Vascular Stapler Research Articles

Renal Transplantation by Automatic Anastomotic Device in a Porcine Model.

Automatic vascular staplers for vascular anastomoses in kidney transplantation may dramatically reduce the operative time and, in particular, warm ischemia time, thus increasing the outcome of transplantation. Ten pigs underwent kidney auto-transplantation by automatic anastomotic device. Kidneys were collected by laparotomy with selective ligations at the renal hilum and perfused with cold storage solution. To overcome the shortage in length of renal hilum, a tract of the internal jugular vein was harvested to increase the length of the vessels. The anastomoses were totally performed by the use of the anastomotic device. On 10 kidney transplants, nine were successful and no complications occurred. Renal resistive indexes showed a slight increase in the immediate postoperative period returning normal at 10 days of follow-up. We demonstrated the possibility to perform renal vascular anastomoses by means of an automatic anastomotic device. This instrument developed for coronary bypass surgery by virtue of the small caliber of the vessels could be adopted on a larger scale for renal transplantation. The reduced warm ischemia time needed for anastomosis may help to achieve a better outcome for the graft and expand the pool of marginal donors in renal transplantation.

Instrumento de grapado quirúrgico vascular para realizar una sutura mecánica entre un vaso sanguíneo y una prótesis sintética

PurposeImplementation and development of an experimental model of mechanical vascular suture between a vessel and a synthetic implant. Material and methodTo use this experimental device, a mathematical model was designed and applied on design computer software. A similar model previously described by the author and included in a scientific document (No. 03/2008/258 copyright) was used as the basis. This method presented the detailed description of the different parts, and specific measurements of this mechanical tool in order to obtain an accurate mechanical system. ResultsThe vascular stapling system described is effective and safe, demonstrating the possibility of performing a circular suture with a diameter greater than 16mm. The stapling device has a proximal area from where 3 rows of staples that pass through mini-slots. The staples are released using a system similar to the mechanical intestinal suture. The prosthesis is fixed within a stem that is semi-hollow allowing the suture after removal of the stapler. ConclusionsThe device describe here allows a mechanical suture between a vessel and a synthetic prosthesis, assisting and shortening the surgical time, which until now was one of the biggest drawbacks to the advancement of laparoscopic vascular surgery.

Surgical Stapler for Right Renal Vein Elongation Using the Inferior Vena Cava in Kidney Transplant.

Elongation of the right renal vein with the inferior vena cava (caval patch) using a vascular stapler offers a safe means of extending the deceased-donor right renal vein, while minimizing the ischemic time of the kidney during preparatory dissection. The aortic patch of the right renal artery also can be preserved, which minimize the danger of arterial stenosis, kinking, and dissection.

Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections.

We are evaluated technique of anatomic major and minor hepatic resections using suprahilar-extrafascial dissection of Glissonean pedicle with vascular stapling device for transection of hepatic vessels intending to minimize operative time, and blood loss. We prospectively analyzed the clinical records of 170 patients who underwent hepatic resection by suprahilar-extrafascial pedicle isolation and stapling technique in our clinic for emergency surgery in Belgrade. Patients who underwent hilar extrahepatic intrafascial dissection were excluded from the study. We performed 102 minor liver resections and 68 major hepatectomies. The minor liver resections were associated with significantly shorter surgery duration (95.1±31.1 vs. 186.6±56.5) and transection time (35.9±14.5 vs. 65.3±17.2) than major hepatectomies (P<0.001 for all). The mean blood loss was 255.6±129.9 mL in minor resection and 385.7±200.1 mL in major resection (P=0.003). The mean blood transfusion requirement was 300.8±99.5 mL for the patients with minor hepatectomy and 450.9±89.6 mL for those with major liver resection (P=0.067). There was no significant difference in morbidity and mortality between the groups (P=0.989; P=0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates. Extrafascial dissection of Glissonean pedicle with vascular stapling represents both an effective and safe surgical technique of anatomical liver resection. Presented approach allows early and easy ischemic delineation of appropriate anatomical liver territory to be removed (hemiliver, section, segment) with selective inflow vascular control. Also, it is not time consuming and it is very useful in re-resection, as well as oncologically reasonable.

1016 Does a living donor program need to switch to the use a vascular stapler? Experience at a tertiary European referral centre

1016 Does a living donor program need to switch to the use a vascular stapler? Experience at a tertiary European referral centre

Single-Site Retroperitoneoscopic Donor Nephrectomy

We have performed retroperitoneoscopic nephrectomy for living kidney donor surgery since 2000. Recently, we introduced single–site retroperitoneoscopic donor nephrectomy (RDN) as a less invasive donor surgery. The procedure was performed in 7 donors (5 women and 2 men) by a single surgeon. The mean age and body mass index of the donors were 62.6 years (range, 53–74 years) and 24.3 kg/m2 (range, 22.3–29.0 kg/m2), respectively. Left-sided nephrectomy was performed in all the donors. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon. A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, Calif, United States) was placed in the incision. The subsequent technique and equipment were the same as those used in conventional 3-port RDN. The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly extracted through the incision. The mean operative time was 197 ± 28 minutes, warm ischemic time was 4.1 ± 1.2 minutes, and blood loss was 75 ± 113 mL. No statistical differences were found between the present method and conventional 3-port RDN. Intraoperative and postoperative complications were not observed in any of the donors. Graft function after transplantation was good, and delayed graft function was not observed in any of the recipients. This technique can be easily introduced in the clinical setting by surgeons experienced in RDN.

Laparoendoscopic single-site nephroureterectomy for morbid obese patients

Since the first laparoendoscopic single-site (LESS) surgery report in urology in 2007 (1) (Rane A e Cadeddu JA), the few reports of LESS extraperitoneal access in the literature were mainly described for less complex cases. The aim of this video is to demonstrate the feasibility of LESS extraperitoneal access in a morbid obese patient presenting a malignant tumor in the renal pelvis. The patient is positioned in 90-degree lateral decubitus. An incision is made below the abdominal skin crease on the left side of the patient and the anterior rectus fascia is vertically incised with manual dissection of the extra/retroperitoneal space. We use an Alexis® retractor to retract the skin maximizing the incision orifice. Three trocars (12, 10 and 5 mm) are inserted through a sigle-port. The pedicle was controlled "en bloc" with a vascular stapler and the bladder cuff treated by the conventional open approach through the same incision. Operative time was 126 minutes with minimal blood loss. The pathology reported high grade papillary urothelial carcinoma in the pelvis (pT3N0M0) and in the ureter (pTa). LESS extraperitoneal nephroureterectomy is feasible and safe, even in more complex cases. It is a good alternative for morbid obese patients and for patients with synchronous distal ureteral tumors for whom an open approach to the bladder cuff is proposed to avoid incisions in two compartments of the abdominal wall.

Suprahilar vascular control and stapling device transection of Glissonian pedicle in major and minor hepatectomies.

In this study we analyzed our experience of suprahilar-posterior intrahepatic Glissonian pedicle approach using an endo-GIA vascular stapling device for the pedicle and hepatic vein division. Sixty-eight 68 major and 102 minor liver resections were performed. The hilar extrahepatic structures remain intact, and during parenchyma dissection by CUSA, the whole right or left or the appropriate segmental pedicle was isolated intrahepatically and then transected using a stapler device. The minor liver resections was associated with significantly shorter surgery duration (95.1 + 31.1 vs. 186.6 +/- 56.5) and transection time (35.9 +/- 14.5 vs. 65.3 +/- 17.2) than major hepatectomies (p < 0.001 for all). The mean blood loss was 255.6 + 129.9 mL in minor resection and 385.7 + 200.1 mL in major resection (p = 0.003). The mean blood transfusion requirement was 300.8 + 99.5 mL for the patients with minor hepatectomy and 450.9 + 89.6 mL for those with major liver resection (p = 0.067). There was no significant difference in morbidity and mortality between the groups (p = 0.989; p = 0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates. Liver transection using CUSA with suprahilar endo-GIA stapling of Glisson's pedicle, as well as major hepatic veins represents an effective and safe surgical procedure.

Video-assisted thoracoscopic right lower lobectomy: the Tianjin Chest Hospital experience.

Video-assisted thoracoscopic surgery (VATS) is now well established as an alternative to open thoracotomy for major pulmonary resections of bronchogenic carcinoma and benign disease. More than 900 VATS major pulmonary resections have been performed in our center over the last 5 years and we here describe our method for VATS right lower lobectomy. In our center, procedures is performed with 3 incisions. For right lower lobes, the patient is placed into the left lateral position. The inferior pulmonary vein is dissected and divided with an endoscopic vascular stapler. The pulmonary artery branches to right lower lobe are divided with endoscopic staplers, and the lower lobe bronchus is divided at last. Throughout the procedure, hilar and mediastinal lymph nodes are dissected and removed in NSCLC. According to our experience, VATS is safe and feasible in thoracotomy for major pulmonary resections.

Anomalous Systemic Arterial Supply to the Basal Segments of the Lung: Feasible Thoracoscopic Surgery

Anomalous systemic arterial supply to the basal segments of the lung is a rare anomaly. This study aimed to evaluate the outcomes of thoracoscopic surgery for this anomaly. We reviewed patients who underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung between October 2007 and September 2012 at our institution. Four patients (mean age 37.5 years; range, 22 to 54) underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung. The mean diameter of the anomalous arteries was 14 mm (range, 10 to 16 mm). Two patients underwent thoracoscopic segmentectomy, 1 of whom had a complicated anomaly that necessitated conversion to thoracotomy. The other 2 patients underwent thoracoscopic lower lobectomy of the left lung. One of them had an aneurysm in the anomalous artery; therefore, endovascular devices were kept on standby in case massive hemorrhage occurred. The anomalous arteries were divided uneventfully using a vascular stapler in all patients. No patient had severe postoperative complications. Thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung is feasible, safe, and minimally invasive, with confirmed effectiveness in typical cases.

Hepatectomia laparoscópica com portal único: experiência pioneira no Brasil

Since the past decade, minimal access surgery is moving towards minimizing the surgical trauma by reducing numbers and size of the laparoscopic ports . A novel technique with a single-incision laparoscopic approach has been recently described. To describe the single-port technique for laparoscopic liver resection. A transumbilical 3-cm skin incision is performed and a single-incision advanced access platform is introduced. Operation began with exploration of the abdominal cavity and ultrasound examination of the liver. Intrahepatic Glissonian access for retrieval of portal pedicles from segments 2 and 3 is performed. Vascular endoscopic stapler is used to divide segments 2 and 3 Glissonian pedicle. Liver is transected with harmonic scalpel and left hepatic vein is divided with stapler. Procedure is completed. Surgical specimen is retrieved through the single umbilical incision. No drains are left in place. Single port laparoscopic left lateral segmentectomy is feasible and can be safely performed in specialized centers by skilled laparoscopic surgeons.

Adverse events of pulmonary vascular stapling in thoracic surgery

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, adverse events (AEs) of stapling are occasionally experienced. The aim of this retrospective study was to analyse the AEs of stapling in pulmonary vascular surgery. A retrospective multi-institutional review was conducted by the 29 institutions of the Central Japan Lung Cancer Surgery Study Group. All staplings of the pulmonary artery (PA) and vein in thoracic surgery were reviewed during the research period. Stapling of the PA and vein was performed 3393 times. The total number of AEs related to stapling was nine (0.27%). Eight events occurred intraoperatively and one occurred immediately after the operation. Intraoperative AE occurred more frequently than postoperative AE. AE in the PA occurred more frequently than in the pulmonary vein. The intraoperative AEs were oozing (n=3), stapling failure (n=2), laceration of the peripheral vasculature at compression (n=2) and technical injury of the vasculature at insertion (n=1). The causes of AEs were reported to be tissue fragility (n=3), stapler rocking during stapling (n=2), stapler-tissue thickness mismatch (n=2) and technical failure (n=1). The only postoperative AE was staple line rupture of the PV stump. No relationship was seen between the incidence of AE and cartridge colours, compression types of staplers or numbers of staple lines. Generally, stapling of the pulmonary vasculatures in recent thoracic surgery has been safe. Furthermore, the knowledge of the possible risks of pulmonary vascular stapling may help to decrease the AEs of stapling.

Laparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection. A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision. The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma. Technical issues initially hindered the development of laparoscopic liver resections [7-10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat. Large series and extensive reviews show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon's view, makes such resections defying. The authors' team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis). In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach.

Validation of the Laparoscopically Stapled Approach as a Standard Technique for Left Lateral Segment Liver Resection

Left lateral sectionectomy (LLS) is the most common type of anatomic laparoscopic liver resection performed, accounting for 20 % of all laparoscopic hepatectomies. Because there has been no standardized surgical technique for laparoscopic left lateral sectionectomy (LLLS), we offer an established operation: laparoscopically stapled left lateral sectionectomy (LSLLS). Our aim was to perform a case-controlled study of LSLLS with traditional (without vascular staplers) laparoscopic left lateral sectionectomy (TLLLS), validating the standardization and reproducibility of LSLLS. From February 2009 to December 2011, a total of 49 LSLLSs were performed. The results were compared with 33 cohort-matched TLLLSs from an earlier time period. Ordered sample cluster analysis was used to determine the learning curve of LSLLS based on the operating time and blood loss. All LSLLS were performed successfully. There were no conversions to laparotomy or hand-assisted laparoscopic resection. Two endoscopic linear staplers were used in each case. Despite a higher hospital cost ($10,892 ± $944 vs. $8,962 ± $943, p < 0.05), LSLLS compared favorably with TLLLS regarding operating time (103 ± 21 vs. 151 ± 32 min, p < 0.05) and blood loss (70.8 ± 41.6 vs. 173.3 ± 131.1 ml, p < 0.05). No specific complications related to laparoscopy were observed. Ordered sample cluster analysis demonstrated a learning curve of 18 cases for LSLLS. This study demonstrates the standardization and reproducibility of LSLLS. We therefore propose LSLLS as the standard technique for lesions located in the left lateral section of the liver.

Laparoscopic Approach to Fibroid Torsion Presenting as an Acute Abdomen in Pregnancy

Uterine leiomyomas (fibroids) are seen in up to 4% of pregnancies, and most commonly present with pain in pregnancy, which can be due to red degeneration or torsion. Most cases previously have been managed with open resection. We report the case of a 35-y-old primagravida woman, presenting with acute lower abdominal pain at 11 wk gestation. Ultrasound demonstrated an 8-cm fibroid only. She demonstrated features of lower abdominal peritonitis and was scheduled for a diagnostic laparoscopy. At operation, a torsed subserosal fibroid was found. She successfully underwent laparoscopic myomectomy with the endoGIA vascular stapler and subsequent Pfannenstiel delivery. The patient was discharged 48 h postoperatively to continue her pregnancy. This case demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy. Previously reported cases in the literature have focused on open resection or bipolar diathermy enucleation and morcellation. A high degree of suspicion should be maintained for the diagnosis in patients presenting to the surgical service with acute lower abdominal peritoneal signs during pregnancy.

Transection of the Liver Parenchyma With an Ultrasound Dissector or a Stapler Device: Results of a Randomized Clinical Study

Perioperative hemorrhage and postoperative bile leakage are severe complications of liver surgery. They may be related to the techniques used to divide the tissue. We designed a randomized clinical trial to compare the cavitron ultrasonic surgical aspirator (CUSA) and an endoscopic stapler device applied in routine clinical hepatic surgical practice. All consecutive patients admitted for elective hepatic resective surgery--at least bisegmentectomy of the liver--were assessed for enrollment in the study. A total of 100 patients were subsequently randomized. There was a good balance between the study groups concerning issues that may be of relevance for the perioperative and postoperative courses. The primary objective of the study was to achieve an approximately 25 % reduction in perioperative blood loss and postoperative bile leakage. Secondary outcome variables were operating time, general postoperative morbidity, length of hospital stay, and direct medical costs. The amount of perioperative or postoperative blood loss did not differ significantly between the two groups. We observed a trend toward shorter transection and operating time for patients in whom staplers were used, but the difference did not reach statistical significance. The postoperative courses were close to identical in the respective study arms with no difference in bile leakage rates or in the total morbidity profiles. The direct medical costs were nonsignificantly lower in the group where staplers were used for liver transection. The results show that the use of endoscopic vascular staplers in liver surgery is feasible and safe. It offers an attractive alternative for division of the liver parenchyma during routine hepatic surgery, being comparable to the use of CUSA without adding extra costs.

Laparoscopic Donor Nephrectomy in Different Anatomical Scenarios: Our Experience

Introduction: Laparoscopic donor nephrectomy currently ranks as the gold standard surgical exercise for renal harvest for transplantation and has been widely practiced in both single and multiple renal arteries.1 We present a video demonstration of this exercise in interesting anatomical scenarios. Methods: Voluntary renal donors underwent a standard workup protocol involving various specialities. Three-dimensional helical computed tomography angiogram (64-slice computed tomography scanner) was employed for delineation of anatomy. The left renal unit was favored on most occasions. All procedures were conducted through transperitoneal access. Four ports were used for left donor nephrectomy and five ports for right side procedure. For right renal harvest, a terminal hand-assisted approach was followed.2 After hilar mobilization, the ureter was divided first followed by control of renal artery and lastly renal vein. In case of multiple arteries or veins, the most accessible artery or vein was clipped and divided first followed by the other member irrespective of vessel caliber. In all cases, control of renal vein was obtained by using 10-mL hem-o-loc clips. Additional titanium clips were used as necessary. In no case, a vascular stapler was utilized. Graft retrieval was undertaken through Pfannenstiel incision for left side and oblique muscle splitting incision on right side. Results and Discussion: Between 1999 and 2011, 715 laparoscopic donor nephrectomies were successfully performed by the same surgeon. Mean donor age was 37.6 years. Mean body mass index was 23.2 kg/m2. 612 left and 103 right side renal allografts were harvested. 315 were men and 400 women. One hundred sixty-five renal units harbored multiple renal arteries (154 cases revealed two renal arteries, 10 cases revealed three renal arteries, and 1 case revealed four renal arteries). Interesting anatomical scenarios included double renal vein (two occasions, both right side), double lumbar vein (five occasions, all left side), double ureter (two occasions, one on left side and one on right side). In all these cases, a laparoscopic approach could be completed uneventfully. Mean warm ischemia time was 3.56 minutes. Mean operation duration was 110.4 minutes. Mean blood loss was 75.5 mL. Laparoscopic donor nephrectomy may be successfully attempted in the presence of different anatomical variants. Although a retroperitoneal approach has been favored by few operators,3 we practice the transperitoneal route as it enables wider working space and the anatomy is familiar. Meticulous attention should be paid during dissection of the ureterogonadal pedicle or the renal hilum to identify anatomical variations and avoid inadvertent injuries. The operator needs to be sufficiently versed with laparoscopic exercises. No competing financial interests exist. Runtime of video: 7 mins 55 secs

Laparoscopic splenic preservation: author’s reply

We welcome the interest in our recent technical note entitled: ‘Control of splenic bleeding during splenic flexure mobilisation by devascularisation of inferior pole of the spleen’ [1]. We thank Dr. Uranues for his expertise in splenic anatomy and agree that our technique is unlikely to induce infarction of the tip of the spleen but does appear to reduce perfusion sufficient to allow preservation of the injured spleen at laparoscopic anterior resection. We accept that this would not be a safe method for achieving haemostasis from a deep parenchymal laceration; however, splenic injuries at anterior resection are typically capsular traction tears. It is noteworthy that the largest published series of splenic injury during colectomy, from the Mayo clinic, reported a 76 % splenectomy rate [2]. Therefore, ongoing splenic capsular bleeding or a potentially evolving haematoma in a patient with a colorectal anastomosis is clearly unacceptable to most colorectal surgeons, and control must unequivocally have been attained by the end of the operation. So, while definitive haemostasis obviously may require splenectomy, the technique we describe facilitates the achievement of haemostasis with splenic preservation while obviating conversion to an open procedure. We thank Drs. Shafique and Ignjatovic for once again highlighting their previous description of this technique at open surgery [3], and we agree that it is the use of an endoscopic vascular stapler at laparoscopic anterior resection, thus avoiding the conversion to open surgery, which is the novel feature of our technique. Having used this technique both at laparoscopic anterior resection and at laparoscopic splenectomy, we feel that the chance of injuring the splenic vein is minimal as the staple line extends well beyond the stapler blade’s extent of division.

Successful laparoscopic division of a patent ductus venosus: report of a case

Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt from the umbilical vein to the inferior vena cava. This report presents the case of an adult patient with PDV, who was successfully treated with laparoscopic shunt division. A 69-year-old male was referred with hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. The safety of a shunt disconnection was confirmed using a temporary balloon occlusion test for the shunt, and the shunt division was performed laparoscopically. The shunt was carefully separated from the liver parenchyma with relative ease, and then divided using a vascular stapler. Portal flow was markedly increased after the operation, and the liver function of the patient improved over the 3-month period after surgery. Although careful interventional evaluation for portal flow is absolutely imperative prior to surgery, a minimally invasive laparoscopic approach can be safely used for treating PDV.

Heterotopic renal transplantation in piglets using vascular closure stapler metallic clips or conventional suturing techniques: comparison of vessel growth and macroscopical study

Background/purposeOur aim was to perform a macroscopic and imaging (ultrasonographic and angiographic) evaluation of vascular closure stapler (VCS) metallic clips for renal transplantation in growing piglets to assess their role for transplantation surgery in young children. If these techniques are to be useful, it is necessary to prove that their use avoids one of the main pitfalls of conventional sutures in this setting, namely lack of growth in the suture line. MethodsTwenty-four piglets were used for this study. Animals were subjected to a heterotopic renal autotransplantation when they were 45 days old. The right kidney was moved from its normal location to the cranial area of the iliac fossa. The end-to-side anastomoses between the renal artery and vein and the aorta and vena cava, respectively, were performed using VCS metallic clips in 6 animals. Continuous polypropylene suturing was used in another 6 piglets, and continuous polyglycolic acid suture was used in 6 additional piglets. A control group of 6 animals without renal autotransplantation was also included in the study. All animals were allowed to grow for 6 months, during which time serial angiographic and ultrasonographic studies were carried out to assess the existence of vascular flow disturbances or stenosis. Similarly, angiographic measurements were obtained to document growth at the anastomotic site. Longitudinal growth was evaluated postmortem after the 6-month growing period. ResultsAngiography showed significant (P < .001) transverse growth in both arteries and veins belonging to the VCS clips, running absorbable suture, or control groups. No significant difference was observed among the 3 groups. Vascular growth in the running nonabsorbable suture (polypropylene) group, however, was significantly less than in the other 3 groups and did not significantly differ from baseline. Baseline luminal diameters at the anastomotic site as measured by angiography in the VCS group were 3.64 ± 0.40 mm in the artery and 5.30 ± 1.43 mm in the vein. After growth, these values increased to 6.87 ± 0.90 mm and 11.27 ± 2.53 mm, respectively. Significant longitudinal growth was evidenced macroscopically after 6 months in both aorta and vena cava in all groups. On the other hand, significant longitudinal growth in the renal artery and vein were only observed in the control, VCS, and absorbable suture groups. ConclusionsIn this experimental setting, satisfactory macroscopic and angiographic vascular growth results were obtained using the VCS clips, suggesting that this suture could be the technique of choice in pediatric transplantation surgery.