Hem-o-lok Clip Dislodgment Causing Death of the Donor After Laparoscopic Living Donor Nephrectomy

Abstract

The self-locking Hem-o-lok vascular clips (Weck Closure Systems, Research Triangle Park, NC) are widely used to control medium and large size vessels in various laparoscopic procedures (1). The self-locking mechanism ensuring adequate closure has made the Hem-o-lok clips popular mainly in laparoscopic donor nephrectomy (LDN) where the relatively short vascular stump remains with the donor (2). Another advantage is cost saving in comparison with the endovascular staplers. The following case report of late clip dislodgement with subsequent donor death has led to the recall in 2005 of the clip manufacturer not to use this clip in LDN (3), and indeed recent reports validated our observation (4). Despite that alert, these clips are still widely used in LDN in the United States (5) and Asia (6). This has prompted us to report that fatal case in the transplant literature. Case Presentation A kidney donation from an unrelated 34-year-old healthy man to his friend was approved by the Israel Transplant Center. Hand-assisted left donor nephrectomy was performed through a transperitoneal approach, whereby both the renal artery and vein were cut after the application of two Hem-o-lok clips to each vessel. The videotape of the procedure showed the two clips on the renal artery before the vessel was cut and again on the renal arterial stump at the end of the procedure. The patient was extubated in the operating room and observed for another 3 hr in the recovery room where he was fully conscious with stable hemodynamic parameters and passing adequate amount of urine. The hemoglobin level at discharge from recovery was 11.2 g/L. At 10 p.m., 12 hr after surgery, on the ward the patient developed a sudden drop of blood pressure associated with loss of consciousness. Hemoglobin level measured during resuscitation was 6 g/L. Resuscitative efforts on the floor were unsuccessful, and the patient was transferred to the operating theater. On arrival at the theater, his carotid pulse was impalpable and both pupils were dilated. On explorative laparotomy through a midline incision, the left renal arterial stump was found opened and both clips could not be visualized. Suture of the arterial stump with infusion of blood products could not reverse his condition, and the patient succumbed to uncontrolled hemorrhagic shock. At postmortem examination, the two closed Hem-o-lok clips were found beside the opened renal artery stump although the two clips on the vein were in satisfactory position. The remaining length of the arterial stump measured 5 mm. Having the videotape showing the two clips on the arterial stump and the finding in the postmortem examination of the two locked clips lying nearby the arterial stump suggest delayed clip dislodgment as the mechanism to explain the hemorrhagic shock in our patient. The Hem-o-lok clip has angled arms designed purposely to leave a little space between the two arms to prevent a full closure, which might damage the vessel. It is our assumption that pain-related adrenergic stimuli associated with temporary elevated blood pressure caused clip dislodgment from the elastic arterial stump. Further reason for failure of these clips is the small amount of tissue that occasionally gets inside the locking mechanism, and thereby interfering with it. The short arterial stump when using the Endo-GIA stapler (Ethicon Endosurgery, Johnson & Johnson, Cincinnati, OH) device may be of a problem in some cases. Other options to maintain enough arterial length such as the use of articulate Endo-TA (Ethicon Endosurgery, Johnson & Johnson, Cincinnati, OH) (5) or the combined use of a Hem-o-lock clip with a regular titanium clip applied distally should be carefully studied (7). Yoram Dekel Department of Urology Rabin Medical Center Beilinson Hospital Petach-Tiqwa, affiliated with Sackler Medical School Tel-Aviv University, Israel Eytan Mor Department of Transplantation Rabin Medical Center Beilinson Hospital Petach-Tiqwa, affiliated with Sackler Medical School Tel-Aviv University, Israel