`163–166.
`
`19. Yip SK, Tan YH, Cheng C. Routine vascular control using the
`Hem-o-lok clip in laparoscopic nephrectomy: animal study and
`clinical application. J Endourol. 2004;18(1):77– 81.
`
`the Endopath ETS35 is less than 1cm (0.50cm vs 1.08cm).
`A small addition of transplant renal vascular length may be
`significant in situations like right-sided donor nephrecto-
`mies, multiple arteries, and in some recipients due to the
`recipient vascular anatomy or body habitus.
`
`CONCLUSION
`
`Various techniques are used to divide the blood vessels
`during procedures, such as laparoscopic donor nephrec-
`tomy. In this cadaveric model, the Endo-TA-30 stapler and
`the placement of 2 polymer locking clips resulted in sig-
`nificantly less compromise of the vessel
`length, when
`compared with the other vascular staplers. These 2 tech-
`niques could be applied during laparoscopic procedures
`where optimizing vascular length is important. The appro-
`priate technique for vascular control can be individualized
`to each patient during laparoscopic donor nephrectomy,
`depending on the vascular anatomy.
`
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