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Re: JSLS 2006;10:254-256 Laparoscopic management of giant ovarian cyst.

As surgeons, we should continue to strive to do what is best for the donor without compromising graft function. The laparoscopic approach is the preferred approach in the vast majority of US transplant centers. The options for laparoscopic control of the renal vessels are staplers or clips. If clips are not used, we must rely on staplers. The vascular staplers and multiple locking clips were given the same safety rating in the authors’ report (reference 3 in the letter). Vascular staplers are also known to malfunction. Vascular stapler malfunction rate was 1.7%, in a report of 565 patients who underwent laparoscopic nephrectomy including donor nephrectomy. In our own experience, vascular stapler malfunction resulted in significant bleeding despite immediate conversion to open surgery.

As surgeons, we should continue to strive to do what is best for the donor without compromising graft function. The laparoscopic approach is the preferred approach in the vast majority of US transplant centers. The options for laparoscopic control of the renal vessels are staplers or clips. If clips are not used, we must rely on staplers. The vascular staplers and multiple locking clips were given the same safety rating in the authors' report (reference 3 in the letter). Vascular staplers are also known to malfunction. Vascular stapler malfunction rate was 1.7%, in a report of 565 patients who underwent laparoscopic nephrectomy including donor nephrectomy. In our own experience, vascular stapler malfunction resulted in significant bleeding despite immediate conversion to open surgery. 1 We continue to use the locking polymer clips when appropriate, for laparoscopic nephrectomies involving pathologic kidneys. We believe that the clips are safe provided at least 2 clips are used and a cuff of vessel distal to the clip is ensured when the vessel is divided. The vessel should also be circumferentially dissected and the clips positioned in a manner so that perivascular tissue is not within its locking mechanism. There have been several reports that have confirmed the clinical safety and efficacy of the clips. 2,3 It is important that all methods of vascular control are available to the surgeon who uses the appropriate device as dictated by a variety of factors that are involved in each patient.

Authors' Response JSLS 2006;10:135-140
The readers bring up an important, albeit relatively new, development in the evolution of the laparoscopic donor nephrectomy. When we originally wrote the manuscript reporting our experience, it predated by 18 months the safety alert issued by the manufacturers of the Hem-o-lok clip. 1 Interestingly, we since independently noted the tenuous nature of the clip alone in securing the renal hilum and have abandoned its use. In all, utilization of this method of vascular control represented less than 1% of a combined series approaching 400 cases.
Fortunately, we did not have a case of clip dislodgement in our limited use of Hem-o-lok clips to control the renal hilum. Our cases of retroperitoneal bleed (now 1% of our total experience) and transfusion (now 0.5%) were early in our experience and unrelated to our hilar ligation technique. Still, we concede that "clip dislodgement seems to be, thankfully, a low frequency, but high impact event." As a result, we advocate only the use of a stapler, either GIA or TA, to control the renal hilum in the laparoscopic donor nephrectomy. phorectomy was performed. The authors stated, "the ovarian cyst reported on herein is the largest intraabdominal cyst managed laparoscopically reported to date." The statement is incorrect. We reported the laparoscopic removal of a 103-pound ovarian cyst in 1996. 2 We removed a 103-pound ovarian mucinous cystadenoma from a 22year-old woman by using a small intraumbilical incision (2 cm) to drain 70 liters of fluid (97 lbs), and an operative laparoscope. A right salpingo-oophorectomy and appendectomy were also performed. The combined weight of the excised cyst and cyst fluid was 103 lbs.
Although we agree with the authors that the large ovarian cysts can be managed laparoscopically or with laparoscopically assisted minilaparotomy, we were disappointed that the authors did not give us the credit for reporting first the laparoscopic removal of the largest ovarian cyst to date.
Incidentally, for the last 5 years we have been successfully using a modified minilaparotomy technique for the removal of very large ovarian cysts that has eliminated the need for laparoscopy. 3 Marco A. Pelosi