To the Editor:The April-June 2006 edition of JSLS contained 2 disturbing papers addressing technical aspects of vascular control in laparoscopic donor nephrectomies. Lallas et al[1] report an algorithm developed during a series of 200 cases performed at the Mayo Clinic in Scottsdale, Arizona in which “early vessel branching or a potential for inadequate vessel length” prompted the use of Hem-o-lok clips on the renal artery. They also report 4 postoperative retroperito-neal hematomas (an incidence of 2%), 2 of which required transfusions (incidence of 1%). Bernie et al[1] report an anatomic study in cadavers, in which use of 2 nonabsorbable polymer ligating clips placed on the “patient” side of the artery and sharp transection leaving a 1-mm cuff of tissue preserves a significantly longer vessel than a GIA stapler. The authors also point out, however, their own direct observation of a clip dislodgement in human surgery, with use of this technique.We have recently reported a sad experience of 66 arterial hemorrhages following donor nephrectomies, including 2 that were fatal and 2 others that resulted in chronic renal failure.[3] By surveying the American Society of Transplant Surgeons' membership, we demonstrated that surgeons believe vascular stump control with techniques involving tissue fixation is safer than those without tissue fixation. It was also clear that the use of clips was statistically more likely to be associated with hemorrhage, and with more severe hemorrhage, than other techniques. Six of these events followed the use of two or more locking clips, at least 3 of which occurred following completion of the procedure. We also note that a significant proportion of these bleeds occurred in cases with early arterial branching in which a particularly short stump was left, exactly as indicated in the Mayo Clinic report.Scientific evidence supporting the safety clips on the renal artery stump is not available. Apart from scarce animal and ex vivo studies with minimal relevance to the clinical setting, it is only multiple small case series that support this use of clips (and in some cases, specifically locking clips) on the renal artery in living donor nephrectomies. We concur that the clip dislodgement seems to be, thankfully, a low frequency, but high impact event. Without supportive evidence that this technique is safe, and with our report of catastrophic consequences, continued use of this approach in any patients, but particularly in the kidney donor who is an otherwise healthy individual, is simply unwarranted. Since publication of our report, a safety alert has been issued by the Hem-o-lok manufacturer, indicating that use of the clips in laparoscopic donor nephrectomies is contraindicated.[3] We strongly agree and point out that, in this setting, it also seems legally indefensible. Some have indicated that the lower cost of clips than staplers is sufficient justification for their use. We believe that cost containment and minimally increased vessel length, though achievable through the use of clips, do not merit disregarding our enormous responsibility to ensure the donor's safety. Clips are an unsafe means of controlling the donor's renal artery stump.Sincerely,