经腹腔及后腹腔腹腔镜活体亲属供肾切取术(附2例报告)

目的：探讨利用腹腔镜及后腹腔镜技术行活体亲属供肾切取的手术方法，评价其安全性、可行性及临床效果。方法：术前对供、受者进行全面的免疫学检查，并对供者作详细的安全性评价，行SPECT检查了解两侧肾功能，DSA了解肾血管的变异情况。分别采用经腹腔及后腹腔的腹腔镜技术行活体亲属供肾切取，并用常规方法移植给受者。结果：2例均成功切取左肾并移植给受者，热缺血时间分别为6min及5min，血管开放后5min及10min供肾泌尿，无排斥反应及与操作技术有关的并发症，供者术后7d及5d出院，生活能自理，无并发症发生。结论：利用腹腔镜技术行活体亲属供肾切取对供者损伤小，术后康复快，对供肾功能无明显影响，技术上安全和可行。     

经腹膜后途径腹腔镜切取亲属活体右侧供肾六例报告

传统的亲属活体供肾切取术需要在供者腰部做一较长切口,术后疼痛明显,住院时间较长,在一定程度上限制了亲属活体供肾的推广。自Clayman等[1]于1991年报道了首例腹腔镜肾切取术以来,国内外许多医学中心采用腹腔镜下活体供肾切取术。我们于2005年4月至2005年7月成功的开展了6例经     

腹腔镜活体供肾切取五例

腹腔镜活体供肾切取术是近年来在肾移植领域发展起来的微创外科技术。2005年3月至8月，我院为5名亲属活体供肾者成功进行了腹腔镜活体供肾切取术，其中1例应用手辅助腹腔镜技术，4例应用纯腹腔镜技术，现报告如下。     

内视镜下小切口亲属活体供肾切取术

目前，亲属活体供。肾移植渐趋广泛，并被人们所接受，常用的亲属活体供。肾切取术式有以下三种：开放式活体供。肾切取术（ODN）、腹腔镜下活体供。肾切取术（LDN）和手辅助腹腔镜活体供肾切取术。许多移植中心采用腹腔镜下活体供肾切取术。最近，我们与韩国YonSei大学Seung Chou Yang教授合作，运用自主开发的手术器械，共对6例活体供肾移植的供者成功地实施了内视镜下小切口活体供。肾切取术，总结报告如下：     

腹腔镜活体亲属供肾切取术临床疗效观察(附5例报告)

目的：总结腹腔镜技术行活体亲属供肾切取术的临床经验，探讨其安全性及临床效果。方法：分别采用经腹腔及经后腹腔途径的腹腔镜技术行活体亲属供肾切取术5例。结果：手术平均用时4h 45min，出血50～1000ml，热缺血时间1min 55s～3min 10s；开放血流后10-30s供肾泌尿，供者术后肾功能正常，7天拆线出院，无手术并发症。结论：与传统手术切取供肾相比，腹腔镜活体亲属供肾切取术使供肾者损伤小，恢复快，且供肾质量仍可得到保障。     

腹腔镜活体供肾切取术10例报告

目的　探讨活体供肾切取新方法。方法　对 10名亲属活体供肾者采用腹腔镜切取供肾 ,供者采用全身麻醉 ,经腹腔途径 ,取右侧卧位 ,在脐旁、剑突下偏右及左腹股沟韧带中点上方1.5cm各开一孔 ,脐旁放入观察镜 ,另两孔为操作孔。供肾经左下腹操作孔的延长切口用手取出。供、受者术后随访 2～ 12个月。结果　供肾切取耗时 (3.6± 0 .6 )h ,热缺血时间平均 4 .5min ;供者术后无并发症发生 ,肾功能正常 ,住院时间 (5± 1)d ,术后 2个月内均恢复正常工作。结论　腹腔镜活体供肾切取术是一种创伤小的供肾切取方法 ,供者术后疼痛轻 ,恢复快。     

3D后腹腔镜下活体供肾切取术的临床分析

目的  总结3D后腹腔镜下活体供肾切取术的经验,并探讨其临床效果和安全性。 方法  收集19例3D后腹腔镜下活体供肾切取术的临床资料。记录手术时间、术中失血量、肾脏热缺血时间、肾动脉长度、肾静脉长度、输尿管长度、切口长度、手术并发症。观察供、受者术后肾功能的情况等。 结果  19例活体供肾切取术均在3D后腹腔镜下顺利完成,无术中改为常规腹腔镜和中转开放者。3D后腹腔镜下活体供肾切取术手术时间80.5～125.2(平均102.3)min;术中出血量40.6～90.4(60.8)ml;肾脏热缺血时间100～230(161)s。供肾动脉长度2.6～3.2(2.9)cm;供肾静脉长度2.2～3.0(2.6)cm;供肾输尿管长度8～13(10)cm;切口长度约5～6 cm,伤口愈合良好;供者术后24 h尿量2 000～2 500 ml;术后3 d查血清肌酐轻度增高1例,术后7 d和1个月复查血清肌酐恢复正常。术后住院时间5～7(6)d。移植手术均获成功,未发生移植肾功能延迟恢复。 结论  3D腹腔镜手术系统可有效提高术中操作的精准性,3D后腹腔镜下活体供肾切取术安全可行。     

后腹腔镜技术活体亲属供肾切取的可行性研究(附10例报告)

目的 :探讨利用后腹腔镜技术行活体亲属供肾切取的安全性和可行性。方法 :在对供受者进行全面的免疫学检查 ,对供者作详细的安全性评价 ,行SPECT检查了解分侧肾功能 ,用DSA了解肾血管的变异情况之后 ,采用后腹腔镜技术对 10例活体亲属供肾进行切取 ,按常规方法移植给受者。结果 :10例均成功切取左肾并移植给受者 ,平均手术时间 (10 2 .6± 19.3)min ,平均术中出血量 (13.0± 9.8)ml,热缺血时间平均 (14 1.8± 72 .1)s,受体血管开放后供肾均泌尿 ,其中 1例患者移植后 1周发生输尿管远端坏死漏尿 ,再次手术后恢复正常。术后无排斥反应及其他与操作技术有关的并发症发生。结论 :利用腹腔镜技术行活体亲属供肾切取对供者损伤小 ,术后恢复快 ,对供肾功能无明显影响 ,技术上安全可行     

亲属活体供肾移植供者的选择和取肾术

1996年以来我院共行亲属活体供肾移植 11例 ,均获得成功。本文就亲属活体供者的选择和取肾术的围手术期处理作一探讨。一、资料与方法1.一般资料 :11例供者均为自愿捐献 ,男 3例 ,女 8例 ,年龄 2 3～ 5 3岁 ,平均 4 4岁 ,无高血压、糖尿病、肾炎及遗传性疾病和肿瘤病史。供受者血缘关系 ,父子 1例 ,母子 6例 ,母女 1例 ,兄弟 2例 ,兄妹 1例。术前供者均行双肾Ｂ型超声波、彩色多普勒、静脉肾盂造影、单光子发射计算机体层摄影 (ＥＣＴ)和肾动脉造影等检查。免疫学检查包括ＡＢＯ血型、淋巴细胞毒交叉配合试验、群体反应性抗体检测和ＨＬＡ配…     

Experience with 247 living related donor nephrectomy cases at a single institution in Japan

There is currently much concern over the morbidity and mortality of donors undergoing nephrectomy for living related renal transplants. Between April, 1970 and July, 1986, 247 cases of living related renal transplants were performed at the Second Department of Surgery, Kyoto Prefectural University of Medicine. The average age of the donors was 50.3±9.7 years, 81 per cent of the donors being parents of the recipients. Minor abnormalities which did not affect the donors suitability were found in 71 cases. Nephrectomies were performed extraperitoneally in all cases. Peri-operative complications, including wound complications in 13 cases, urinary infection in 12 cases and pulmonary complications and arrythmia in 4 cases, were considered to be minor in nature. A variety of renal function tests, carried out two weeks after nephrectomy revealed normal levels, although they had become slightly worse than those estimated pre-operatively. Long-term sequalae in the follow-up period from 18 months to 16 years and 2 months, was studied on 124 donors who answered questionnaires. Currently, there are 5 late deaths, none of which are directly related to the nephrectomy. Of the 124 donors, 85.5 per cent stated that there had been no change in their physical states following surgery. Pain or a feeling of discomfort at the wound site was reported by 10 donors (8.1 per cent) and hypertension was observed only in 3 (2.4 per cent). No major complication directly related to the donor nephrectomy was found, except for one case of incisional hernia. The donor nephrectomy operation thus appeared to be quite safe, and successful long-term sequelae can be obtained if the donor is selected carefully, according to the strict prospective evaluation of medical state and renal functions.     

机器人辅助腹腔镜活体供肾切取术31例报告

目的  评估机器人辅助腹腔镜活体供肾切取术的安全性和有效性。 方法  回顾性分析2013年11月至2015年8月第四军医大学西京医院实施的31例机器人辅助腹腔镜活体供肾切取术的供、受者的临床资料。 结果  31例均顺利完成供肾切取术,手术时间110~190 min,术中出血量20~100 ml,供肾热缺血时间100~160 s,保留肾静脉长度1.8~3.0 cm,肾动脉长度1.4~2.3 cm。2例供肾取出时发生脾脏损伤,行脾脏修补术;1例供者术后出血,经止血、纠正贫血后好转。31例供者术后均随访6个月以上,均未发生远期并发症。31例受者中,1例出现移植肾功能延迟恢复,经治疗后于术后1个月血清肌酐恢复正常。移植肾存活率为100%。 结论  机器人辅助腹腔镜活体供肾切取术具有安全、可靠、创伤小、恢复快、不影响供肾功能等优势,可作为供肾切取有效而安全的手术方式。     

经腹膜后腹腔镜活体供肾切取(附22例报告)

目的  总结经腹膜后腹腔镜活体供肾切取的治疗经验。方法 对2012年1月至2014年5月在中山大学附属第一医院采用经腹膜后腹腔镜活体供肾切取术的22例供者的临床资料进行回顾性分析。手术先采用纯腹腔镜手术方式分离输尿管、肾血管及肾周脂肪, 然后采用腹股沟上内侧平行切口(利用腹侧穿刺口)为取肾切口, 最后在手辅助下离断肾血管并取出肾脏。记录供者手术过程、术后随访情况。结果 取右侧供肾1例, 左侧供肾21例。22例手术过程顺利, 均无中转开放手术, 手术时间(123±31)min。取肾手术切口长度为(7.2±0.5)cm。术中出血15~80 ml, 热缺血时间60~150 s。供肾的肾动脉长度为2.0~3.2 cm, 肾静脉长度为1.0~3.5 cm。随访1~21个月, 术后1 d、1周和1个月后的血清肌酐(Scr)水平分别为(120±57)、(95±25)、(90±21)μmol/L。22例供者中, 术后并发肾窝血肿、伤口愈合不良各1例。术后1周供者疼痛评分0~5分, 术后1个月0~1分。无供者感觉捐肾对总体健康有明显影响, 1例供者觉得对体力有一定影响。结论 在严格选择供体的情况下, 开展经腹膜后腹腔镜活体供肾切取具有良好的安全性。由于其切口较小, 术后疼痛程度轻, 对供者的生存质量影响较小。      

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.     

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1%) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant lver, which was the only postoperative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preoperative screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.     

Therapeutic living donor nephrectomy

Therapeutic living donor nephrectomy is defined as a nephrectomy that is performed as therapy for an underlying medical condition. The patient directly benefits from having their kidney removed, but the kidney is deemed transplantable. The kidney is subsequently used as an allograft for an individual with advanced renal disease. Therapeutic donor nephrectomy can be successfully utilized for a heterogenous cohort of disease processes as both treatment for the donor and to increase the number of suitable organs available for transplantation. We describe four cases of therapeutic donor nephrectomy that were performed at our institution. Of the four cases, two patients elected to undergo therapeutic donor nephrectomy as treatment for loin pain hematuria syndrome; one after blunt abdominal trauma that resulted in complete proximal ureteral avulsion; and the fourth after being diagnosed with a small renal mass. Based on our data presented to the United Network for Organ Sharing Board of Directors (UNOS) in December 2015, living donor evaluation has been made simpler for patients electing to undergo therapeutic donor nephrectomy. UNOS eliminated the requirement for a psychosocial evaluation for these patients. As the organ shortage continues to limit transplantation, therapeutic donor nephrectomy should be considered when appropriate.     

Hand-assisted laparoscopic and open living donor nephrectomy in Korea

BACKGROUND: We compared the results of hand-assisted laparoscopic living donor nephrectomy (LLDN) and conventional open living donor nephrectomy (OLDN). METHODS: The clinical data on 49 hand-assisted LLDN and 21 OLDN on the left side performed at two institutions in Korea from January 2001 to February 2003 were reviewed. Demographic data of donors and recipients were similar in the two groups. RESULTS: There was one conversion to an open procedure due to bleeding in the LLDN group. The median operation times (180 min in LLDN versus 170 min in OLDN) and warm ischemic times (2.5 min in LLDN versus 2.0 min in OLDN) in the two groups were similar. The estimated mean blood loss, duration of hospital stay and complication rate was also similar in the two groups. The LLDN group reported less pain (visual analog scale) postoperatively (4.1 versus 5.3), but this was not significant (P=0.058). The time to oral intake in the LLDN group was significantly longer by an average of 1 day (P=0.001). Return to work was sooner in the LLDN group (4.0 weeks versus 6.0 weeks; P=0.026). The recipient graft function was equivalent between the two groups. Hand-assisted LLDN appears to be a safe and effective alternative to OLDN. CONCLUSION: Our findings suggest that this technique may give the ability provide grafts of similar quality to OLDN, while extending to the donors the advantages of a traditional LLDN procedure.     

腹股沟斜切口在后腹腔镜活体供肾切取术中的临床应用分析

研究腹股沟斜切口在后腹腔镜活体供肾切取术中应用的安全性和有效性。方法回顾性分析2008年5月至2012年3月在烟台毓璜顶医院泌尿外科行后腹腔镜活体供肾切取术的76例供者临床资料,根据供肾取出切口的不同将其分为两组,腹股沟切口组40例供者和腰部切口组36例供者分别采用腹股沟斜切口和腰部切口取出供肾。比较两组供者手术时间、术中出血量、供肾血管长度、住院时间、术后切口并发症发生情况和切口美容满意度。结果腹股沟切口组40例供者手术均成功;腰部切口组33例供者手术成功,3例因肾粘连和肾周脂肪组织较多改开放手术;两组均未发生死亡和严重并发症。两组手术时间和术中出血量差异均无统计学意义（P均＞0.01）。腹股沟切口组供肾热缺血时间为（1．6±1．2）min,短于腰部切口组,差异有统计学意义（t＝5．18,P＜0．01）。腹股沟切口组左、右侧供肾动脉血管长度分别为（2．6±0.4）cm和（3．7±0．3） cm,均长于腰部切口组;腹股沟切口组左、右侧供肾静脉血管长度分别为（3．50±0．40）cm和（1．70±0．23）cm,均长于腰部切口组,差异均有统计学意义（t＝4．75,7．32,76．3,6．45,P均＜0.01）。腹股沟切口组术后需接受镇痛治疗和腰腹部外观不对称的供者比例均低于腰部切口组,切口美容满意度高于腰部切口组,差异有统计学意义（χ2＝12．52,7．41,32.53,P均＜0．01）;腹股沟切口组无供者发生切口膨出,腰部切口组有6例供者发生切口膨出,两组比较差异有统计学意义（P＝0．009）。腹股沟切口组住院时间明显短于腰部切口组（t＝3.42,P＜0．01）。结论采用腹股沟斜切口的后腹腔镜活体供肾切取术能够提高手术安全性,保证最佳供肾血管长度,明显缩短供肾热缺血时间,减少切口并发症,提高供者切口美容满意度,值得临床推广。     

Can right‐sided hand‐assisted retroperitoneoscopic donor nephrectomy be advocated above standard laparoscopic donor nephrectomy: a randomized pilot study

Endoscopic techniques have contributed to early recovery and increased quality of life (QOL) of live kidney donors. However, laparoscopic donor nephrectomy (LDN) may have its limitations, and hand‐assisted retroperitoneoscopic donor nephrectomy (HARP) has been introduced, mainly as a potentially safer alternative. In a randomized fashion, we explored the feasibility and potential benefits of HARP for right‐sided donor nephrectomy in a referral center with longstanding expertise on the standard laparoscopic approach. Forty donors were randomly assigned to either LDN or HARP. Primary outcome was operating time, and secondary outcomes included QOL, complications, pain, morphine requirement, blood loss, warm ischemia time, and hospital stay. Follow‐up time was 1 year. Skin‐to‐skin time did not significantly differ between both groups (162 vs. 158 min, P = 0.98). As compared to LDN, HARP resulted in a shorter warm ischemia time (2.8 vs. 3.9 min, P < 0.001) and increased blood loss (187 vs. 50 ml, P < 0.001). QOL, complication rate, pain, or hospital stay was not significantly different between the groups. Right‐sided HARP is feasible but does not confer clear benefits over standard right‐sided LDN yet. Further studies should explore the value of HARP in difficult cases such as the obese donor and the value of HARP for transplantation centers starting a live kidney donation program (Dutch Trial Register number: NTR3096). Nevertheless, HARP is a valuable addition to the surgical armamentarium in live donor surgery.