title: Renal Vascular Clamp Placement: A Potential Cause of Incomplete Hilar Control during Partial Nephrectomy.
abstract: OBJECTIVE
  Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined.
  
  
  METHODS
  Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p <0.05 considered significant.
  
  
  RESULTS
  None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg.
  
  
  CONCLUSIONS
  Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding.
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: David
authors.initials: D
authors.lastname: Tryon
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Kristene
authors.initials: K
authors.lastname: Myklak
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Muhannad
authors.initials: M
authors.lastname: Alsyouf
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Carol
authors.initials: C
authors.lastname: Conceicao
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Brandon
authors.initials: B
authors.lastname: Peplinski
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Javier L
authors.initials: JL
authors.lastname: Arenas
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Daniel
authors.initials: D
authors.lastname: Faaborg
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: Herbert C
authors.initials: HC
authors.lastname: Ruckle
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California.
authors.forename: D Duane
authors.initials: DD
authors.lastname: Baldwin
mesh_terms: D000328:Adult; D002102:Cadaver; D003250:Constriction; D004867:Equipment Design; D006801:Humans; D007668:Kidney / Q000098:blood supply* / Q000601:surgery*; D010535:Laparoscopy / Q000295:instrumentation; D008297:Male; D009392:Nephrectomy / Q000379:methods*; D012077:Renal Artery / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000295:instrumentation
keywords: hemostasis; kidney neoplasms; minimally invasive surgical procedures; nephrectomy; surgical instruments