What is the recommended hemostasis technique after partial nephrectomy using pressure and hemoclip (hemostatic clip)?

Hemostasis Technique After Partial Nephrectomy Using Pressure with Hemoclip

The recommended hemostasis technique after partial nephrectomy is the modified pledget clip technique, which uses Hem-o-lok® clips with polyglactin sutures passed through renal parenchyma over rolled oxidized cellulose bolsters to achieve secure hemostatic compression. 1

The Modified Pledget Clip Technique

This standardized approach provides reliable hemostasis and reduces the risk of suture tearing through the renal capsule during knot tying 1:

Step-by-Step Technique

Preparation:

• Pre-prepare a 9-inch No. 0 polyglactin suture on a CT-X needle by placing a knot approximately 2-3 inches from the end 1
• Place a Hem-o-lok® clip on the suture proximal to the knot on the needle side 1

Parenchymal Reconstruction:

• Pass the suture through the renal parenchyma on one side of the renal defect 1
• Pull the pledgeted locking clip flush against the renal capsule 1
• Pass the suture over a pre-fashioned, rolled oxidized regenerated cellulose bolster placed in the partial nephrectomy bed 1
• Pass through the other side of the renal defect 1
• Cinch the renal parenchyma tightly against the bolster 1
• Tighten the exiting suture with a second locking Hem-o-lok® clip, securing the bolster snugly into the partial nephrectomy bed 1
• Tie the two free ends of the suture together over the bolster, tightly reapproximating the defect 1
• Place 3-4 similar parenchymal stitches across the defect until reconstruction is complete 1

Key Advantages of This Technique

The pledget clip technique provides multiple benefits 1:

• Securely maintains tight hemostatic compression of the renal parenchyma over the rolled cellulose bolsters 1
• Decreases the risk of suture tearing or pulling through the renal capsule during knot tying 1
• Provides "another level of refinement and safety, particularly for larger parenchymal defects after substantive resections" 1
• Facilitates intraoperative efficiency with fewer technical variables to troubleshoot 1

Collecting System Repair

Before parenchymal reconstruction, repair any collecting system entry with a running 2-zero polyglactin suture on a CT-1 needle 1, 2. This step is critical and must be completed prior to the pledget clip technique.

Adjunctive Hemostatic Measures

While the pledget clip technique is the primary method, additional considerations include:

Oxidized cellulose hemostats (Surgicel™):

• Effective for rapid hemostatic closure and supporting parenchymal closure 3
• Particularly helpful for repairing large and irregular renal parenchymal defects 3
• Used as the bolster material in the pledget clip technique 1

Gelatin matrix thrombin sealant (FloSeal):

• Can be applied topically to cover the partial nephrectomy bed before sutured renorrhaphy 4
• Significantly reduces overall complications (37% vs 16%, p=0.008) and trends toward lower hemorrhagic complications (12% vs 3%) 4
• Now considered routine at high-volume centers 4

Critical Technical Points

Hilar control is essential for achieving a bloodless field 1, 2:

• Transperitoneal approach: Use en bloc hilar control with Satinsky clamp through an additional lower quadrant port 1
• Retroperitoneal approach: Satinsky clamp can also be used effectively and is more reliable than bulldog clamps 1

Warm ischemia time should ideally be kept under 30 minutes 5, 2, 6 to preserve renal function while performing the hemostatic reconstruction.

Common Pitfalls to Avoid

• Do not use hemostatic bioadhesive agents alone without proper suture reconstruction - the pledget clip technique provides the structural foundation 1
• Avoid inadequate tension on the clips - the clips must be pulled flush against the renal capsule to provide adequate compression 1
• Do not skip collecting system repair - this must be completed before parenchymal reconstruction to prevent urinary fistulas 1, 2
• Ensure adequate bolster placement - the rolled cellulose bolster must be properly positioned in the nephrectomy bed before suturing 1

Postoperative Monitoring

Place a perirenal drain in patients undergoing collecting system repair 1. Maintain the drain for at least 5 days and remove on an outpatient basis when output remains less than 50 cc daily for 3 consecutive days 1.