Unsolved Controversies Vascular Control

Live donor nephrectomy can be a dangerous operation. Five donor deaths have been reported in the United States. Of these, two occurred due to hemorrhage. One of these donors suffered anoxic brain damage and lived in a vegetative state for four years before dying recently (87).

Conversion of a laparoscopic nephrectomy to open nephrectomy is most commonly performed for vascular control. The overall rate of conversion reported is 2.1% in 3478 donors (Table 3).

Vascular injuries are the most feared complication in laparoscopic surgery (88-90). Vascular injuries may occur at the time of peritoneal entry, during placement of the Veress needle or the trocars. Injuries may also occur at any step of the surgical dissection or vascular stapling. Vascular injuries occurring during laparoscopic donor nephrectomy may be classified as minor or major injuries. Minor injuries are defined as those that can be handled laparoscopically without jeopardizing the outcome of the surgery for either the donor or the recipient. Minor bleeding from injury to gonadal, lumbar, or adrenal veins falls into this category. However, if these injuries are not controlled rapidly, they can quickly become major problems. Major vascular injuries are defined as those that result in conversion to open surgery or graft loss. Major vascular injury is the most common cause for conversion to open surgery.

Sixty percent of the vascular injuries requiring open conversion occur during the use of the endovascular stapler (10). Therefore, complete dissection prior to use and great care in avoiding other clips and staples when applying the endovascular staplers are essential. With major vascular injuries, quick conversion will minimize blood loss and maximize the chances for a successful outcome for both the donor and the recipient.

The optimal technique for vessel control is another point of debate in laparoscopic donor surgery. The current methods of control of renal vessels are laparoscopic clips, endovascular staples, or Hem-O-Lok clips. These methods fail infrequently, but when they do fail, major complications and even donor death may occur. Most centers, including ours, use some form of endovascular staples. Although not perfect, the endovascular staples provide reliable division and simultaneous hemostasis of the renal vessels. As per our experience, staple failure may occur, and one must always be prepared for staple failure (91). Prior to firing any vascular staples, we always double check to ensure that we have vascular clamps and an open tray immediately available for rapid conversion to control bleeding if needed. In the event of a staple misfire and a major vascular injury, a delay in conversion could result in a surgical catastrophe. Another method followed by some centers for achieving vascular control is the use of Hem-O-Lok clips. Proponents of this technique argue that the vascular length is better preserved with this device. However, a single Hem-O-Lok slipping off the renal artery within 24 hours did lead to exsanguination

TABLE3 â–  Relative Advantages of Different Laparoscopic Approaches

Standard transperitoneal

Hand-assisted

Retroperitoneal

Incisional stability

****

**

***

Incisional pain

****

***

**

Vascular control (emergency)

*

****

*

Warm ischemia time

*

***

*

Operative time

***

*

***

Disposables cost

**

*

**

Surgical experience required

*

***

*

Risk of intraperitoneal organ injury

***

***

*

* Lowest; **** highest.

Currently, the biggest risk to the donor is potential vascular catastrophe. There is room for device reliability improvement even for the available excellent products.

and a donor death. Therefore, multiple clips should be used for safety. The ultimate goal is to provide the maximum vessel length with the safest method; the renal vein length is especially important. However, this should not in any way comprise donor safety.

Currently, the biggest risk to the donor is potential vascular catastrophe. There is room for device reliability improvement even for the available excellent products.

Laparoscopic donor nephrectomy requires much more skill and finesse than laparoscopic radical nephrectomy. There is no margin of error. Superb technique is absolutely essential to obtaining good donor outcome and recipient graph function.

The real challenge with laparoscopic donor nephrectomy is achieving and maintaining the skill levels required for the entire laparoscopic team. The team participating in the surgery includes surgeons, anesthesiologist, circulating nurses, and surgical technicians. Each one of these team members plays a vital role. Team cohesion, consistency, and skill are all vital to successful outcomes—especially in the event of an emergency.

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