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CASE REPORT
Failure of Hem-o-lok clips used on a renal artery after
laparoscopic renal surgery
Masato Yanagi1, Tsutomu Hamasaki2, Hiroyuki Shimizu3, Ryoji Kimata2, Hayato Takeda1, Jun Akatsuka1, Yuki Endo1,Tatsuro Hayashi1, and Yukihiro Kondo1
Department of Urology, Nippon Medical School Hospital, Tokyo, Japan, 2Department of Urology, Nippon Medical School Musashikosugi
Hospital, Kanagawa, Japan, 3Department of Urology, Hasegawa Hospital, Tokyo, Japan

1

Abstract : Hem-o-lok clips are commonly used for renal artery ligation in laparoscopic renal surgery. However,failure of the renal artery ligation clips is potentially fatal. A 61-year-old man underwent hand-assisted laparoscopic nephroureterectomy using a retroperitoneal approach for left ureteral carcinoma. One hour postoperatively, he was diagnosed with hemorrhagic shock. An immediate laparotomy revealed two closed, undamaged
Hem-o-lok clips around the left renal artery. Pulsatile bleeding was observed, and the renal artery was immediately ligated with non-absorbable thread. We determined that the failure of the Hem-o-lok clips on the renalartery was caused by the lack of space between the two Hem-o-lok clips and the distal renal artery cuff beyond
the distal clip. To prevent a potentially fatal failure of the renal artery ligation clips, one should maintain a sufficient space between the Hem-o-lok clips and an adequate distal renal artery cuff beyond the distal clip. J. Med.
Invest. 68 : 393-395, August, 2021
Keywords : Hem-o-lok clip, laparoscopic renal surgery, renal artery

INTRODUCTION
Hem-o-lok clips are commonly used to ligate the renal arteryin laparoscopic renal surgery (1). However, the FDA reported
in 2006 that Hem-o-lok clips may become dislodged following
ligation of the renal artery after laparoscopic donor nephrectomy (LDN). Hem-o-lok clips are now contraindicated for use inligating the renal artery during laparoscopic nephrectomies inliving donor patients because of the hemorrhagic deaths of several living kidney donors owing to failure of Hem-o-lok ligatingclips used on the renal artery (2, 3). In LDN, surgeons need toharvest the longest possible segment of renal artery, a factor
which might be related to the failure of Hem-o-lok ligation clips
used on the renal artery. Here, we present a case from 20 years
ago involving a patient who survived failure of Hem-o-lok clips
used on the renal artery after laparoscopic nephroureterectomy(LNU). This case is reported to warn surgeons about the properuse of Hem-o-lok clips in laparoscopic renal surgery.

CASE REPORTA 61-year-old man (weight, 58.6 kg ; height, 158 cm) was diagnosed with left ureteral carcinoma, cT1N0M0. He had a historyof hypertension and normal preoperative laboratory values. Heunderwent hand-assisted LNU using a retroperitoneal approachwith a 3-port (hand port, laparoscope, and instrument trocar)
approach. The two renal arteries and one renal vein were ligatedusing Hem-o-lok clips. First, two Hem-o-lok clips were applied
to the patient side and one Hem-o-lok clip was applied to thekidney side of these vessels. The vessels were then transected
Received for publication March 30, 2021 ; accepted July 4, 2021.
Address correspondence and reprint requests to Masato Yanagi, Department of Urology, Nippon Medical School Hospital, 1-1-5 Sendagi,Bunkyo, Tokyo, Japan and Fax : +81-3-5685-1794.

using surgical scissors. Because one of the two renal arteries wasbehind the renal vein, only one XL Hem-o-lok clip was applied tothis artery, and the vein was then transected. After transecting
the renal vein, the renal artery was dissected to a sufficient
length to apply three XL Hem-o-lok clips. Three XL Hem-o-lokclips were tightly applied to the renal artery, and the artery wastransected (Fig. 1). After releasing the kidney, the incision of thehand port was extended toward the lower abdomen, and the left
ureter and bladder cuff were removed. Two information drains
were placed in the retroperitoneal cavity. All surgical procedures
were performed in the retroperitoneal cavity and were completed
without any intraoperative complications. The operating timewas 260 min. The estimated blood loss was 240 mL. One hour
after the operation, 1,200 mL of blood was suddenly discharged
from the drain placed in the Retzius cavity. The other drain,
placed in the retroperitoneal cavity, was occluded. The patient’s
systolic blood pressure dropped to 80 mmHg. Due to the reddish
color of blood from the drain, he was diagnosed with hemorrhagic shock due to failure of Hem-o-lok clips on the artery. Thedrains were immediately clamped, the patient was transported
to the operating room, and a laparotomy was performed using
the retroperitoneal approach with a flank incision in the lateral
decubitus position. Two closed, undamaged XL Hem-o-lok clips
and a large hematoma were found around the left renal arteryand were removed. Pulsatile bleeding was observed in one of
the left renal arteries transected after transecting the renal
vein. The two XL Hem-o-lock clips were removed from the renalartery. The renal artery was immediately ligated with a non-absorbable thread. Two ligatures with non-absorbable threads
and one penetrating ligature with a non-absorbable thread wereadded to the renal artery to prevent postoperative bleeding. No
other bleeding events were observed. The time from the confirmation of postoperative bleeding to ligation of the bleeding renalartery was 165 min. A total of 12 units of red cell concentrate
and 6 units of fresh frozen plasma were required for transfusion.
The patient was discharged 14 days after surgery.

The Journal of Medical Investigation Vol. 68 2021

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M. Yanagi, et al. Failure of Hem-o-lok clips

DISCUSSION
In laparoscopic surgery, failure of the ligating clips used on therenal artery is potentially fatal (2). The Japanese Society of Endourology recommends maintaining a sufficient space betweenHem-o-lok clips used on the renal artery (4). The artery between
the two clips serves as a cushioning material, and the clips aremuch less likely to slip out. Tereflex Medical’s instructions clearly state, “In procedures other than laparoscopic donor nephrectomy, Teleflex Medical recommends ligation of the renal arterywith more than one clip on the patient side with a minimum
distal renal artery cuff of 2-3 mm beyond the distal clip. (5)” In
the case presented, the cause of failure of the Hem-o-lok clips on
the renal artery was the lack of space between the two clips andthe lack of a distal renal artery cuff beyond the distal clip (Fig.1).
Because the retroperitoneal approach was used in this case,the tamponade effect from the localized retroperitoneal cavity
prevented continuous heavy bleeding. Fortunately, the patient
survived. However, when the same events occur in patients after
laparoscopic renal surgery using the transperitoneal approach,the result is likely fatal. Based on our experience with this case,

we recognized the importance of maintaining sufficient space between the Hem-o-lok clips used on the renal artery and leaving adistal renal artery cuff of more than 2 mm beyond the distal clip.
To avoid potentially fatal consequences, our current practice isto apply three Hem-o-lok clips on the patient side of the renal artery, when maintaining sufficient space between the Hem-o-lokclips used on the renal artery and leaving a distal renal artery
cuff of more than 2 mm beyond the distal clip are possible (Fig.
2). In the 20 years since this case, we have had no further casesof postoperative bleeding from the renal artery.
In laparoscopic renal surgery excluding LDN, it is important
to maintain a sufficient space between Hem-o-lok clips used on
the renal artery and a distal renal artery cuff of more than 2 mm
beyond the distal clip to avoid failure of the ligating clips used on
the renal artery. A sufficient length of the renal artery should
also be dissected for such procedures.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

Figure 1. The procedure of transecting the renal artery in the presented case

Yellow arrows show the renal artery.
A. Three Hem-o-lok clips are applied to the renal artery without sufficient space.
B. The renal artery is transected without a distal renal artery cuff beyond the distal clip.
C. Two Hem-o-lok clips are placed on the patient side of the renal artery.

Figure 2. The current procedure for transecting the renal artery in our institution
A. Three Hem-o-lok clips are applied on the patient side of the renal artery.
B. The renal artery is transected with a minimum distal renal artery cuff of 2-3 mm beyond the distal clip.

The Journal of Medical Investigation Vol. 68 August 2021
FUNDING STATEMENT
No funding was received for this study.

ACKNOWLEDGEMENTS

3.

4.

The authors thank Editage for English editing.

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