Haemostatic Efficacy and Safety of Suturing, Ligaclips, and Hem-o-Lok Clips in Laparoscopic Nephrectomy

By Akhtar Nawaz¹, Asif Khan², Muhammad Waqas¹, Muhammad Saad Hamid¹, Anwar Ul Haque³

Affiliations

1. Department of Urology, Institute of Kidney Disease, Peshawar, Pakistan
2. Department of Urology (Paediatrics), Swat Medical College, Swat, Pakistan
3. Department of General Surgery, Saidu Medical College, Swat, Pakistan

doi: 10.29271/jcpsp.2026.08.1011

ABSTRACT
Objective: To compare the haemostatic efficacy and safety of suturing, Ligaclips, and Hem-o-Lok clips in laparoscopic nephrectomy.
Study Design: A descriptive study.
Place and Duration of the Study: Department of Urology, Institute of Kidney Disease, Peshawar, Pakistan, from January 2020 to December 2024.
Methodology: This study included 200 patients (aged 15–60 years) undergoing laparoscopic nephrectomy for non-functioning kidneys. The exclusion criteria were bleeding disorders, incomplete records, unrelated open conversions, and bilateral cases. Patients were grouped by ligation method: suturing (n = 53), Ligaclips (n = 74), and Hem-o-Lok clips (n = 73). Outcomes included ligature slippage, blood loss, transfusion, conversion, complications, adjacent injury, and length of hospital stay. Data were analysed using ANOVA/Kruskal–Wallis tests, chi-square/Fisher's exact tests, and multivariable regression analysis.
Results: Baseline demographic and clinical characteristics were similar across groups (p >0.05). Haemoglobin reduction was lowest with Hem-o-Lok clips (0.70 ± 0.30 g/dL), higher with Ligaclips (1.00 ± 0.20 g/dL), and highest with suturing (1.20 ± 0.30 g/dL; p <0.001). Hospital stay was longer with suturing (median 4.0 [4-5] days) compared with Hem-o-Lok (4.0 [3-4] days) and Ligaclips (4.0 [3-5] days; p = 0.03). Conversion to open surgery occurred only in the Ligaclips group (9.6%), with none in the Hem-o-Lok or suturing groups (p <0.001). Regression analysis showed diabetes as the only independent predictor of complications, with higher odds of ligature slippage (OR = 6.71 [1.02-50.68]; p = 0.046) and injury to adjacent structures (OR = 8.38 [2.29-33.47]; p = 0.002).
Conclusion: Hem-o-Lok clips provide relatively reliable ligation during laparoscopic nephrectomy in terms of haemoglobin reduction, hospital stay, and conversions to open surgery.

Key Words: Laparoscopic nephrectomy, Hem-o-Lok clips, Ligaclips, Suturing, Vascular ligation, Surgical complications.

INTRODUCTION

Laparoscopic nephrectomy has emerged as the gold standard minimally invasive surgical intervention for the removal of non- functioning kidneys.¹ When compared with traditional open nephrectomy, this approach has several clinical benefits, such as reduced postoperative pain, shorter hospitalisation time, accelerated recovery times, and decreased overall morbi- dity.^2,3 In adults, renal dysfunction most commonly results from chronic stone disease, recurrent infections, obstructive uro- pathy, renal masses, and systemic conditions such as diabetes and hypertension (HTN). In such cases, nephrectomy is often indicated to relieve symptoms, prevent complications, and preserve the functional capacity of the contralateral kidney.^4,5

Bleeding control represents a critical component of laparo- scopic nephrectomy. Inadequate vascular ligation may lead to serious intraoperative and postoperative complications, including haemorrhage, haematoma formation, prolonged operative duration, and, in severe cases, conversion to open surgery.⁶ Consequently, the selection of an appropriate ligation technique is pivotal to ensure both the safety and effec tiveness  of  the  procedure.⁷

Various techniques are used to maintain haemostasis during laparoscopic nephrectomy, with suturing, Ligaclips, and Hem-o-Lok clips being among the most commonly utilised.⁸ Suturing is a traditional and reliable method; however, it is technically demanding and typically associated with longer operative times. Ligaclips, which are metal-based, allow for quicker application but carry a potential risk of slippage or migration.⁹ In contrast, Hem-o-Lok clips—non-metallic, polymer-based devices with a locking mechanism—have gained popularity in recent years due to their ease of use and improved security in vascular control, especially in urological procedures.¹⁰

Several studies have investigated ligation methods in laparoscopic nephrectomy. Lachkar et al. conducted a syste-matic review comparing Hem-o-Lok clips and staplers in donor nephrectomies, concluding that both are generally safe but noting risks of clip displacement and variation in outcomes, including bleeding and conversion rates.¹¹ Ponsky et al., in a large multi-institutional review, found Hem-o-Lok clips to be safe when properly applied, with no failure in over 1,600 laparoscopic nephrectomies; however, their cohort included varied surgical indications and did not directly compare multiple ligation methods.⁸

To the best of the authors’ knowledge, no local study has evaluated the comparative efficacy and safety of suturing, ligating clips, and Hem-o-Lok clips in laparoscopic neph- rectomy for non-functioning kidneys due to pelviureteric junction (PUJ) obstruction, stones, or renal masses. This study intended to fill that gap by highlighting the most effec- tive and safest ligation method, improving clinical decision-making in resource-constrained settings, and potentially reducing operative time, blood loss, and complication rates. The objective of this study was to compare the efficacy and safety of suturing, Ligaclips, and Hem-o-Lok clips in laparo-scopic nephrectomy.

METHODOLOGY

This retrospective cohort study was conducted in accor-dance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The research was carried out at the Department of Urology, Institute of Kidney Disease, Peshawar, Pakistan, from January 2020 to December 2024. Data were retrieved from institutional urology records spanning from January 2020 to December 2024. Ethical approval for the study was obtained from the relevant Institutional Review Board (Approval No. 2836; dated 19 August 2025). As part of standard clinical practice at the institute, patients had provided informed consent allowing the use of their anonymised medical records for research purposes.

The study population comprised patients aged 15 to 60 years who had undergone laparoscopic nephrectomy due to non-functioning kidneys, with aetiologies including PUJ obstruction, renal calculi, or renal masses. A total of 200 cases that met the inclusion criteria were selected and categorised into three groups based on the type of ligation method used. Patients were excluded if they had docu-mented bleeding disorders or coagulopathies, incomplete surgical records or missing outcome data, conversions to open surgery for reasons unrelated to haemostatic failure. Patients who underwent simultaneous bilateral neph-rectomy were excluded to maintain procedural uniformity and to avoid confounding due to increased operative complexity and higher complication risk. Because simul-taneous bilateral nephrectomy represents a distinct surgical procedure with different operative characteristics and risk pro-files, these cases were not included in the present analysis. Eligible participants were identified through the hospital’s surgical database using specific procedural codes for laparo-scopic nephrectomy.

A formal sample size calculation was performed using the pwr package in R software 4.3.3. The calculation was based on a one-way ANOVA for three groups, assuming a medium effect size (Cohen’s f = 0.25), a significance level (α) of 0.05, and 80% power. The estimated sample size required was 159 participants (approximately 53 per group) to detect a statistically significant difference.

All procedures were performed under general anaesthesia with endotracheal intubation. Patients were positioned in the lateral decubitus position, and pneumoperitoneum was established using the Veress needle or the open technique. Three to four laparoscopic ports were placed under direct vision. After mobilisation of the colon, the renal hilum was carefully dissected to expose the renal artery and vein. Vascular control was achieved using one of three ligation methods, which served as the primary intervention groups in this study. In the suturing group, intracorporeal knot tying with non-absorbable sutures (e.g., 2-0 silk or polypropylene) was used to secure the vessels. In the Ligaclips group, multiple titanium clips were applied across the artery and vein, followed by division between the clips. In the Hem-o-Lok group, polymer locking clips were used to ensure secure placement proximal to the vascular origin before transection. Following vascular ligation, the ureter was clipped and divided. The kidney was then mobilised and retrieved using an endoscopic bag through a slightly extended port site. Haemostasis was confirmed, and a drain was placed when indicated. All port sites were inspected and closed appro-priately. Postoperative care included pain management, intravenous fluids, early ambulation, and monitoring of vital signs, urine output, and drain output. Patients were discharged once they achieved clinical stability and tolerated oral intake. The ligature method was selected based on surgeon preference and case-specific intraoperative considerations.

Data were collected, including age (years), gender, HTN status, diagnosis, diabetes mellitus (DM), and type of nephrectomy. HTN was recorded as yes if the patient had a documented diagnosis of HTN, defined as a systolic blood pressure consistently at or above 140 mmHg and/or a diastolic pressure at or above 90 mmHg on two separate clinical visits; otherwise, it was recorded as no. Diagnosis was categorised as either masses for patients undergoing nephrectomy due to renal tumours, or non-functional kidney for those with confirmed loss of renal function. DM was recorded as yes if the patient had a random blood sugar (RBS) level above 200 mg/dL or a physician-documented diagnosis of diabetes; otherwise, it was marked as no. The type of nephrectomy was classified as radical nephrectomy when the entire kidney and surrounding tissues were removed, or as simple nephrectomy when only the kidney was removed without adjacent structures.

The study outcomes were assessed to evaluate both the efficacy and safety of the different vascular ligation methods. The primary outcomes included ligature slippage, defined as any loosening or displacement of the suture, titanium clip, or Hem-o-Lok clip that compromised vessel closure, which was noted intraoperatively by direct visual inspection and the need for reinforcement, and mean operative time, recorded in minutes from skin incision to completion of wound closure. Secondary outcomes focused on patient safety and included intraoperative blood loss (measured in millilitres using suction canisters and surgical sponges), blood transfusion require-ment, conversion to open surgery due to haemostatic failure, postoperative haemorrhagic complications, injury to surround-ing structures, and length of hospital stay (days).

Table I: Baseline demographic and clinical characteristics of patients by vascular ligation method.
 

Characteristics	Hem-o-Lok clips n = 74	Ligaclips n = 73	Suturing n = 53	p-values
Age (years)	34.0 (28.0, 47.0)	41.0 (29.0, 52.0)	41.0 (30.0, 51.0)	0.25
Gender	-	-	-	0.40
Female	41 (55.41)	33 (45.21)	29 (54.72)	-
Male	33 (44.59)	40 (54.79)	24 (45.28)	-
HTN	-	-	-	0.37
No	45 (60.81)	52 (71.23)	33 (62.26)	-
Yes	29 (39.19)	21 (28.77)	20 (37.74)	-
Diagnosis	-	-	-	0.18
Masses	29 (39.19)	37 (50.68)	29 (54.72)	-
NFK	45 (60.81)	36 (49.32)	24 (45.28)	-
Diabetes	-	-	-	0.29
No	59 (79.73)	65 (89.04)	45 (84.91)	-
Yes	15 (20.27)	8 (10.96)	8 (15.09)	-
Nephrectomy	-	-	-	0.09
Radical	29 (39.19)	37 (50.68)	31 (58.49)	-
Simple	45 (60.81)	36 (49.32)	22 (41.51)
Median (IQR), n (%); Kruskal–Wallis rank-sum test; Pearson's chi-squared test. NFK, non-functional kidney.

Table II: Comparison of intraoperative and postoperative outcomes by vascular ligation method.

Characteristics	Hem-o-Lok clips (n = 74)	Ligaclips (n = 73)	Suturing (n = 53)	p-values
Haemoglobin reduction (g/dL), mean ± SD	0.70 ± 0.30	1.00 ± 0.20	1.20 ± 0.30	<0.001*
Ligature slippage, n (%)	-	-	-	0.56
No	72 (97.30)	69 (94.52)	52 (98.11)	-
Yes	2 (2.70)	4 (5.48)	1 (1.89)	-
Postoperative bleeding complications, n (%)	-	-	-	0.16
No	73 (98.65)	71 (97.26)	49 (92.45)	-
Yes	1 (1.35)	2 (2.74)	4 (7.55)	-
Length of hospital stay (days), median (IQR)	4.0 (3.0–4.0)	4.0(3.0–5.0)	4.0 (4.0–5.0)	0.03**
Injury to surrounding structures, n (%)	6 (8.11)	6 (8.22)	2 (3.77)	0.57
Need for transfusion, n (%)	1 (1.35)	2 (2.74)	0 (0.00)	0.63
Conversion to open surgery, n (%)	0 (0.00)	7 (9.59)	0 (0.00)	<0.001
*ANOVA test, **Kruskal-Wallis rank-sum test; Fisher’s exact test.

Table III: Multivariable linear regression analysis of predictors of haemoglobin reduction and length of hospital stay (days).

Predictors	Category	Haemoglobin reduction (estimate, 95% CI)	p-values	Hospital stay (estimate, 95% CI)	p-values
Groups	Hem-o-Lok (reference)	–	–	–	–
	Ligaclips	0.219 (0.185 to 0.253)	<0.001	0.213 (-0.118 to 0.544)	0.205
	Suturing	0.431 (0.394 to 0.469)	<0.001	0.475 (0.117 to 0.833)	0.010
Age	Median (IQR)	0.001 (-0.0005 to 0.0028)	0.266	-0.002 (-0.013 to 0.009)	0.700
Gender	Male (reference)	–	–	–	–
	Female	-0.028 (-0.058 to 0.001)	0.059	0.076 (-0.203 to 0.355)	0.595
HTN	No (reference)	–	–	–	–
	Yes	0.007 (-0.025 to 0.038)	0.680	-0.130 (-0.432 to 0.172)	0.393
Diabetes	No (reference)	–	–	–	–
	Yes	0.003 (-0.037 to 0.044)	0.868	-0.230 (-0.615 to 0.155)	0.243
Diagnosis	Masses (reference)	–	–	–	–
	NFK	-0.236 (-0.342 to -0.129)	<0.001	0.494 (-0.511 to 1.498)	0.337
Nephrectomy	Simple (reference)	–	–	–	–
	Radical	0.221 (0.115 to 0.326)	<0.001	0.573 (-0.435 to 1.581)	0.262

Table IV: Multivariable logistic regression analysis of postoperative complications following nephrectomy.

Variables	Postoperative bleeding OR (95% CI)	p-values	Ligature slippage OR (95% CI)	p-values	Need of transfusion OR (95% CI)	p-values	Injury to structure OR (95% CI)	p-values
Group (reference: suturing)
Ligaclips	0.30 (0.04–1.73)	0.197	4.63 (0.55–108.47)	0.219	2.43×108 (NA–Inf)	0.998	3.34 (0.65–26.25)	0.182
Hem-o-Lok clips	0.12 (0.01–1.02)	0.087	1.76 (0.14–43.60)	0.669	1.54×108 (NA–Inf)	0.998	2.43 (0.45–19.22)	0.332
Age (years)	1.03 (0.96–1.10)	0.438	1.03 (0.96–1.11)	0.438	0.97 (0.86–1.05)	0.466	1.00 (0.95–1.05)	0.971
Gender (female)	2.69 (0.53–20.37)	0.264	4.98 (0.75–99.20)	0.155	2.60×10⁻9 (NA–Inf)	0.998	1.06 (0.31–3.80)	0.921
HTN (yes)	0.53 (0.06–2.93)	0.497	0.30 (0.01–2.17)	0.300	0.68 (0.03–9.19)	0.773	0.72 (0.17–2.68)	0.635
Diabetes (yes)	8.24×10⁻8 (NA–2.80×1066)	0.993	6.71 (1.02–50.68)	0.046	5.01×10⁻9 (NA–Inf)	0.999	8.38 (2.29–33.47)	0.002
Diagnosis (NFK)	0.39 (0.00–18.11)	0.683	0.09 (0.00–233.55)	0.802	0.13 (0.00–Inf)	1.000	0.20 (0.00–44.48)	0.738
Nephrectomy (simple)	4.98 (0.10–523.09)	0.493	3.14 (0.00–17630.60)	0.904	1.68×10⁻8 (0.00–Inf)	1.000	0.86 (0.00–365.97)	0.976

Clinical information was systematically collected from patient charts, operative reports, and postoperative follow-up notes using a structured data abstraction form. To reduce selection bias, all consecutive eligible patients during the study period were included. Clinical information was systematically extrac-ted from patient charts, operative reports, and postoperative follow-up records using a structured data abstraction form. Data extraction was performed independently by two investi-gators to ensure accuracy and consistency. Any discrepancies were resolved through consensus review of the original medical records. Potential confounding factors were addressed by comparing baseline clinical and demographic charac-teristics across the different ligation groups.

Data were analysed using R software version 4.3.3. Conti-nuous variables, including age, haemoglobin reduction, and length of hospital stay, were summarised as mean ± standard deviation (SD), while categorical variables were reported as frequencies and percentages. Normality of continuous data was assessed using the Shapiro-Wilk test. For comparisons of demographic characteristics, baseline parameters, and outcomes across the three ligature groups (Hem-o-Lok clips, Ligaclips, and suturing), one-way analysis of variance (ANOVA) or the Kruskal–Wallis test was used for continuous variables, whereas the chi-square test or Fisher's exact test was used for categorical variables, as appropriate. Multivariable logistic regression was used for binary outcomes, and linear regression for continuous outcomes, adjusting for age, gender, HTN, diabetes, diagnosis, and type of nephrectomy. Model assumptions were checked, and a p-value of <0.05 was considered statistically significant.

RESULTS

A total of 200 cases were included in the study: 53 in the suturing group, 74 in the Ligaclips group, and 73 in the Hem-o-Lok group. The distribution of the variables was assessed for normality using the Shapiro-Wilk test. Age (W = 0.954, p <0.001) and hospital stay duration (W = 0.908, p <0.001) were not normally distributed, whereas the change in haemoglobin levels followed a normal distribution (W = 0.992, p = 0.38).

Baseline characteristics were not different across the groups. Age (p = 0.25), gender (p = 0.40), HTN (p = 0.37), diabetes (p = 0.29), indication for nephrectomy (masses vs. NFK, p = 0.18), and type of nephrectomy (radical vs. simple, p = 0.09) did not differ significantly (Table I).

Haemoglobin reduction differed significantly across groups, being lowest with Hem-o-Lok clips (0.70 ± 0.30 g/dL), higher with Ligaclips (1.00 ± 0.20 g/dL), and highest with suturing (1.20 ± 0.30 g/dL; p <0.001). Hospital stay was also significantly different, with patients in the suturing group having a slightly longer median stay (4.0 [4.0–5.0] days) compared to those in the Hem-o-Lok and Ligaclips groups (both 4.0 [3.0–4.0] and 4.0 [3.0–5.0], respectively; p = 0.03). Conversion to open surgery occurred only in the Liga- clips group (9.6%), with none in the Hem-o-Lok or suturing groups (p <0.001). Other outcomes did not differ signifi-cantly between groups: ligature slippage (p = 0.56), postoperative bleeding complications (p = 0.16), injury to surrounding structures (p = 0.57), and need for transfusion (p = 0.63; Table II).

Compared with Hem-o-Lok clips, haemoglobin reduction was significantly higher with Ligaclips (0.219, 95% CI 0.185 to 0.253; p <0.001) and suturing (0.431, 95% CI 0.394 to 0.469; p <0.001). Radical nephrectomy was also associated with a greater haemoglobin reduction (0.221, 95% CI 0.115 to 0.326; p <0.001), whereas a diagnosis of non-functional kidney was associated with a significantly smaller reduction (-0.236, 95% CI -0.342 to -0.129; p <0.001). For hospital stay, suturing was associated with a significantly longer duration than Hem-o-Lok (0.475, 95% CI 0.117 to 0.833; p = 0.010). No significant associations were observed for age, gender, HTN, diabetes, or diagnosis (p >0.05; Table III).

In multivariable logistic regression, most predictors were not significantly associated with postoperative complications. For ligature slippage, diabetes was the only significant factor, with diabetic patients showing higher odds than non-diabetic patients (OR 6.71, 95% CI 1.02-50.68; p = 0.046). Similarly, diabetes was strongly associated with an increased risk of injury to surrounding structures (OR 8.38, 95% CI 2.29- 33.47; p = 0.002). No significant associations were observed between group type (Hem-o-Lok or Ligaclips versus sutur-ing), age, gender, HTN, diagnosis, or type of nephrectomy and postoperative bleeding, transfusion requirement, or other complications (all p >0.05; Table IV).

DISCUSSION

This study showed that Hem-o-Lok clips provided the most reliable and safe method of ligation during laparoscopic nephrectomy. Patients ligated with Hem-o-Lok clips had the smallest reduction in haemoglobin, a shorter duration of hospital stay, and no cases requiring conversion to open surgery. In contrast, the use of Ligaclips was associated with significantly greater reduction in haemoglobin and a 9.6% conversion rate, while suturing was associated with greater intraoperative blood loss and a longer hospital stay. Rates of postoperative complications—including bleeding, need for transfusion, and injury to adjacent structures—were not different statistically among the groups. Diabetes was an independent predictor of ligature slippage and vascular injury.

The differences observed between the ligation techniques can be attributed to their distinct biomechanical and tech-nical properties. The locking mechanism of Hem-o-Lok clips ensures firm engagement with the vessel wall, thereby reducing the risk of slippage and limiting intraoperative blood loss.^12,13 Ligaclips, while simple and quick to apply, lack comparable locking stability, which may explain the higher rate of conversion to open surgery.¹⁴ Suturing, although regarded as a reliable method, is technically more demanding, prolongs operative time, and can cause greater tissue trauma, resulting in inc-reased haemoglobin reduction and extended hospitalisation.¹⁵ The association of diabetes with ligature slippage and vascular injury likely reflects compromised vascular integrity and im-paired tissue healing in these patients, making secure haemo-stasis more difficult to achieve.^16,17

The current findings are consistent with previous large clinical series on the safety of Hem-o-Lok clips. In a multi-institutional retrospective review from the early 2000s, Ponsky et al. reported no instances of clip failure when Hem-o-Lok clips were correctly applied, establishing their reliability for renal vascular control.⁸ Similarly, the present results demonstrate low complication and conversion rates with Hem-o-Lok use, reinforcing this safety profile. Moreover, this study adds procedure-specific evidence by showing that Hem-o-Lok clips are associated with reduced intraoperative blood loss and shorter hospital stays, further supporting their role as a secure and effective option for vascular control in laparoscopic nephrectomy.

Gercek et al. compared Hem-o-Lok clips with endovascular staplers and found no significant differences in complication rates, conversion to open surgery, transfusion requirements, or length of hospitalisation.¹⁸ However, they reported that Hem-o-Lok use was associated with longer operative time and greater estimated intraoperative blood loss.¹⁸ These findings differ from the current study’s results, where Hem-o-Lok application was linked to less haemoglobin reduction and a shorter hospital stay. Several factors may explain this discrepancy. Gercek et al. used staplers as the comparator, whereas this study assessed Hem-o-Lok against Ligaclips and suturing. Staplers allow simultaneous tissue division and staple-sealing, which has been reported to shorten operative time and reduce immediate bleeding compared with clip application. Differences in patient characteristics, such as the proportion of partial versus radical nephrectomies, tumour complexity, or emergency versus elective cases, may influence bleeding risk.¹⁹ Surgeon’s experience and technical variability in clip placement may affect outcomes, with staplers sometimes preferred for larger vascular pedicles to expedite control.²⁰ Outcome measures also differed, as Gercek et al. used estimated blood loss, whereas the present study assessed changes in haemoglobin levels. Furthermore, the timing of postoperative haemoglobin measurement may also have influenced the results.

Zheng et al. evaluated a hybrid technique in partial nephrec-tomy using a monolayer suture reinforced with a Hem-o-Lok clip, which demonstrated reduced intraoperative bleeding and shorter warm ischaemia time compared with traditional double-layer suturing, without increasing complication rates.¹⁵ Their findings underscore two practical points also reflected in this data: first, Hem-o-Lok clips can serve as a valuable adjunct to standard haemostatic methods rather than functioning solely as a replacement; and second, integrating secure vascular control with meticulous parenchymal repair may help minimise blood loss while preserving renal function. Although Zheng et al. focused on partial nephrectomy, their findings complement those of the present nephrectomy series, suggesting that Hem-o-Lok clips may have broad applicability across renal surgeries when used in an appropriate surgical context.

The findings of the present study have practical implications for urologists performing laparoscopic nephrectomy. Reliable vascular control is essential for minimising intraoperative blood loss and avoiding conversion to open surgery. Based on the results, Hem-o-Lok clips may represent a useful option for achieving secure vascular ligation, particularly in centres seeking efficient and reproducible techniques for laparoscopic renal surgery.

The current results must be interpreted in light of several important limitations. First, this was not a randomised controlled trial, and although baseline demographic and clinical characteristics were broadly comparable across groups, the non-randomised design introduces the possibility of selection bias. Surgeons may have chosen a particular ligation technique based on intraoperative factors such as vessel size, tissue quality, or perceived bleeding risk, which could have influenced outcomes independent of the method itself. Additionally, unmeasured confounders—including variations in surgical expertise, subtle differences in patient comorbidities, or intraoperative decision-making—may have contributed to the observed differences between groups. Second, although the sample size was sufficient to demons-trate statistically significant differences in common outcomes such as haemoglobin reduction and hospital stay, it may not have been large enough to adequately evaluate rare but clinically significant complications. Events such as clip migra-tion, delayed haemorrhage, or late vascular complications occur infrequently but can have serious consequences. Detecting these outcomes requires much larger multicentre datasets with extended follow-up, which were beyond the scope of this study.

Third, this study did not assess cost-effectiveness, which is an increasingly important factor in surgical decision-making. While Hem-o-Lok clips were shown to provide reliable vascular control with favourable clinical outcomes, their relative expense compared to alternatives such as suturing or metallic clips was not analysed. In high-resource settings, the clinical advantages of Hem-o-Lok clips may justify their use; however, in resource-limited settings, the balance between cost and benefit is a critical consideration. A formal economic analysis, taking into account device cost, ope-rative time, hospital stay, and complication rates, would provide valuable insight for policymakers and surgical teams when selecting the optimal method of vascular control.

Finally, this study was conducted at a single institution, which may limit generalisability. Local protocols, surgical training, and case selection may differ from those in other centres, and the results may not fully translate to broader clinical practice.

Future multicentre randomised trials incorporating larger sample sizes, standardised surgical protocols, extended follow-up, and cost-effectiveness evaluations are warranted to validate these findings and strengthen their generalis-ability. Comparative analysis of cost-effectiveness between Hem-o-Lok clips, staplers, and suturing techniques would be particularly important in informing practice, especially in resource-constrained settings. Extended follow-up is also essential to assess the long-term effectiveness of vascular control and the preservation of renal function.

CONCLUSION

Within the limitations of this retrospective cohort study, Hem-o-Lok clips appeared to be a reliable and safe option for vascular ligation in laparoscopic nephrectomy. Compared with Ligaclips and intracorporeal suturing, their use was associated with a smaller reduction in haemoglobin, shorter hospital stay, and no observed conversions to open surgery. In contrast, overall rates of postoperative complications—such as bleeding, transfusion, or injury to adjacent structures—were similar across groups. Diabetes was noted as an inde-pendent predictor of ligature slippage and vascular injury. These findings should be interpreted cautiously, and further prospective or randomised studies are needed to confirm these observations.

ETHICAL APPROVAL:
Ethical approval for this study was obtained from the relevant Institutional Review Board of Hayatabad Medical Complex, Peshawar, Pakistan (Approval No. 2836; dated 19 August 2025). All procedures were conducted in accordance with the ethical standards of the institution and the principles of the 1964 Declaration of Helsinki and its subsequent amendments.

PATIENTS’ CONSENT:
Informed consent was obtained from all individual participants included in the study for the use of anonymised medical records for research purposes.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTIONS:
AN, MW: Data acquisition, drafting, and final approval.
AK: Conception, drafting, and final approval.
MSH: Data interpretation, critical revision, and final approval.
AUH: Data analysis, drafting, final approval, and agreement to be accountable for all aspects of the work.
All authors approved the final version of the manuscript to be published.

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