![]() One of these patients required open conversion due to significant bleeding at the renal arterial staple line. The initial 15 patients had both vessels transected with the Endo-GIA stapler. Meng et al 16 described their experience with laparoscopic donor nephrectomy in 97 patients. We currently use Hem-o-Lok clips or the Endo-TA stapler for the vessels, depending on the vascular anatomy and relationship of the vessels to the trocars. Having a second clip applier could minimize this. If 2 polymer clips are used, the warm ischemia time could be increased due to the need to reload clips. 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. We use the most medial trocar for the Endo TA to achieve the best possible angle with the origin of the renal artery. The future development of the TA stapler with articulation could overcome this problem. This could be a significant drawback if an appropriately placed trocar is not used during a laparoscopic donor nephrectomy. This could result in some vessel length loss if the stapler is not placed flush with the vessel. The Endo-GIA, while reliable and articulating, requires 2 hands to operate. The Endopath ETS35 stapler does not open easily when maximally articulated. The Endo TA stapler is potentially safer than the other 2 staplers that divide the vessels between 3 rows of staples on each side. Although the failure rate was only 1.7%, this is a salient concern for those performing laparoscopic donor nephrectomy using staplers. ![]() ![]() Chan et al 15 reported a series of 10 cases of endovascular stapler malfunction during 565 laparoscopic radical nephrectomies using the Endo-GIA. Twenty-two events occurred during laparoscopic donor nephrectomy but did not result in graft dysfunction or loss. Deng et al 14 reported 55 cases from the Food and Drug Administration database of endovascular gastrointestinal stapling device complications. Staplers, while generally reliable, can malfunction. Practical issues with the vascular staplers are important to understand. However, this cannot be expeditiously done via the laparoscopic approach. 13 Suture ligation is the standard method of vascular control during open donor nephrectomy. This is especially true for right-sided donors where the vein tends to be shorter and in patients with multiple arteries. One important requirement is obtaining adequate vessel length. With continued and increased use of laparoscopy for donor nephrectomy, safety for the donor and adequate graft quality are critical. Laparoscopic donor nephrectomy has duplicated the success of open surgery, while minimizing patient morbidity and analgesic requirement. Length differences were based on squared lengths. A Box-Cox transformation was performed for the length data to comply with the normal distribution assumption. Statistical analyses were performed using ANOVA to compare the vessel-length data among the 4 kinds of staples, followed by a post-hoc pair-wise comparison between groups. Fifteen attempts were made using each method. Each technique was applied, and the length recorded by the same investigator using calipers. 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. 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. The Endo Ta-30 stapler deploys 3 rows of staggered staples, but does not cut. We trimmed the stapled end to measure the amount of vessel lost. The Endo-GIA stapler fires 6 rows of staggered staples, and cuts between rows 3 and 4. We attempted to determine the length of blood vessel lost with each method of vascular division. (4) Endo Ta-30 stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT).
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