Mini incision live donor nephrectomy: an optimal approach for the developing countries

OBJECTIVE: Laparoscopic donor nephrectomy (LD) is rapidly gaining popularity, however, this may not be affordable by donors in many developing countries because of its high cost. We describe our mini flank incision (MD) donor nephrectomy technique and its outcome. METHODS: A 7-10-cm subcostal rib sparing transverse incision was given 2 cm lateral to the tip of the 12th rib, towards the lateral border of rectus muscle. All dissections were performed with help of long retractors and instruments, vessels were transfixed and cut. In last 45 cases, vessels were clipped with Liga or Weck clips. Donors and recipients outcome was analysed. RESULT: From January 2000 to December 2002 a total of 148 patients underwent donor nephrectomy by mini incision technique. Mean patient age was 44.8 +/- 7.3 yr (range 20-70 yr). Nephrectomies were performed in 115 patients on the left side and in 33 cases on the right side. The mean incision length was 9.1 +/- 1.8 cm (range 7-10 cm). Mean operative time was 105 +/- 10.5 min (70-130 min). Mean analgesic (Tramadol) requirement was 205 +/- 52 mg; postoperative hospital stay was 2.2 +/- 0.5 d. Twelve per cent patients developed fever and 4% had superficial wound infection in postoperative period. Three patients required blood transfusion. Mean convalescence period was 22 +/- 2.8 d. CONCLUSION: Extrapleural, extraperitoneal, subcostal mini incisions live donor nephrectomy is a relatively safe procedure with low morbidity. This technique has a shorter hospital stay, early convalescence and better cosmesis. It is cost-effective and is an ideal substitute for the developing country.     

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.     

后腹腔镜下活体供肾切取术的临床应用

目的探讨后腹腔镜下活体供肾切取技术。方法2003年12月至2004年6月通过后腹腔镜途径取活体供肾6例，均取左肾。供受关系为：同胞兄弟姐妹4例，父→子1例，母→子1例。配型情况：1例无错配，2例2点错配，3例3点错配。群体反应性抗体及淋巴细胞毒试验阴性。取侧卧位，用3个穿刺点，经后腹腔游离肾脏，用直线切割器分别切断动脉和静脉，在两个穿刺点之间切6—7cm的切口将肾取出，剪除动静脉上的钉子，灌注液灌注。供肾植于受体右髂窝。常规应用三联免疫抑制剂预防排斥反应。结果6例活体肾移植均获成功。移植肾术后第1天尿量3500—6500ml，平均．5036ml；Cr227-1170μmol／L，平均598μmol／L。术后1个月时Cr平均值为129μmol／L。随访3～9个月肾功正常，均未发生排斥反应。结论后腹腔镜取肾术安全可行，对供体创伤小，但要求有熟练的腹腔镜和肾移植操作技术。     

Laparoscopic live donor nephrectomy: a comparison with the conventional open approach

PURPOSE: Laparoscopic live donor nephrectomy is an emerging technique that has not yet gained widespread acceptance in the transplant community due to perceived technical difficulties. However, the potential advantages of decreasing donor morbidity, decreasing hospital stay and improving convalescence while producing a functional kidney for the recipient may prove to enhance living related renal transplantation. We report our early experience with laparoscopic live donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 50 consecutive laparoscopic nephrectomies performed from October 1998 to May 2000 and compared them with 50 consecutive open donor nephrectomies, which served as historical controls. RESULTS: Donor age, donor sex and number of HLA mismatches did not differ statistically in the 2 groups. In the laparoscopic and open nephrectomy groups mean followup was 109 and 331 days (p = 0.0001), mean operative time was 234 and 208 minutes (p = 0.0068), mean estimated blood loss was 114 and 193 ml (p = 0.0001), and mean hospital stay was 3.5 and 4.7 days (p = 0.0001), respectively. Average renal warm ischemia time was 2.8 minutes in the laparoscopic nephrectomy group. Serum creatinine did not differ statistically in the 2 groups preoperatively or postoperatively at days 1 and 5, and 1 month. The rate of recipient ureteral complications in the laparoscopic and open nephrectomy groups was 2% (1 of 50 cases) and 6% (3 of 50), respectively (not significant). CONCLUSIONS: Laparoscopic live donor nephrectomy is an attractive alternative to open donor nephrectomy. Laparoscopic nephrectomy results in less postoperative discomfort, an improved cosmetic result and more rapid recovery for the donor with equivalent functional results and complications.     

Laparoscopic live donor nephrectomy

Laparoscopic donor nephrectomy offers numerous advantages when compared with the traditional open approach. For the donor, it has resulted in a shorter hospital stay, fewer postoperative analgesic requirements, earlier return to activities of daily living and employment, and decreased financial loss owing to absence from the workforce. For the recipient, the procedure does not adversely impact on allograft function, graft survival, or patient survival.     

腹腔镜活体供肾摘除术

腹腔镜活体供肾摘除术是近几年才在我国许多肾移植中心起步开展的微创取肾手术,该术式有效地增加了活体供肾来源,促进了现阶段我国活体供肾肾脏移植的开展.本文就腹腔镜活体供肾摘除术在国内外的发展现状进行综述.     

Laparoscopic live donor nephrectomy

BACKGROUND: The demand for renal transplants is greater than the available kidneys. Live donation is one way of increasing the supply. Laparoscopic removal of the donor kidney appears to reduce morbidity for the donors. Some who are hesitant because of the morbidity associated with open nephrectomy are willing to consider the laparoscopic donor nephrectomy. METHODS: Laparoscopic donor nephrectomy was offered to all but three donors since the commencement of the programme in 1997. Data were collected both prospectively and retrospectively for the first 120 donors. Venous and arterial anatomy was assessed preoperatively by computed tomographic angiography. RESULTS: All but four donor procedures were completed laparoscopically. Three of these were for bleeding that could not be safely controlled laparoscopically and the fourth was a planned conversion to deal with the renal vessels, in the first right nephrectomy. Two kidneys were lost due to arterial thrombosis and two underwent segmental infarction after the loss of one of two or three separately anastomosed vessels. Three recipients had delayed function and two of them required dialysis postoperatively. Other minor complications occurred but were uncommon. CONCLUSIONS: Laparoscopic live donor nephrectomy is safe for the donor and the transplant kidney. It offers the advantage of decreased morbidity for the donor, with a shorter hospital stay, earlier return to normal activity and, for some, early return to work.     

Laparoscopic live donor nephrectomy

Live donor renal transplantation has many advantages including greater graft and patient survival, shorter waiting periods, improved human leukocyte antigen matching, and less cold ischemia. Until recently, disincentives from the operation, such as prolonged hospitalization, postoperative pain, and significant convalescence, have deterred live donor renal transplantation. This article describes the technique of laparoscopic live donor nephrectomy and briefly reports the results. The procedure has resulted in improved postoperative recovery and shorter convalescence, with no effect on recipient renal function.     

Hand-assisted laparoscopic surgery (HALS) for live donor nephrectomy is more time- and cost-effective than standard laparoscopic nephrectomy

Background: Hand-assisted laparoscopy (HALS) was introduced to increase the safety of living donor nephrectomies. Herein we evaluate the first HALS living donor nephrectomies performed at our center. Methods: Traditional laparoscopic nephrectomies (TLS) (n = 11) and HALS nephrectomies (n = 11) were included in the study. One patient from the TLS group was excluded because the operation was converted to open nephrectomy. We compared the operating times (OT) and warm ischemia times (WIT) for the two procedures and calculated the operating costs. Results: Mean OT was 270 min in the TLS group and 197 min in the HALS group; thus, there was, a significant reduction of 27% with HALS. WIT was 297 sec for the TLS group and 214 sec for the HALS group, for a reduction of 28%. Costs were also lowered for HALS. Conclusion: In addition to shortening both OT and WIT, HALS enhances the safety margin of the procedure, especially during trocar placement. It is further helpful in preventing torsion of the kidney and controlling potential bleedings, as well as during vascular stapling and kidney removal.     

Use of a minimally invasive donor nephrectomy program to select technique for live donor nephrectomy

BACKGROUND: Live donor nephrectomy (LDN) is a major surgical procedure with an accepted low mortality and morbidity. Minimally invasive donor nephrectomy (MIDN) has been shown to decrease the wound morbidity associated with the lumbotomy of the classic open technique. Transplant programs face the challenge of initiating their MIDN programs without jeopardizing the safety of the donor and the graft quality. We present the experience at the University of Calgary after the initiation of a MIDN program, with a preoperative selective approach using the 3 major techniques for LDN. METHODS: From December 2001 to May 2004, 50 consecutive, accepted, live kidney donors were evaluated and chosen to undergo nephrectomy by an open, laparoscopic, or hand-assisted technique. Patients were chosen for a particular technique based on the criteria of vascular anatomy, size of abdominal cavity, previous surgery, and technical implications for the recipient. RESULTS: A total of 15 open, 11 laparoscopic, and 24 hand-assisted nephrectomies were performed. There were no statistically significant differences in sex, age, or body mass index between the groups. There were statistically significant differences in surgical times (P < .001) and in the number of days spent in the hospital (P < .001). All kidneys had primary function. There were 2 conversions in the hand-assisted group and 1 blood transfusion in the open group. Death-censored graft survival was 100% with an observation time of 20 months (SD +/- 9 months; range = 3-32 months). One graft from the hand-assisted group was lost from patient death with functioning graft 8 months after transplant. CONCLUSIONS: The learning curve for MIDN does not necessarily need to impact donor or recipient outcomes. The initiation of an MIDN program can be implemented safely if the cases are selected carefully and the use of the classic open technique is kept as an alternative.     

Laparoscopic live donor nephrectomy: a technical road map

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.