Since the introduction of the laparoscopic nephrectomy in 1991 by Clayman and colleagues, advancements in minimally invasive surgical equipment have expanded the application of laparoscopic techniques to several reconstructive urologic procedures. Laparoscopic stapling and clipping devices have been developed to provide more efficient and facile alternatives to hand-suturing to achieve hemostasis, tissue dissection, and tissue approximation. In addition, there are a variety of hemostatic agents and tissue sealants in the urologic surgeon’s armamentarium. Despite the availability of these devices and robotic platforms, it is also important for laparoscopic surgeons to develop intracorporeal suturing and knot-tying skills in cases of device malfunction or unavailability. This chapter reviews the various clips, staplers, adjunct hemostatic agents, and suturing techniques available to perform nonrobotic reconstructive laparoscopic urologic procedures.
Occlusive clips are ideal for smaller vessels and provide a rapid, effective alternative for hemostasis. These clips are typically made of titanium and vary in size from 5 to 12 mm. Absorbable clips are also available, and there is no difference in adhesion formation between metallic and absorbable clips.
An occlusive clip starts out in a V shape, and as it is applied, the tips close first from distal to proximal ( Fig. 4.1 ), which ensures that the entire structure to be ligated is contained within the clip. Weck Hem-o-lok nonabsorbable polymer ligating clips (Teleflex, Research Triangle Park, NC) are also available in four sizes (M, ML, L, XL), utilizing 5- or 10-mm trocars ( Fig. 4.2 ). These clips perform the same function as sutures by penetrating and locking through multiple layers of tissue. The engaging clip-latching mechanism allows the surgeon to have tactile feedback when the clip locks close. It is important to note that Weck Hem-o-lok clips are contraindicated in the control of the renal artery during donor nephrectomies because of the risk of clip dislodgement. In addition, it is important not to cross clips.
Occlusive clip appliers can be classified into the following categories: multiple or single load and disposable or multiple use. Disposable clip appliers typically cost more than single-load reusable models, but the multiple-load feature makes their use much more efficient than withdrawing the instrument for the placement of each new clip. The majority of laparoscopic clip appliers used today are single-use and multiple-load, carrying between 15 and 30 clips per unit ( Table 4.1 ).
|LIGAMAX 5||10-mm LIGACLIP||12-mm LIGACLIP||Endoclip||Endoclip II||Endoclip III||Right-Angle Acuclip|
|Manufacturer||Ethicon Endo-Surgery||Ethicon Endo-Surgery||Ethicon Endo-Surgery||Covidien||Covidien||Covidien||Covidien|
|Trocar size (mm)||5||10||12||5, 10||10||5||10|
|Number of clips||15||20||20||12–20||20||16||20|
|Sizes of clip||Medium/large||Medium/large||Large||Medium, medium/large, large||Medium/large||Medium/large||Medium/large|
|Clip loading||Automatic||Automatic||Automatic||Separate lever||Automatic||Automatic||Automatic|
The diameter of the shaft generally depends on the size of the clips. In general, shafts of 5 mm are available for small clips, 10 mm for medium/large, and 12 mm for large clips. The LIGAMAX single-use clip applier with a 5-mm shaft (Ethicon Endo-Surgery, Cincinnati, OH) is used to apply medium/large titanium clips. Its hinged jaws are retracted within the shaft until the handles are squeezed, and then the jaws advance and expand with a clip automatically loaded.
Three hundred and sixty-degree rotating shafts are present on all appliers and allow the tips to be placed around the target tissue at an ideal angle. Automatic loading clips are also available in many models, which immediately reload another clip into firing position. In addition, newer models may have a visual indicator showing the number of clips left.
The vessel or other structure to be clipped should be dissected until the entire structure can be contained within the clip, without a significant amount of overlying tissue, to ensure maximum closure of the clip on the vessel. It is important to make sure the dissected window is large enough to accommodate the placement of several clips, with room to divide the structure with endoscopic scissors. Clips are typically used for small- to medium-sized vessels, with one or two clips on either side before the vessel is divided.
Once the clip applier’s jaws are completely around the structure, firmly squeeze the handle until the clip is placed ( Fig. 4.3 ). Then withdraw the clip applier at the same angle used for the approach to avoid accidentally displacing the clip. Place additional clips as necessary, and then divide the tissue. A right-angle clip applier may be necessary to achieve the appropriate angle and requires the use of a 10-mm trocar. It is important to avoid electrocautery near the clips to prevent conductive tissue injury and clip dislodgement.
Laparoscopic linear staplers are essential tools for the rapid division of tissue and vessels. The device deploys multiple closely spaced parallel rows of titanium staples. Most models require manually squeezing the handle three to four times to complete deployment of the staples and activating the knife to divide the tissue. Newer models have a battery-powered automatic device that allows for easier deployment and greater stapler stabilization with one hand.
Linear staplers can be broadly classified into cutting and noncutting staplers. Cutting staplers deploy loads with six intercalated rows of staples. With deployment of the stapler, staples are forced out of the load, through the tissue, and against an opposing anvil, and then it closes back upon itself ( Fig. 4.4 ). After the staples are fired, a knife follows and divides the tissue, leaving three rows of staples on each side. The staple line extends past the range of the cutting knife to avoid incising unstapled tissue ( Fig. 4.4 ). Noncutting staplers, which fire three to four parallel rows of staples, are useful for closing enterotomies and repairing bladder injuries.
Laparoscopic linear cutting staplers are available in varying lengths (30/35, 45, and 60 mm), with most models offering an articulating head, which gives a greater range of angles for application from a fixed trocar. All models offer a 360-degree rotating shaft, which is essential for proper placement of the stapler. The size of the stapler requires the use of a 12-mm trocar or larger. Staplers today allow the same instrument to fire between 8 and 25 separate staple reloads before disposal ( Table 4.2 ). The Endopath ETS-Flex stapler (Ethicon, Cincinnati, OH) is illustrated in Fig. 4.5 .
|Echelon Endopath||Endopath ETS-Flex Articulating||Echelon Flex Endopath||Echelon Flex Powered Endopath||Multifire Endo GIA 30||Multifire Endo TA 30||Endo GIA Universal||Endo GIA Ultra Universal|
|Manufacturer||Ethicon Endo-Surgery||Ethicon Endo-Surgery||Ethicon Endo-Surgery||Ethicon Endo-Surgery||Covidien||Covidien||Covidien||Covidien|
|Trocar size (mm)||12||12||12||12||12||12||12||12|
|Staple size(s)||Mesentery/thin, vascular/thin, regular, regular/thick, thick, very thick||Mesentery/thin, vascular/thin, regular, thick||Mesentery/thin, vascular/thin, regular, regular/thick, thick, very thick||Mesentery/thin, vascular/thin, regular, regular/thick, thick, very thick||2.0, 2.5, and 3.5 mm||2.5 and 3.5 mm||2.0, 2.5, 3.5, and 4.8 mm||2.0, 2.0–3.0, 3.0–4.0, and 4.0–5.0 mm|
|Staple length(s) (mm)||45 |
|30||30||30, 45, and 60||30, 45, and 60|