Athermal tension adjustable suture ligation of the vascular pedicle during robot-assisted prostatectomy

We report a simple figure-of-eight tension adjustable suture to ligate the vascular pedicle (VP) during robot-assisted radical prostatectomy (RARP).

During nerve-sparing RARP, after the rectum has been mobilized, the VP is isolated and prepared for transection. Previous reports describe placing of hemostatic clips (metallic or Hem-o-lok™) or laparoscopic bulldog clamps (30 mm) to control and oversew the VP; both techniques are quite assistant dependent. We present a bulldog clamp alternative by placing a figure-of-eight fashion, a 6-cm 3-0 poliglecaprone on an SH needle with a small loop tied in the suture end. After the needle has been placed through the VP, it is then threaded through the preformed loop and then a small Hem-o-lok clip is placed and cinched down to occlude the blood vessels. Next, the VPs are transected. The clip can be further cinched, mimicking the technique used in partial nephrectomy, to control bleeding when encountered. Data were collected prospectively to demonstrate safety.

We report on 74 men totaling 143 VPs using this new technique. The average operative time was reduced by 15 minutes compared with using bulldog clamps. In the initial 10 cases (20 attempts), inadvertent transection of the suture occurred three times. In these three cases, hemostasis was (easily) controlled with additional sutures.

The pedicle stitch technique offers an assistant independent alternative for a simple and precise athermal means to control the VP.