Letter to the Editor
Endovascular staplers are widely used to manage vessels in laparoscopic donor nephrectomy because of their feasibility and safety. During operation, stapler use may decrease warm ischemia time compared with Hem-o-lok (Research Triangle Park, Durham, NC) or titanium clips (1). Right-sided laparoscopic donor nephrectomy using staplers allows safe and feasible harvest of the full length of the right renal vein without compromising warm ischemia time (2). A previous report of Hem-o-lok clip dislodgement encouraged transplant surgeons to use endovascular stapler devices (3). This letter presents a case of late endovascular stapler failure requiring subsequent donor cardiopulmonary resuscitation with the goal of alerting transplant surgeons to maintain careful stapler management.
A kidney donation from a healthy 52-year-old man to his wife was approved by our hospital transplant center. Hand-assisted left donor nephrectomy was performed, and the renal artery and vein were cut using an Endo GIA 30-mm articulating vascular stapler (Autosuture; Covidien Surgical, Mansfield, MA). There was no acute bleeding in the renal pedicle area. The kidney donor was extubated in the operating room and observed in the recovery room for 2 hr. Before discharge from the recovery room, the patient was fully conscious with stable vital signs, and his hemoglobin level was 15.2 g/dL. In the ward, 8 hr after the surgery, the patient developed a minimal drop of blood pressure and a slightly rapid pulse rate. After intravenous fluid infusion, the patient’s blood pressure and pulse rate recovered briefly. At 10 hr after the surgery, the patient developed drowsy consciousness and a sudden drop of blood pressure with a hemoglobin level of 8.7 g/dL. Cardiopulmonary resuscitation was performed, and the patient was transferred to the operating room. During exploratory laparotomy through a midline incision, the left renal artery was partially opened and ligated with a suture tie. After confirmation that there was no active bleeding at the previous operative site, the exploratory laparotomy was completed. At 8 hr after the exploratory laparotomy, the patient showed stable vital signs and alert mentality. At 14 days after the second surgery, the patient remained stable, and his serum creatinine level was 1.5 mg/dL.
A video of the laparoscopic donor nephrectomy showed that three-row vascular staples remained in perfection after stapling the renal vessels. However, there was partial tearing of several staples securing the main renal artery. Dekel et al. (3) previously reported that pain-related adrenergic stimuli associated with temporarily elevated blood pressure could cause clip dislodgment from an arterial stump. This mechanism may also explain the findings in the present case. Endovascular stapler malfunctions have been reported during laparoscopic nephrectomy (4–8). Of 2078 cases reported in 5 previous studies, 22 (1.05%) stapler malfunctions requiring transfusion or open conversion were reported.
Ligation of renal vessels for laparoscopic donor nephrectomy is critical. Double Hem-o-lok clipping, double titanium clipping, or single stapling of the renal artery may cause problems in some cases. The use of a single medium-large titanium clip distal to a single 10-mm Hem-o-lok clip near the root of the aorta may be appropriate to ensure adequate tightness of the renal artery ligation (9). Combinations of methods should be carefully studied to improve the safety of each method.
Koo Han Yoo
Gyeong Eun Min
Department of Urology
School of Medicine
Kyung Hee University
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