Eliminating knot tying during warm ischemia time for laparoscopic partial nephrectomy

Purpose: Rapid intracorporeal suturing represents a challenge when performing laparoscopic partial nephrectomy (LPN). During warm ischemia time (WIT) knot tying is a major time-consuming step. We present our technique of eliminating knot tying during LPN and the outcomes of our initial series. Materials and Methods: Between October 2002 and October 2003, 32 patients underwent LPN for clinical T1a renal tumors. Our technique includes initial placement of a 5Fr ureteral catheter for collecting system irrigation. The renal hilum is clamped, the tumor is sharply excised and freehand suturing of the collecting system and renal parenchyma is performed using 2-zero and zero polyglactin sutures prepared with an absorbable clip (LapraTy, Ethicon Endosurgery Inc., Piscataway, New Jersey) at the terminal end. Once the suture is passed an additional clip is used to cinch it down, obviating the need for knot tying. This technique is used for closure of the collecting system as well as for placement of parenchymal compressive sutures over bolsters. Subsequent testing for watertightness with methylene blue solution is performed. Results: Pathological mean tumor size was 2.1 cm (range 0.3 to 4.2). Mean operative time was 224.2 minutes (range 105 to 396). In 21 cases (65.6%) the collecting system was entered, necessitating further suturing. Mean WIT was 33.1 minutes (range 13 to 55) and mean estimated blood loss was 222.7 cc (range 5 to 600). No postoperative bleeding or urine leaks were encountered in this series. Conclusions: The use of LapraTy clips as an alternative to knot tying in LPN is safe and efficient. It simplifies the procedure and allows completion of the necessary suturing tasks during an acceptable WIT.