Polymer Clips Research Articles

Polymeric Clips for Stump Closure in Laparoscopic Appendectomy.

Many different techniques are used to perform laparoscopic appendectomy in terms of locations of trocars and closure of the appendiceal stump. They include mechanical endostaplers, endoligature, metal clips, bipolar endocoagulation, polymeric clips and intracorporeal sutures. The method of choice for appendiceal stump closure should be inexpensive and easy to perform. Non-absorbable polymer clips is an acceptable option for this purpose. Polymeric clips provide considerable cost savings as compared with endoscopic staplers, and are easy to apply in comparison to suture ligature techniques. In this study, we aimed to investigate outcomes of appendectomy carried out by using polymeric clips in 123 patients without any intraabdominal collection of pus or abscess. As such, the authors found polymeric clips to be safe, cheap and effective for stump closure in laparoscopic appendectomy.

Three-Dimensional Printing of Surgical Clips: An In Vitro Pilot Study and Trial of Efficacy.

Three-dimensional (3D) printing applications have increased over the past decade. Our objective was to test rapid prototyping of a 3D printed surgical clip for intraoperative use. Our prototype was modeled after the 10 mm Weck® Hem-o-lok® polymer clip (Teleflex, Inc., Wayne, PA). A 3D computer-aided design model of the Hem-o-lok clip was reverse engineered using commercial microscopy and printing was done using an Objet Connex500 multijetting system (Stratasys, Eden Prairie, MN). The initial polymer was Objet VeroWhitePlus RGD835; the addition of Objet TangoBlackPlus FLX980 during the design process improved hinge flexibility. The 3D printed clips were then pressure tested on rubber Penrose tubing and compared in vitro versus commercial Hem-o-lok clips. Initial 3D printed clips were not functional as they split at the hinge upon closure of the clip jaws. Design changes were made to add Objet TangoBlackPlus FLX980 at the hinge to improve flexibility. Additional modifications were made to allow for clips to be compatible with the Hem-o-lok endoscopic clip applier. A total of 50 clips were tested. Fracture rate for the printed clips using a clip applier was 54% (n = 27), whereas none of the commercial Hem-o-lok clips broke upon closure. Of the 23 printed clips that closed, mean leak was at 20.7 κPa (range 4.8-42.7). In contrast, none of the commercial clips leaked, and fill continued until Penrose rupture at mean 46.2 κPa (44.8-47.6). This pilot study demonstrates feasibility of 3D printing functional surgical clips. However, the performance of our first generation clips is poor compared with commercial grade product. Refinement in printers and materials available may allow for customization of such printed surgical instruments that could be economically competitive to purchasing and stocking product.

Laparoscopic Appendectomy Using Hem-o-lok Polymer Clips: A Single-Center Experience

Although the surgical technique of laparoscopic appendectomy (LA) stump has been well understood, there are many alternative techniques in relation to torocar positioning and closure of appendicular stump. In recent times, Hem-o-lok polymer clips (HOLP) was implemented in several studies in the closure of appendicular stump because of its lower cost and easy implementation. The purpose of this study to investigate the safety, usefulness, and cost effectiveness of HOLP for the closure appendecular stumps in LA. The study was carried out between December 2011 and December 2013. Patients with acute appendicitis were included in the study. Two groups were defined as patients with the HOLP and patients with endoloop. The prospectively collected data, including age, sex, body mass index, operative time, hospital stay, cost effectiveness, intraoperative, and postoperative complications were retrospectively analyzed. A total of 66 (35 male, 31 female) LA were performed. The endoloop group consisted of 30 patients (16 male, 14 female, and mean age, 30.4 ± 1.8), while the HOLP group consisted of 36 patients (19 male, 17 female, and mean age, 28.6 ± 1.6). The mean operative time was 42.5 ± 1.3 in the HOLP group and 53.8 ± 1.5 in the endoloop group (P < 0.0001). The mean hospital stay was 2.1 ± 0.2 days in HOLP group and 2 ± 0.2 in the endoloop group (P = 0.73). Both patient groups had no intraoperative complication, and no cases were converted to open procedure. Total hospital cost was 1170.8 ± 6.3 dollars in the HOLP group and 1094 ± 6.9 dollars in the endoloop group (P < 0.0001). The use of HOLP for the appendicular stumps in LA is a feasible, safe, and cost-effective procedure in patients with uncomplicated acute appendicitis.

Nonabsorbable polymer clip as a cause of chronic perineal pain after radical prostatectomy: Description of a case treated by transperineal approach

The occurrence of persistent perineal pain caused by surgical clips has rarely been described after radical prostatectomy (RP). We describe the case of a patient complaining of chronic perineal pain occurred soon after robotic RP, refractory to conventional medical therapy and exacerbated by the sitting position. Pain was related to a nonabsorbable polymer clip used to secure lateral pedicles. A transpeerineal approach was used to perform an hydrodissection of the rectovesical space at the level of the surgical clip combined with local injection of mepivacaine and betametasone. The patient experienced a clinically significant reduction of pain that remained stable at three months' follow-up.

ALTERNATIVE TECHNIQUE FOR CHOLECYSTECTOMY COMPARABLE TO SINGLE PORT

ABSTRACTBackground: With the advancement of laparoscopic surgery, new techniques have been proposed and disseminated in order to reduce the surgical aggression and get better cosmetic results. Aim:To present alternative technique for videocholecystectomy comparable to single port technique using conventional material for laparoscopic surgery. Method:Introduction of laparoscopic devices using two incisions; gallbladder traction with thread, exposition of Calot triangle, and ligature of cystic pedicle with polymer clips. Results:Nine operations were carried out with this method, without complications and no increase in operative time, being compared to conventional videocholecistectomy, however vastly superior in aesthetic results. Conclusion:The technique is feasible, reproducible, showing benefits to patient´s safety

Use of Polymeric Clip (Hem-O-Lock) for Appendiceal Stump Ligation as a Favorable Technique in Laparoscopic Appendectomy

Background: Laparoscopic appendectomy (LA) has become the standard choice for acute appendicitis. Several techniques to close the appendiceal stump were investigated, and use of polymeric clips, are shown safe and cost effective. Objectives: Evaluation of the efficacy and safety of appendiceal stump closure with polymeric clips in LA. Methods: This is a retrospective cohort study included 35 patients who underwent LA, between April 2013 and August 2016 in Rasool-e-Akram university hospital. appendiceal stumps ligation were performed by polymeric clips. One month follow up after surgery was performed for all patients. Demographic information of patinets, surgery, complications, readmission and pathological reports, were collected from medical records and data base. Results: Thirty-five patients were included in this retrospective study. Nineteen patients were male and 16 patients were female (54.3% vs 45.7%). The mean age was 28.49 ± 9.56 years, mean operative time was 59.6 ± 11.8 minutes and mean hospitalization was 2.54 ± 0.7 days. There was no intraoperative complication and intraabdominal abscess formation. Also no readmission and no perioperative death were recorded in documents. In pathologic reports, there were 15 (42.8%) suppurative and one gangrenous (2.8%) appendicitis. Conclusions: Application of polymeric clips for stump ligation is safe, cost effective and time saving, and could be used as favorable technique in LA.

Clinical Outcome of Retrograde Laparoscopic Appendicectomy Using Single Hem-O-Lock Clip for Complicated Versus Non-Complicated Appendicitis

Background: Laparoscopic appendicectomy is safe and feasible for non-complicated appendicitis. The use of retrograde appendicectomy allows feasibility also for complicated cases. Using single polymer clip for securing appendicular stump is safe as well as two clips. Objectives: To evaluate the clinical outcome of using single Hem-O-Lock polymer clip and to compare technical feasibility of retrograde laparoscopic appendicectomy for complicated versus non-complicated appendicitis in adults. Patients and Methods: A single institute prospective study was done between August 2012 and April 2014. From 78 patients presenting with acute appendicitis to emergency unit, Zagazig University hospitals, only 60 patients were eligible. Three retrograde laparoscopic appendicectomy ports were used in both groups (group I, complicated appendicitis and group II, non-complicated appendicitis) and a single Hem-O-Lock polymer clip was applied to secure the appendicular stump. Standardized data collection was performed and data collected by the attending resident and attending physician. The primary clinical outcome was the severity of pain at 1 - 7 days. Secondary outcomes included the duration of operation (minutes), procedure-related complications, conversion rates, and length of hospital stay. Results: Four patients (15.4%) were converted to open surgery; three patients in group I and one in group II. Four patients developed postoperative complications; three patients in group I and one in group II. Operative time was less in group II and was statistically different and the P value was significant 0.05. Conclusions: Retrograde laparoscopic appendicectomy using single polymer clip makes easy access to operating in complicated and non-complicated appendicitis.

Appendiceal stump closure using polymeric clips reduces intra-abdominal abscesses.

Polymeric clips (hem-o-lok ligation system) are a novel alternative for securing the base of the appendix during laparoscopic appendectomy. There is a lack of systematic evaluation of polymeric clips to close the appendiceal stump with regard to postoperative intra-abdominal abscesses. The aim of this study was to compare the hem-o-lok ligation system with conventional devices. The outcome of 813 consecutive patients, operated between 2009 and 2013 receiving laparoscopic appendectomy either with hem-o-look or endoloop for acute appendicitis, was analysed. The risk of postoperative intra-abdominal abscesses was investigated for two different techniques to close the appendiceal stump using univariate and multivariate analyses. Hem-o-lok clips were used in 54% (n=435) and endoloop sutures were applied in 46% (n=378) of the patients. Based on the multivariate analysis, the postoperative lack of antibiotics as well as the application of endoloop was identified as an independent predictive factor for the development of postoperative intra-abdominal abscesses. Comparing the closure techniques, the odds ratio (OR) was 0.25 (95% CI 0.09-0.69; p<0.008). Closure of the appendiceal stump using the non-absorbable hem-o-lok ligation system did result in a reduced rate of intra-abdominal surgical abscesses as compared to the application of endoloops.

Post-laparoscopic cholecystectomy Mirizzi syndrome induced by polymeric surgical clips: a case report and review of the literature.

BackgroundLaparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it.Case presentationWe describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications.ConclusionsPostoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.

Absorbable polymeric surgical clips for appendicular stump closure: A randomized control trial of laparoscopic appendectomy with lapro-clips.

A randomized control trial was performed to evaluate the effectiveness and safety of absorbable polymeric clips for appendicular stump closure in laparoscopic appendectomy (LA). Patients were randomly enrolled into an experimental group (ligation of the appendicular base with Lapro-Clips, L-C group) or control group (ligation of the appendicular base with Hem-o-lok Clips, H-C group). We identified 1,100 patients who underwent LA between April 1, 2012 and February 3, 2015. Overall, 99 patients (9.0%, 99/1,100) developed a complication following LA (47 [8.5%] in the L-C group and 52 [9.5%] in the H-C group (P = 0.598). No statistically significant differences were observed in intra-abdominal abscesses, stump leakage, superficial wound infections, post-operative abdominal pain, overall adverse events, or the duration of the operations and hospital stays between the groups (all p > 0.05). Adverse risk factors associated with the use of absorbable clips in LA included body mass index ≥ 27.5 kg/m2, diabetes, American Society of Anesthesiologists degree ≥ III, gangrenous appendicitis, severe inflammation of the appendix base, appendix perforation, and the absence of peritoneal drainage. The results indicate that the Lapro-Clip is a safe and effective device for closing the appendicular stump in LA in select patients with appendicitis.

Adipose-derived Stem Cells as a Potential Additive Therapy in Chronic Compression Neuropathy in Rodents: a Diffusion Tensor Imaging Study

Introduction Compression neuropathy and nerve root compression are a leading cause of morbidity as well as a major cause of work impairment. Surgical and conservative treatments are widely used but there is still a lack of long-lasting effects. We seek to provide an additive therapy consisting of injected adipose-derived stem cells (ASCs) in the epineurium of a chronic nerve compression rodent model. In animal studies, evaluation of peripheral nerve injury and therapy monitoring is commonly performed using clinical scoring and histopathological workup. Recent developments in magnetic resonance imaging allow for the direct evaluation of nerve fiber integrity. Here we present the evaluation of this imaging method, diffusion tensor imaging (DTI) in the context of chronic sciatic nerve compression. Material and Methods We created a compressive lesion with a polymer clip on the left sciatic nerve of Sprague-Dawley rats. 0.5 million ASCs were injected in the epineurium under ultrasound guidance two weeks after the crush injury in a first group. The second group was injected with culture medium as control. The clips were removed in a third group who benefited from an intraoperative injection of ASCs and a fourth group underwent the same procedure but received the sham injection. Gait analyses with calculation of the Sciatic-Function-Index using a computed track were performed before the cells or sham injections as well as after two and four weeks. Two weeks post injection, respectively four weeks, post-mortem imaging was acquired on a 3-Tesla scanner. The Fractional Anisotropy (FA), a measure of fiber integrity, was measured for the proximal and distal part of the lesion and for the contralateral nerve. Afterwards, histomorphometry of cross sections of the nerve, histochemistry for muscle fiber typing and calculation of the gastrocnemius muscle weight ratio were undertaken. Results The FA showed no differences between the injured and uninjured side at the proximal site. Distally, the FA was clearly reduced on the injured side. The FA in the group treated with ASCs who underwent clip removal was significantly higher as well as the FA ratio (distal value/ proximal value). These findings could be correlated with clinical and histological analyses that showed faster regeneration and faster clinical recuperation in this group associated with reduced muscle atrophy. Conclusion ASCs alone seem to be insufficient to provide a clinically relevant treatment in this context of severe crush injury. Nonetheless, regenerative cells could be an interesting additive therapy after surgical decompression. Furthermore, our results indicate that DTI may be used to quantitatively assess sciatic nerve injury after treatment using ASCs in a rat model.

MP34-03 THREE-DIMENSIONAL PRINTING OF SURGICAL CLIPS: A PILOT STUDY AND TRIAL OF EFFICACY

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology III1 Apr 2016MP34-03 THREE-DIMENSIONAL PRINTING OF SURGICAL CLIPS: A PILOT STUDY AND TRIAL OF EFFICACY Noah Canvasser, Shuvro De, Aaron Lay, Raul Fernandez, and Jeffrey Cadeddu Noah CanvasserNoah Canvasser More articles by this author , Shuvro DeShuvro De More articles by this author , Aaron LayAaron Lay More articles by this author , Raul FernandezRaul Fernandez More articles by this author , and Jeffrey CadedduJeffrey Cadeddu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1561AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Three-dimensional (3D) printing was first introduced in 1984. Since then, there has been a dramatic increase in its application from the automobile and aircraft industry to more recent use in medicine. In Urology specifically, applications of 3D printing have included laparoscopic trocars, surgical models, and ureteral stents. Our goal was to test rapid prototyping of a 3D printed surgical clip. METHODS Our prototype was modeled after the 10mm Weck Hem-o-lok® polymer clip (Teleflex Inc., Wayne, PA, USA). A 3D CAD model of the Hem-o-lok® clip was reverse-engineered using commercial microscopy. Printing was done using an Objet500 Connex multi-jetting system (Stratasys, Eden Prairie, MN, USA), which allowed for adjustment of the proprietary polymers in order to optimize flexibility and strength. Multiple clips were produced and tested with different features and material combinations to improve functionality. The 3D printed clips were then tested by applying them across a ¼′′ width penrose drain filling with normal saline. Leak pressures were measured using a digital pressure gauge. Results were compared to commercially available 10mm Hem-o-lok® clips. RESULTS Initial 3D printed clips were not functional as they split at the hinge upon closure of the jaws of the clip. Design changes were made to use a different material mix at the hinge from the rest of the body of the clip. Additional modifications were made to allow for clips to be compatible with the Hem-o-lok® endoscopic clip applier (Figure 1). Printed clips all leaked fluid when applied across a ¼′′ width penrose drain at mean 2.37 PSI (122.6 mmHg). In contrast, 10mm Hem-o-lok® clips did not leak. Mean 7.92 PSI (409.6 mmHg) was reached until the penrose drain burst. CONCLUSIONS This pilot study demonstrates feasibility of 3D printing functional surgical clips. However, the performance of our first generation clips is limited compared to commercial grade product. Refinement in printers and materials available may allow for customization of printed surgical instruments that could be economically competitive to purchasing and stocking product. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e471-e472 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Noah Canvasser More articles by this author Shuvro De More articles by this author Aaron Lay More articles by this author Raul Fernandez More articles by this author Jeffrey Cadeddu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Bronchial Stumps in Anatomic Lung Segmentectomy

Stapling or suturing techniques are commonly used to close bronchial stumps in lung lobectomy, although with the segmentectomy procedure, various types of closure are likely to be performed. Weinvestigated the safety of various types of bronchial closure methods used in anatomic lung segmentectomy. Between 2005 and 2013, we performed anatomic lung segmentectomies including segmentectomies through open thoracotomy for 41 patients and thoracoscopy for 167 patients. Bronchial closures were performed through open and thoracoscopy methods for 66 and 231 stumps, respectively. Data were collected regarding segmental bronchus type, stump closure methods, and closure-related complications. Since 2006, bronchial caliber was measured from preoperative 1 mm(3) computed tomography. In the open group, 17 stumps (26%) were closed by stapling, 48 (73%) by thread ligation, and 1(1%)by suturing. In the thoracoscopy group, 116 stumps (50%) were closed by stapling, 76 (33%) by thread ligation, and39 (17%) by polymer clip ligation (p < 0.001). Staplers were used for all bronchial trunks that supplied more than a single segment; the mean diameter was 8.1mm. For single segmental bronchi, ligation was usedfor 80% in the open group and stapling for 75% inthe thoracoscopy group; the mean diameter was 6.6mm. For subsegmental bronchi, ligation or clipping were applied for 95% in both groups; the mean diameter was 4.6 mm. One bronchopleural fistula was observed at 6 months postoperatively in upper division segmentectomy of the left upper lobe using a stapler in the open group. Ligation can be used safely for small-diameter segmental bronchial stump closures in anatomic lung segmentectomies or subsegmentectomies. The use of a polymer clip can be an alternative method toclose the bronchial stump of subsegmentectomies.

Comparative Study of the Clinical Outcome of Retrograde Laparoscopic Appendicectomy Using a Single Polymer Clip for Complicated Versus for Non-Complicated Appendicitis

Objective To evaluate the clinical outcome of using single Hem-O-Lock polymer clip and compare technical feasibility of retrograde laparoscopic appendicectomy for complicated versus non-complicated appendicitis in adults. Methods A single institute prospective study of 78 patients presenting with acute appendicitis, Only 60 patients were eligible, 3 port retrograde laparoscopic appendicectomy were used in both groups and a single Hem-O-Lock polymer clip applied to secure the appendicular stump. The primary clinical outcome was the severity of pain at 1-7 days. Secondary outcomes included the duration of operation (minutes), procedure-related complications, conversion rates and length of hospital stay. Results Four patients (15.4%) were converted to open surgery, three in group I and one patient in group II. Four patients developed postoperative complications, three in group I and one patient in group II. Operative time was less in Group II. The difference in conversion rates and post-operative complication between two groups is statisticallynot significant with a P value> 0.05. Conclusion Retrograde laparoscopic appendicectomy using single polymer clip make easy access operating complicated as well as non-complicated appendicitis.

Methods for closure of appendix stump during laparoscopic appendectomy procedure.

The most frequent abdominal pathology requiring emergent surgery is acute appendicitis. Laparoscopic appendectomy has been performed for the treatment of acute appendicitis since 1983. Closure of the appendix stump is vital to prevent severe postoperative complications. Different methods are described for closure such as stapler, endoloop, titanium clips, non-absorbable polymer clips (hem-o-lok clip), handmade loops, transsection by Ligasure or with bipolar cautery. The ideal method should be safe, applicable and cheap. The most appropriate method remains to be controversial. All methods are reported as safe, but some have higher costs, and some prolong the operation. In this article, we reviewed clinical and experimental studies on different methods of stump closure, and we tried to compare the benefit of these methods over others.

V8-12 MALFUNCTION OF LINEAR CUTTING STAPLER IN KIDNEY SURGERY

INTRODUCTION AND OBJECTIVES: Numerous techniques exist for hilar control during laparoscopic and robotic nephrectomy. These include locking polymer clips, titanium clips, and individual or en bloc staple ligation. Staplers are most commonly employed for renal vein division and control. Stapling has proven safe, reproducible, rapid, and secure. Nevertheless, various types of stapler malfunction have been reported in the MAUDE (Manufacturer and User Device Experience) database with a failure incidence of 0.003%. Urologists must be acutely aware of these rare but potentially devastating scenarios. This video summarizes and illustrates various malfunction scenarios, and their proper management. METHODS: This video is a multicenter cases collection including 6 videos which exemplify linear cutting stapler failure on both the artery, and vein. Both inciting factors, and techniques for the surgeon to extricate themselves from these terrifying scenarios are depicted. The authors collected their experiences to offer recommendations, technical maneuvers and tips, both to prevent and solve these problems. RESULTS: There are two mechanism of action, depending on the brand and stapling mechanism. Some simultaneously staple and cut, others make a complete staple line, followed by cutting. We only present malfunction that occur with the second mechanism. Failures depicted include complete vein or artery transection, cutting failure with incomplete staple line, failure to release from tissue, staple line over a previous clip, as well as an unspecified stapler malfunction. CONCLUSIONS: Staplers are frequently used in urologic surgery, however the incidence of malfunction is quite low, so low that a resident may never see a staple malfunction during training. This educational video was therefore made to demonstrate the spectrum of potential types of device malfunctions. We hope that our recommendations serve as a teaching tool to minimize the risk of stapler misuse, and to deal with these dangerous complications.

Routine Vascular Control Using the Nonabsorbable Polymer Ligating Clips in Open Pancreaticoduodenectomy-Early Postoperative Outcomes in Consecutive 98 Cases.

The purpose of this study was to evaluate the utility of the nonabsorbable polymer ligating clips during open pancreaticoduodenectomy. Ninety-eight consecutive patients underwent open pancreaticoduodenectomy using either the polymer clip (hem-o-lock R) system for gastroduodenal artery and right gastric artery control or conventional knot tying (n = 151) for these artery control. The two groups were similar regarding demographic data, preoperative/intraoperative characteristic, pathologic findings, anastomotic leakage, and intraperitoneal collections or abscess. There were no intraoperative complications. Overall, postpancreatectomy hemorrhage occurred in 26 patients (10.44%) including 16 patients (6.4%) with severe hemorrhage, for clip system group was 1% (1 of 98), 8.6% (13 of 151) for the conventional technique group (P = 0.011). Only one patient (1%) of clip group required intervention treatment (vascular complications unassociated with ligation), with no death. For conventional ligation group, a total of 12 patients (7.9%) underwent intervention treatment with two deaths. Eight of these patients were diagnosed with intraperitoneal hemorrhage from visceral artery pseudoaneurysms, which originated from the gastroduodenal artery in four patients, hepatic artery in one, common hepatic artery in two, and celiac trunk in one. Postoperative mortality was 1.6% (4 of 249), all in the conventional group. The polymer clip technique is easy, safe, and effective for control of the gastroduodenal artery and right gastric artery in the open pancreaticoduodenectomy.

A Necessary Step Toward Kidney Donor Safety: The Transition From Locking Polymer Clips to Transfixion Techniques in Laparoscopic Donor Nephrectomy

Donor safety is of paramount importance in addressing end-stage renal failure through living kidney transplantation. The United States Food and Drug Administration (FDA) issued a Class II recall on the use of Hem-o-lok (Teleflex, Limerick, Pennsylvania, United States) polymer clips on the renal artery in laparoscopic donor nephrectomy (LDN) in June 2006 following 3 reported cases of donor deaths secondary to slipped ligature. The National University Hospital of Singapore made the transition regarding hilar control in minimally invasive donor nephrectomy, from using polymer and titanium clips to transfixion techniques (pure or hand-assisted laparoscopic) via laparoscopic staples or intracorporeal suturing, respectively. This study assessed safety during the transition in arterial transfixion techniques in minimally invasive donor nephrectomy for both donors and recipients. Forty-five consecutive kidney donors underwent donor nephrectomy over a 2-year period starting from June 2010. A total of 37 donors who underwent LDN (pure laparoscopic or hand-assisted laparoscopic) were included in the analysis. Of the 37 patients, 23 kidney donors had renal arterial control using Hem-o-lok while 14 patients from November 2011 onward underwent transfixion of the renal artery. The 2 groups of donor who underwent renal arterial control by either clips ligature or transfixion technique were comparable. The outcomes for the recipients in each group were similar with no statistical difference between postoperative creatinine level, incidence of delayed graft function, or graft survival at 1 year. We conclude that the transition in renal arterial control technique to transfixion techniques in LDN in line with FDA recommendation is feasible and affords equivalent donor and recipient outcomes.

Application of laparoscopy in the modified nerve plane-sparing radical hysterectomy of cervical cancer

The aim of this study was to assess the feasibility and safety of laparoscopic nerve plane-sparing radical hysterectomy (NPSRH) and compare with that of open NPSRH. One hundred and thirty-four patients with FIGO stage Ib1-IIa2 cervical cancer were enrolled in the study. Thirty-three patients underwent laparoscopic NPSRH. During the operation, the pelvic autonomic nerve plane which is directly underneath the ureter was integrally preserved by dissecting the pelvic spaces laparoscopically. The vessels around the nerve plane were controlled by Hem-o-lok polymer clips. One hundred and one patients underwent open NPSRH without special instruments. The clinical, pathological and surgery-related parameters were compared between the two groups. Moreover, postoperative short-term bladder function of these patients was also analyzed. There was no significant difference between the laparoscopic group and open group in terms of age, body mass index, previous surgery, FIGO stage, pathologic type, etc. (P > 0.05). The mean duration of surgery in the laparoscopic group was significantly longer [(303.8 ± 67.5) min vs. (272.4 ± 57.5) min] (P < 0.01). But, the laparoscopic group had less blood loss [177.0 ml vs. 474.5 ml, P < 0.01] and blood transfusion rate [ 6.1% (2/33 cases) vs. 49.5% (50/101 cases), P < 0.001]. There was no significant difference regarding the proportion of patients who firstly passed the post-void residual urine volume (PVR) test (P > 0.05). The median time of catheterization between the two groups were also comparable (P > 0.05). However, the postoperative hospital stay was significantly shorter in the laparoscopic group [median postoperative hospital stay 9.2 days vs. 11.0 days, P < 0.001]. Laparoscopic NPSRH is feasible. It seems to be comparable with open NPSRH in terms of preserving pelvic nerve function, but is more favorable in terms of blood loss and postoperative recovery.

Laparoscopic Nephropexy with Polymer Clips

We present our initial experience and long-term results with transperitoneal laparoscopic nephropexy with nonabsorbable polymer clips. Seven patients aged 34 to 47 years previously diagnosed with mobile kidney presented with chronic pain refractory to analgesics and underwent a transperitoneal laparoscopic nephropexy procedure with nonabsorbable polymer clips by fixing the perirenal tissue to the transversus abdominis fascia and triangular ligament. Mean operation time was 20 minutes. All patients were discharged after 24 hours. Follow-up intravenous pyelogram (IVP) at 60 and 150 days showed the right kidneys in a more cephalad position, and showed pelvicaliceal dilatations and that the ureteral kinks seemed to be resolved. On days 15, 60, 90, and 150 of the first- and second-year follow-ups, severity of pain was 1 of 10 on the visual analog scale. We believe that the technique of transperitoneal laparascopic nephropexy with nonabsorbable polymer clips on patients with symptomatic mobile kidney is safe and easy to perform and shows successful long-term results.