腹腔镜和手助腹腔镜活体供肾切取术

作为终末期肾病的有效治疗方法,活体供肾肾移植术有了很大发展,其中腹腔镜活体取肾术因创伤小、术后疼痛程度轻、供者恢复快、住院时间短等优点,迅速在国外许多移植中心推广应用,但腹腔镜活体取肾术亦有其局限性,如热缺血时间长,供者须面对较大的手术风险,对术者的手术操作技巧亦有很大要求;而手助腹腔镜活体供肾切取术因术者一只手伸入到手术区域,增加了左手触诊与协助手术操作的灵活性,有益于产生三维立体感,降低了手术难度,具有较大的发展前景,值得推广应用.     

"Deviceless" hand-assisted laparoscopic donor nephrectomy

Hand-assisted laparoscopic nephrectomy (HLN) in living donors is a minimally invasive surgical modality that uses classic laparoscopic techniques combined with the surgeon's hand as a support tool during renal dissection. We describe our experience with 14 donors undergoing HLN with a novel “deviceless” technique (DL-HLN). We used a midline or a paramedian incision. The first 10-mm trocar (camera) was inserted near the umbilicus and another 10-mm trocar placed under laparoscopic vision at the level of the anterior axillary line above the iliac crest. DL-HLN was performed in 14 patients (11 women and 3 men) of overall mean age of 40 years (range = 33-60). Left nephrectomy was performed in all cases. Mean surgical time was 105 minutes (range = 60-150). Estimated blood loss was 50 to 800 mL (mean = 200 mL). Mean warm ischemia time was 3.5 minutes (range = 2-11). Mean hospital stay was 4 days (range = 3-6). In one case, uncontrollable hemorrhage developed due to a renal vein lesion at the level of the adrenal vein outlet, requiring conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.9 to 2.6 mg/dL (mean = 1.6). We used no device in our technique. The pneumoperitoneum was maintained by the sealing effect of the muscular fascia around the surgeon's wrist. Moreover, the kidney was removed through the hand port without an Endobag. Our modified HLN technique avoids the use of costly disposables and offers the advantages of a smaller incision.     

Laparoscopic and hand-assisted laparoscopic live donor nephrectomy.

Renal grafts from living donors represent an important source of organs, particularly for young patients with chronic renal failure. Laparoscopic donor nephrectomy is a relatively new technique, which has the potential to increase the pool of available kidney grafts by removing some disincentives to live donation. The technique used for left kidney donation at our center, the first to introduce laparoscopic live donor nephrectomy in Italy, is described in this report. To further reduce warm ischemia time, the kidney is preloaded inside the extraction bag and 2 staplers are used to transect the renal artery and vein. The spread of the new technique in our country and in the rest of Europe is likely to raise the issue of training in laparoscopic surgery for transplant surgeons.     

Comparison of laparoscopic versus hand-assisted live donor nephrectomy

BACKGROUND: The aim of the present study was to compare hand-assisted laparoscopic live donor nephrectomy with the classic laparoscopic method, using meta-analytical techniques. METHODS: A literature search was performed for studies comparing hand-assisted laparoscopic nephrectomy with classic laparoscopic nephrectomy for live kidney donation between 1999 and 2005. The following end points were evaluated: operative time, warm ischemia time, intraoperative adverse events, donor and recipient postoperative complications, and length of hospital stay. RESULTS: Nine comparative studies matched the selection criteria, reporting on 376 patients, of whom 202 (53.7%) had hand-assisted laparoscopic nephrectomy and 174 (46.3%) had the classic laparoscopic technique. Conversion to open surgery was 2.97% in the hand-assisted group and 4.60% in the laparoscopic group (P=0.35). Total operative and warm ischemia times were significantly shorter for hand-assisted laparoscopy by 30.03 minutes (P=0.02) and 1.14 minutes (P<0.001), respectively. The intraoperative blood loss was less for the hand-assisted laparoscopy group by 34.16 mL (P=0.008), although intraoperative (3.46% vs. 7.47%; P=0.24) and postoperative (5.94% vs. 10.34%; P=0.30) donor complications and recipient complications (including delayed graft function and primary nonfunction, 8.41% vs. 7.42%; P=0.32) were similar between the hand-assisted and laparoscopic groups. CONCLUSION: Hand-assisted laparoscopic nephrectomy appeared to have the same donor and recipient complication rate with standard laparoscopy but offered substantial advantages in terms of shortened operative and warm ischemia time as well as decreased intraoperative bleeding.     

Telementoring facilitates independent hand-assisted laparoscopic living donor nephrectomy

Laparoscopic living donor nephrectomy is a major advance but a challenging procedure to learn even after laparoscopic training. It requires significant previous training in both laparoscopic and transplant surgery. Telementoring has been shown to reduce the laparoscopic learning curve in other fields. Of six cases of hand-assisted laparoscopic (HAL) living donor nephrectomy at our institution, an on-site mentor supervised the initial two. We present the subsequent four cases as the first documented examples of telementored HAL live donor nephrectomy. Telelink was established with a Comstation (Zydacron, UK) incorporating a Z360 telementoring codec and four ISDN lines (512 kb/s) with time delay of 500 ms for both audio and video. The remote surgeon in Minnesota (USA) could change independently between the laparoscopic and external views. The operating surgeons were able to look at the mentor and converse with him throughout. There were no adverse events in recipients and graft function was excellent. With regards to the telementored group the mean operative time was 240 minutes, the mean warm ischemic time 189 seconds, the mean estimated blood loss 171 mL, and the mean length of hospital stay 3 days. Telementoring for laparoscopic donor nephrectomy is feasible, effective, and likely to aid independent practice by providing continued supervision and reducing the learning period.     

Comparison of open live donor nephrectomy, laparoscopic live donor nephrectomy, and hand-assisted live donor nephrectomy: a cost-minimization analysis

BackgroundLive donor kidney transplantation is the treatment of choice for end-stage renal disease. Open donor nephrectomy (ODN) was the standard until the introduction of the laparoscopic donor nephrectomy (LDN) in 1995. Hand-assisted laparoscopic donor nephrectomy (HALDN) was added shortly thereafter. The laparoscopic techniques are associated with increased operating room times and equipment costs; however, these techniques speed patient return to normal activity. The aim of this study is to evaluate the cost of these techniques.Materials and MethodsA decision analysis model was developed to simulate outcomes for donors undergoing ODN, LDN, and HALDN. Outcomes were simulated from both the institutional perspective (IP) and the societal perspective (SP). Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength.ResultsFrom the IP, ODN is the least costly strategy with a cost of $11,000, while the cost is $15,200 for HALDN and $15,800 for LDN. From the SP, HALDN is the least costly strategy costing $27,800, while the cost for LDN is $29,000 and for ODN is $41,000. In sensitivity analysis, ODN only became the dominant strategy if the days till return to work exceeded 58 in the HALDN strategy. LDN and HALDN were nearly equivalent as the rate of open conversion of LDN approached zero.ConclusionsHALDN is the least costly donor nephrectomy strategy, especially from the SP. The primary determinants of cost in this model are conversion to open and days till return to work.     

Minimal incision living donor nephrectomy compared to the hand-assisted laparoscopic living donor nephrectomy

BACKGROUND: There has been a surge of minimally invasive procedures for living donor nephrectomy. We compared our minimal incision living donor (MILD) nephrectomy to hand-assisted laparoscopic (HAL) living donor nephrectomy METHODS: We conducted a Medline search and compared our first 45 MILD nephrectomies to the data from the University of Michigan (UM), Tulane University (TU), and the University of Chicago (UC). RESULTS: The MILD incision was smaller than the cumulative incisions in the UM and UC groups (8.6, 11 and 10.4 cm, respectively). The operating times were similar in the UM and UC groups (209, 246, and 215 min, respectively). The UM and TU lengths of hospital stay (1.8 and 2.2 days) were shorter than those of the MILD and UC groups (2.5 and 2.8 days). CONCLUSIONS: MILD nephrectomy has results similar to those of HAL living donor nephrectomy. It allows the surgeon with a traditionally trained background to perform a safe, minimally invasive operation without laparoscopic technology.     

Clinical skills acquisition for hand-assisted laparoscopic donor nephrectomy

PURPOSE: The learning curve associated with laparoscopic surgery may be associated with higher patient risk, and in the setting of kidney donation such risk may be unacceptable. We characterize the learning curve for hand-assisted laparoscopic donor nephrectomy in the context of a urology training program, and establish a case volume threshold after which improvements in laparoscopic skill can be demonstrated. MATERIALS AND METHODS: The study included 245 consecutive laparoscopic cases, including 111 donor nephrectomies, performed in 2 (1/2) years to characterize various measures of experience. Documentation of resident involvement in each case was made by a single surgeon and collected prospectively. Outcomes assessed included operative time, blood loss and intraoperative complications. RESULTS: Of the 111 hand-assisted donor nephrectomies the resident was surgeon in 47%. Operative time proved a reliable and sensitive measure of surgeon experience. Increasing laparoscopic experience, as measured by several parameters, was associated with decreasing operative time (each p <0.02). Measurable improvements in laparoscopic skill were realized after participating in 13 (p = 0.007) or serving as surgeon in as few as 6 (p = 0.02) hand-assisted donor nephrectomies. Conversion (2%) and intraoperative complication rates (3%) were low. CONCLUSIONS: Skills for hand-assisted laparoscopic donor nephrectomy can be safely taught in the context of a urology training program independent of resident training level. We documented measurable improvements in laparoscopic skill as gauged by operative time. Our findings provide a basis by which expectations can be set for laparoscopic skill acquisition in the context of a residency program and for the laparoscopically na?ve surgeon.     

Right donor nephrectomy: a comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches

BACKGROUND: We compare the anatomic and functional outcomes of right live-donor nephrectomy (LDN) using either a hand-assisted approach (HALDN) or a pure retroperitoneoscopic approach (RLDN) in two institutions. PATIENTS AND METHODS: Data were recorded prospectively in 59 patients undergoing right LDN using either hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation. RESULTS: Demographics were similar with respect to age (41.1+/-11.5 vs. 44.5+/-8.5 years) and human leukocyte antigen mismatches (2.7+/-1.8 vs. 2.6+/-1.6). Operative times were longer for HALDN (3.4+/-0.7 vs. 3.0+/-0.7 hours, P <0.04), whereas warm ischemia time was shorter (3:55+/-1:47 vs. 4:55+/-0:55 minutes, P <0.001). Length of renal vein and artery were equivalent (2.4/3.4 vs. 2.3/3.2 cm, P =0.5). Complication rates were similar (10% vs. 7%, P =0.5), including conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1) in the HALDN group, and a small parenchymal injury (n=1) and a capsular tear (n=1) in the RLDN group. Donor length of stay and convalescence were similar in both groups (43.5+/-14.1 vs. 45.7+/-25.3 hours, P =0.1; convalescence 23.5+/-5.3 vs. 20.2+/-4.1 days, P =0.5). One-week, 1-month, and 1-year serum creatinine levels were equivalent with both approaches. No grafts were lost in either group. CONCLUSIONS: This study confirms that the HALDN and RLDN techniques can provide kidney grafts with equivalent-length vessels and excellent function.     

手助腹腔镜与开放手术活体供肾取肾术的系统评估

目的 系统评价手助腹腔镜下活体供肾切取术(HLDN)与开放活体供肾切取术(ODN)的安全性及效果。方法 采用计算机互联网检索Pubmed数据库、Sciverse数据库、考克兰图书馆数据库、中国知网、中文科技期刊数据库、中国生物医学文献数据库及万方数据库收录期刊已发表的包含HLDN和ODN两种术式的随机对照试验(RCT)研究。两位研究者根据纳入、排除标准独立筛选文献,应用RevMan 5.2软件进行Meta分析。结果 通过筛选共纳入10个RCT,共1 230例患者。Meta分析结果提示,活体供肾取肾时,与ODN术式比较,HLDN术式的手术时间和热缺血时间较长[合并比值比(OR)值为35.81,95%可信区间(CI)13.98~57.65,P=0.001;合并OR 43.99,95% CI 32.31~55.66,P<0.00001],但HLDN术式的术中出血量较少(合并OR-78.90,95% CI -123.59~-34.22,P=0.0005)、并发症发生率较低(合并OR0.58,95%CI0.39~0.86,P=0.006)、住院时间较短[权重均差(WMD)为-1.15,95%CI-1.40~-0.90,P<0.00001];两组患者的术后进普食时间差异无统计学意义(WMD为-0.11,95%CI -0.67~-0.45,P=0.70)。结论 与ODN术式比较,HLDN术式提高了手术的安全性,降低了手术难度,值得临床推广应用。     

Hand-assisted laparoscopic donor nephrectomy: comparison to pure laparoscopic donor nephrectomy

Hand-assisted laparoscopic surgery is assumed to be easier to learn than the standard approach and simplifies intact kidney removal. Herein we have presented our experience performing hand-assisted laparoscopic donor nephrectomy (HALDN) compared with contemporary pure laparoscopic donor nephrectomy (LDN). We retrospectively analyzed 55 patients who underwent LDN. Among the procedures, 21 were HALDN and 34 were pure LDN. We compared the two groups with regard to operative time, warm ischemic time (WIT), estimated blood loss, conversion rate, postoperative stay, and complications. For the HALDN group, the mean operative time was 191 minutes, WIT varied from 2 to 11 minutes, and bleeding estimates varied from 100 to 4000 mL. The overall complication rate of 28.6% included: vessel injury, urinary leakage, and paralytic ileus. In the LDN group, the mean operative time was 184 minutes, WIT varied from 2 to 10 minutes, and bleeding estimated varied 100 to 3000 mL. Three patients (8.8%) had complications including ureteral obstruction (n = 1) and vessel injury (n = 2). There was no significant difference between the two groups about the procedure and the complications. Our series suggested that HALDN and LDN were similar, with a tendency toward better results in LDN group, which also shows lower costs.     

A comparison of traditional open,minimal-incision donor nephrectomy and laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) and minimal-incision donor nephrectomy (MILD) are less invasive procedures than the traditional open donor nephrectomy approach (ODN). This study compares donor and recipient outcome following those three different procedures. Sixty consecutive donor nephrectomies were studied (n=20 in each group). Intra-operative variables, analgesic requirements, donor recovery, donor/recipient complications and allograft function were recorded prospectively. Operating and first warm ischaemia times were longer for LDN than for ODN and MILD (232±35 vs 121±24 vs 147±27 min, P<0.001; 4±1 vs 2±2 vs 2±1 min, P<0.01). Postoperative morphine requirements were significantly higher after ODN than after MILD and LDN (182±113 vs 86±48 vs 71±45 mg; P<0.0001). There was no episode of delayed graft function in this study. Donors returned to work quicker after LDN than after ODN and MILD (6±2 vs 11±5 vs 10±7; P=0.055). Donor and recipient complication rates and recipient allograft function were comparable. We concluded that MILD and LDN reduce postoperative pain and allow a faster recovery without compromising recipient outcome.     

Renal artery clip dislodgement during hand-assisted laparoscopic living donor nephrectomy

The main reason for conversion in laparoscopic donor nephrectomy (LDN) is peroperative bleeding. One of the advantages of hand-assisted laparoscopic donor nephrectomy (HDLN) is facilitated control in case of bleeding. This report describes two methods to avert conversion in HLDN in the case of abrupt major arterial bleeding. In the first case, during left HLDN the clips placed on the renal artery dislodged, and the surgeon managed to control the bleeding by compressing the focus of the bleeding with his finger. A balloon occlusion catheter was inserted through a groin incision in the aorta and advanced to the origo of the renal artery. Due to control of the hemorrhage, it was possible to close the renal artery stump by laparoscopic suturing, and a conversion was averted. The patient was discharged after 5 days, without signs of damage to the remaining kidney. In the second case, during right HLDN, the clips on the renal artery dislodged during stapling of the renal vein. The bleeding was controlled by finger compression and new clips were placed. The cuff of the artery was long enough to be clipped again. The patient was discharged after 5 days. Graft function was excellent in both cases. Major arterial bleeding can be controlled and managed in hand-assisted laparoscopic surgery. The use of a balloon occlusion catheter is an elegant way to avert conversion.     

Comparison of hand-assisted laparoscopic and open donor nephrectomy in living donors

Objectives:   Although the advent of (hand-assisted) laparoscopic donor nephrectomy has had a positive effect on the donor pool, there is still some concern about the increased morbidity and safety of the laparoscopic donor nephrectomy. The aim of this study was to compare the results of hand-assisted laparoscopic donor nephrectomy (HALD) with open donor nephrectomy (ODN).
Methods:   A single-center non-randomized analysis of 202 living donor kidney transplantations (44 ODN, 158 HALD) between January 1995 and April 2006 was conducted.
Results:   The left kidney was harvested in 75% in the ODN group and 53% in the HALD group ( P  = 0.009). There was no conversion in the HALD group. Mean donor operative time for HALD (174 min) was longer than for ODN (124 min, P  < 0.001). The mean donor hospital stay (4.9 days vs 9.6 days, P  < 0.001) was significantly less for HALD. HALD had lower mean creatinine values at day 7 and 1 month ( P  = 0.001 and P  = 0.002) and lower urological complication rates ( P  = 0.02) compared with ODN. The 1-year graft survival rates of the ODN and the HALD group were 84% and 95% ( P  = 0.006), respectively.
Conclusion:   hand-assisted laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy with potential benefits compared with ODN.     

Prospective randomized comparison of clinical results between hand-assisted laparoscopic and open splenectomies

Background  

Although some studies have compared laparoscopic and hand-assisted laparoscopic splenectomy (HALS) in splenomegaly cases, no study has analyzed the differences between HALS and open splenectomy (OS). This study aimed to compare the HALS and OS techniques in splenomegaly cases.     

Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy

PURPOSE: The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy. MATERIALS AND METHODS: Our first 10 laparoscopic live donor nephrectomies were matched with 40 open donor nephrectomies by gender, age and body mass index. Data were obtained by pain scales, SF-12 survey instruments, questionnaires and chart abstraction. RESULTS: Operative time was longer for the laparoscopic approach (mean 95 versus 215 minutes). However, laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery (mean 2.9 versus 1.8 days), returned sooner to nonstrenuous activity (mean 19.0 versus 9.9 days) and reported less pain 6 weeks postoperatively (mean 2.3 versus 0.6) (p 相似文献