To investigate the method and advantages of treating the renal hilum with Hem-o-lok ligature clips during laparoscopic nephrectomy and its application value. Methods: From January 2004 to September 2006, 56 cases of laparoscopic nephrectomy were performed in our department, among which 38 cases were treated with Hem-o-lok clips intraoperatively, including 9 cases of laparoscopic simple nephrectomy, 18 cases of laparoscopic radical nephrectomy for nephrocalcinosis, and 11 cases of laparoscopic full-length ureterectomy. The operating time, intraoperative bleeding, whether to open in transit, postoperative gastrointestinal function recovery time, postoperative hospitalization time and postoperative complications were observed. Results: All 38 cases of laparoscopic nephrectomy in which Hem-o-lok clamps were applied to deal with the renal hilum were successful, and none of them were converted to open surgery, and there were no intraoperative or postoperative renal vascular bleeding or other serious complications. The operative time ranged from 35 to 270 min, with an average of 165 min; the intraoperative bleeding volume ranged from 50 to 600 ml, with an average of 187 ml; the postoperative recovery time of gastrointestinal function ranged from 18 to 72 h, with an average of 32 h; the postoperative hospital stay ranged from 7 to 16 d, with an average of 11 d. Conclusion: In laparoscopic nephrectomy, the Hem-o-lok ligature clip can safely, quickly and reliably treat the renal vessels of the renal tip, and is a novel and effective vascular control system with broad application prospects. Utility of hem-o-lok ligation system in laparoscopic nephrectomy PING Hao1 XING Nian-zeng1 ZHANG Jun-hui1 YAN Yong1 NIU Yi-nong1 (1Department of Urology, Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, 100020) Abstract Objective: To explore the advantages of Hem-o- lok ligation system in the applications Methods: From January 2004 to September 2006, 56 laparoscopic nephrectomies were performed. Hem-o-lok clips were used to control renal artery and vein in 38 cases, including 9 simple nephrectomies, 18 radical nephrectomies and 11 The operative time, estimated intraoperative blood loss, conversion rate, recovery time of intestinal function, and postoperative hospital day, as well as the number of nephroureterectomies, were used to control renal artery and vein in 38 cases. The operative time, estimated intraoperative blood loss, conversion rate, recovery time of intestinal function, postoperative hospital day, as well as complication rate were recorded and studied retrospectively. Thirty-eight laparoscopic nephrectomies uing Hem-o-lok clips for renal pedicle control were accomplished successfully without conversion to open surgery. The operative time was 35-270 min (average 165min). The intraoperative bleeding was 50-600 ml (average 187 ml). The mean recovery time of intestinal function was 32h (range18-72h). The postoperative hospital staying was 7~16d, with the average of 11 days. Conclusions: The renal pedicle control using the Hem-o-lok ligation system is Keywords Hem-o-lok clips; laparoscopic nephrectomy; renal pedicle Currently laparoscopic nephrectomy is being used as a minimally invasive urological procedure. The laparoscopic nephrectomy is being used as a minimally invasive urological procedure, which has many advantages over open surgery, such as less trauma and faster recovery. During the operation, the control of renal pedicle vessels is very critical, and the more common clinical methods of vessel ligation are mainly silk ligation, Endo-GIA/Endo-GUT and titanium clips. Recently, a new vascular ligation system-Hem-o-lok ligature clip, a non-absorbable multi-polymer with a snap-lock structure, was introduced by WECK, USA, which can safely and quickly control the renal tubular vessels effectively [1]. The authors applied Hem-o-lok clips in 38 cases of laparoscopic nephrectomy from January 2004 to September 2006 to manage the renal hilum arterioles with satisfactory results, which are reported below. 1 Data and methods 1.1 Clinical data In this group of 38 cases, 23 cases were male and 15 cases were female. The age ranged from 26 to 81 years old, with an average of 57 years old. There were 18 cases of renal cancer, 6 cases of pyel cancer, 3 cases of ureteral cancer, 2 cases of duplicated renal ureter, 2 cases of renal tuberculosis, 4 cases of severe hydronephrosis, and 3 cases of atrophic kidney. Laparoscopic radical nephrectomy for renal cancer was performed in 18 cases; laparoscopic ureterectomy in 11 cases; laparoscopic simple nephrectomy in 9 cases. Hem-o-lok ligature clips were applied to control the renal hilum vasculature during surgery. All patients were confirmed preoperatively by urological ultrasound, IVU, CT or MRI. 1.2 Surgical instruments Stryker complete laparoscopic equipment instruments including 0o and 30o laparoscopes, fully automatic pneumoperitoneum machine, camera monitoring system, monopolar and bipolar electrocoagulation system, cold light source and routine laparoscopic instruments. Ultrasonic knife and Ligasure vascular closure system. hem-o-lok ligature clamps and clamping forceps from Weck. 1.3 Surgical method Thirty-one cases in this group were operated by the retroperitoneal route. After general anesthesia the patient was placed in the healthy side position with the lumbar region elevated. The skin was incised about 2 cm below the costal margin in the posterior axillary line (point A), the lumbodorsal fascia was bluntly separated with vascular forceps, and the retroperitoneal space was separated deeply with the fingers, and a homemade balloon was placed through this incision, inflated with 400-500 ml to dilate the retroperitoneal space and maintained for 1 to 3 minutes to establish the retroperitoneal cavity. From this point, the retroperitoneal cavity was inserted with the index finger, and a 5-mm trocar was placed under the rib margin in the anterior axillary line (point B) and a 10-mm trocar was placed 2 transverse fingers above the iliac spine in the mid-axillary line (point C) under finger guidance. a 10- to 12-mm trocar was placed at point A, and the incision was closed with sutures. In simple nephrectomy, first identify the psoas major muscle, identify the extraperitoneal fat, peritoneum, and perirenal fascia, open the perirenal fascia and fat capsule with ultrasonic knife or Ligasure, and bluntly free the perirenal fat along the perirenal fat and renal surface to the renal hilum; in huge hydronephrosis, drainage and decompression can be performed first to fully expose the dissected The arterioles of the renal hilum are fully exposed. Two L-size (13 mm) Hem-o-lok clips are placed immediately adjacent to the aorta on the proximal renal artery, and the distal end is closed and cut off directly with Ligasure or the renal artery is clamped with a titanium clip, and then the vessel is dissected. The renal vein was located below the anterior renal artery, and the renal vein was visible by separating the adipose tissue at the renal sinus. 2 L-gauge Hem-o-lok clips were placed on the proximal end of the renal vein and 1 Hem-o-lok clip on the distal end, and the renal vein was cut with scissors. The puncture hole at point A was enlarged and the kidney was removed. When performing radical nephrectomy, the perinephric fascia is first separated between the surface of the psoas major muscle and the perinephric fascia to the hilum, where the perinephric fascia is opened, and the renal artery and renal vein are found and separated according to the arterial pulsation. The same method is used to treat the renal hilum vessels with Hem-o-lok, and the perinephric fascia is freed outside the perinephric fascia, and the perinephric fascia and its internal organ tissues such as the kidney, tumor, adrenal gland and upper ureter are completely removed. In the case of renal pelvic cancer after conventional nephrectomy, the ureter should be separated downward as far as possible, changed to supine position, an oblique incision of 6-8 cm was made in the lower abdomen, the affected kidney was found by entering the retroperitoneal space on the affected side and raised from the incision, the lower segment of the ureter was freed extraperitoneally up to the bladder, the ureteral wall segment and part of the bladder were removed in a cuff-like manner, and the kidney and the whole ureter were removed through the incision. The remaining 7 cases were operated by the transabdominal route, opening the lateral peritoneum, freeing the kidney and treating the renal hilum in the same way as the retroperitoneal approach. 2 Results All 38 laparoscopic nephrectomies were successful, with no intermediate open surgery. In all cases, there was no intraoperative or postoperative dislodgement, loosening of the ligature clip or incomplete ligation, no renal vascular bleeding or other serious complications. The operative time was 35-270 min, mean 165 min; intraoperative bleeding was 50-600 ml, mean 187 ml; postoperative gastrointestinal function recovery time was 18-72 h, mean 32 h; postoperative hospitalization time was 7-16 d, mean 11 d. The postoperative clinical outcome was satisfactory, with 6-18 months of follow-up, and no tumor recurrence, incisional implantation or distant metastasis was seen in patients with tumor. Patients with renal tuberculosis had stable disease and disappearance of tuberculosis symptoms. 3 Discussion With the rapid development of laparoscopic technology in urology, laparoscopic nephrectomy has become one of the routine procedures in urology. Compared with traditional open nephrectomy, laparoscopic surgery has numerous advantages, which makes the surgery itself less traumatic, more efficient and less painful. And in laparoscopic nephrectomy, the most critical step is the separation and ligation of the renal hilum vessels. How to deal with the renal clitoris more safely and effectively in laparoscopic surgery is a hot topic of research for many scholars in recent years. At present, the more clinically used ligating materials include titanium clips and Endo-GIA/Endo-CUT, which are easier and faster to operate in laparoscopy than traditional silk ligation, but still have many shortcomings. The titanium clip is a metal ligature clip with a smooth occlusal surface, which can easily slip off when dealing with the renal vessels, especially when ligating the renal veins, which cannot completely wrap around the vessels due to the wide diameter of the renal veins, thus leading to larger bleeding. endo-GIA or Endo-CUT is safer and more reliable in dealing with the renal vessels, but the histocompatibility is poor and the absorbable material is prone to bacterial attachment in the body, which sometimes causes tissue reactions. sometimes causing tissue reactions; the products are expensive and difficult to be accepted by some patients for widespread application; and there are reports of intraoperative Endo-GIA malfunction in individual cases, resulting in serious complications [2]. The new ligature system-Hem-o-lok ligature clip greatly overcomes the shortcomings of the above ligature methods and makes laparoscopic nephrectomy more perfect [3, 4].Hem-o-lok clip is a non-absorbable multi-polymer inert material that has no tissue rejection, does not support bacterial growth, has a tough texture, and has no cutting effect on vascular tissue. It also has a hinge and safety snap-lock structure, and the nail leg of the ligature clip is designed in an arch shape, which effectively improves the ligature extension and increases the ligature range. The inner layer of the ligature clip also has anti-slip teeth, which makes the ligation firm and not easy to slip off. In this study, the authors applied Hem-o-lok clips in 38 laparoscopic procedures to deal with the renal hilum vessels. The renal artery was first separated and exposed during the procedure, and after two Hem-o-lok clips were applied proximally, the distal end could be dissected directly using Ligasure, which significantly saved the procedure time. When applying the Hem-o-lok, care should be taken to see the end of the ligature clamp as much as possible to ensure that the state of the ligature can be clearly seen when the clasp is closed. When the surgeon’s hand feels the ‘kata’ closing sound, it indicates that the clamp is safely closed and the ligature clamp can be withdrawn. The renal vein is relatively difficult to handle, and often the renal vein diameter is reduced only after the ligature has cut off the renal artery, adrenal vein and gonadal vein, and then the kidney can be lifted with a curved forceps or suction device to make the renal vein tense for ligation, and a total of three Hem-o-lok clamps are placed on the proximal and distal ends of the vessel in turn to ensure that the ligature clamp completely wraps around the vessel. When cutting the vessel, care should be taken to leave at least 1 to 2 mm of tissue distal to the ligature clips, and then disconnect them. As a result, all procedures were performed smoothly, without any case of ligature clip dislodgement and loosening, without serious complications such as renal vascular bleeding, without intermediate open abdomen, with short operation time and fast recovery of patients, showing the great advantages of Hem-o-lok in laparoscopic nephrectomy for renal tip management. We found in the clinical application that Hem-o-lok clip is easy to operate under laparoscopy, and it makes the operation process safe, fast and reliable with satisfactory intraoperative and postoperative results, mainly in the firm snapping structure, which can wrap around the tissue vessels without the risk of slipping and taut opening; even strength of wrapping around the vascular tissue, which can keep the vascular endings active; tactile feedback when closing, which is safer and more reassuring; postoperative X-ray, CT /The safety test conducted by Joseph et al [5] on Hem-o-lok in 2004 found that Hem-o-lok can withstand an arterial vascular pressure of 800 mmHg and can be used safely for hypertensive patients. Recently, the Hem-o-lok has been used again in transplant nephrectomy, significantly simplifying the procedure, improving safety, and facilitating the recovery of the transplanted kidney [6]. In conclusion, the use of Hem-o-lok ligature clips in laparoscopic nephrectomy to deal with the renal tip significantly increases the minimally invasive nature of laparoscopy, and the emergence of Hem-o-lok is another great leap forward in laparoscopic ligature technology, which has a broad application prospect in clinical practice. [Ref] 1. Kapoor R, Singh KJ, Suri A, et al. Hem-o-lok clips for vascular control during laparoscopic ablative nephrectomy: a single-center experience[ J]. J Endourol, 2006, 20: 202-204. 2. Chan D, Bishoff JT, Ratner L, et al. Endovascular gastrointestinal stapler device malfunction during laparoscopic nephrectomy: early recognition and management[J]. J Urol, 2000, 164: 319-321. 3. Janetschek G, Bagheri F, Abdelmaksoud A, et al. Ligation of the renal vein during laparoscopic nephrectomy: an effective and reliable method to replace vascular staplers[J]. J Urol, 2003, 170: 1295-1297. 4. Izaki H, Fukumori T, Takahashi M, et al. Clinical research of renal vein control using Hem-o-lok clips in laparoscopic nephrectomy[J]. International journal of Urology, 2006 , 13: 1147-1149. 5. Joseph J, Leung YY, Eichel L, et al. Comparison of the Ti-knot device and Hem-o-lok clips with other devices commonly used for laparoscopic nephrectomy [J]. other devices commonly used for laparoscopic renal-artery ligation[J]. J Endourol, 2004, 18: 163-166. 6. Meng MV, Freise CE, Kang SM, et al. Techniques to optimize vascular control during laparoscopic donor nephrectomy[J]. Urology, 2003, 61: 93-97.