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.     

Hand-assisted laparoscopic donor nephrectomy is safe and results in increased kidney donation

The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 +/- 0.3 and 1.3 +/- 0.8 mg/dL for creatinine, 3.3 +/- 0.8 and 6.7 +/- 3 days for length of stay, and 110.4 +/- 76.9 and 111.6 +/- 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.     

Hand-assisted laparoscopic donor nephrectomy

Background: The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature. Methods: From January to September 2000, ten hand-assisted LDNs of the right kidney were performed. Results: The median operation time was 140 min (range, 120--400 min), and the warm ischemia time was 2.5 min (range, 1--4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes. Conclusions: Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN. apd: 3 April 2001     

活体供肾移植:手助腹腔镜供肾切除优于常规腹腔镜供肾切除

目的　比较活体供肾移植中手助腹腔镜供肾切除 (Hand -assistedlaparoscopicdonornephrectomy ,HALDN)和完全腹腔镜活体供肾切除 (Laparoscopicdonornephrectomy,LDN)以及对供肾者和接受肾移植者的影响。　方法　回顾总结 1996年 10月～ 2 0 0 1年 2月MountSinai医学中心所有LDN和HALDN的病例资料。 1996年 10月开始行LDN手术 ,1999年 6月转而行HALDN手术。　结果　与LDN组相比 ,HALDN组手术时间明显缩短 ( ( 2 11± 7)minvs ( 2 5 7± 5 )min ,P <0 0 5 ) ,术中出血量明显减少 ( ( 12 2± 17)mlvs ( 2 86± 33)ml,P <0 0 5 ) ,肾脏热缺血时间明显缩短 ( ( 10 6± 6 )svs ( 2 5 7± 8)s,P <0 0 5 ) ,术后淋巴漏和血栓形成发生率 ( 0 %vs 13 7% ( 16例 ) ;2 5 % ( 2例 )vs 6 8% ( 8例 ) ,P <0 0 5 )明显下降。　结论　在活体供肾移植中 ,HALDN似乎优于LDN ,但尚需要前瞻性对照研究予以进一步证实。     

Techniques in laparoscopic donor nephrectomy

What's known on the subject? and What does the study add? Innovations in laparoscopic surgery have provided transplant surgeons with a range of techniques as well as a vast array of minimally invasive instruments. Whilst randomized control trials have compared open and laparoscopic donor nephrectomy, there is a paucity of high quality data comparing different laparoscopic approaches. This article summarizes the main techniques of laparoscopic donor nephrectomy currently in use and reviews the evidence available for each. In addition, controversial aspects of donor nephrectomy are examined, including the technological advances applicable to this operation. Increasing numbers of living donor kidney transplants are being performed worldwide, and the majority of donor operations are now laparoscopic. Transperitoneal ‘pure’ and hand‐assisted laparoscopic donor nephrectomy are the two most commonly performed procedures, although retroperitoneal approaches are advocated by some centres. Controversy persists with respect to the technical aspects of donor nephrectomy, including both the approach and the method of ligation of the hilar vessels. More recently, robot‐assisted, laparo‐endoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) ‐assisted donor nephrectomy have also been performed, further increasing the number of options available, but creating uncertainty as to the ideal approach.     

Rhabdomyolysis after laparoscopic donor nephrectomy

Rhabdomyolysis is a postoperative complication that may result in acute renal failure owing to excessive myoglobinuria. After uncomplicated laparoscopic left transperitoneal donor nephrectomy, a 32-year-old man developed anuric acute renal failure secondary to postoperative rhabdomyolysis that required intermittent hemodialysis for 2 weeks. The presumed risk factors in this case were the patient's high body mass index, intraoperative flank position with flexion, a solitary kidney, and the duration of surgery. Our current surgical technique has been modified to drop the kidney bridge early, immediately after visualization of the hilum.     

Hand-assisted laparoscopic live donor nephrectomy

BACKGROUND: Hand-assisted laparoscopic donor nephrectomy (HLDN) may have advantages over laparoscopic donor nephrectomy, such as shorter learning curve, operation and warm ischaemia times. The aim of this study was to evaluate the feasibility and safety of HLDN. METHODS: Between January 2000 and October 2002, 50 consecutive HLDN procedures were performed through a low transverse abdominal incision, 23 right sided and 27 left sided. RESULTS: The median age of the donors was 44 years. No HLDN required conversion to an open procedure. The median operating time for HLDN was 153 min. The median warm ischaemia time was 3 (range 1.0-4.5) min and the median blood loss was 50 (range 20-500) ml in both left- and right-sided procedures. Eight patients suffered ten minor complications during their admission. The duration of hospital stay was 5 days for donors. Three recipients developed graft failure owing to acute rejection, renal vein thrombosis and ischaemic necrosis. CONCLUSION: Both left- and right-sided HLDN procedures were feasible and safe through a low transverse abdominal incision.     

Early experience with robotically assisted laparoscopic donor nephrectomy

The da Vinci robotic system became available at our institution in late August 2000. We decided to use this system to perform robotically assisted laparoscopic donor nephrectomies. A prospective study was conducted of 10 consecutive patients who underwent robotically assisted laparoscopic donor nephrectomy between January and May 2001. The mean operative time was 166 minutes. The mean hospital stay was 1.8 days. The need for parenteral pain medication was limited to the first postoperative day. All kidneys were transplanted successfully; no rejections occurred. This early experience suggests that the results of robotically assisted laparoscopic donor nephrectomy are similar to those of laparoscopic donor nephrectomy. We believe that robotic surgery, which enables regaining of the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, allows us to perform the donor nephrectomy with greater precision, confidence, and comfort.     

Hand-assisted transperitoneal laparoscopic living donor nephrectomy

OBJECTIVE: We introduced and evaluated the advantages and disadvantages of the hand-assisted transperitoneal laparoscopic technique for living donor nephrectomy. MATERIALS AND METHODS: In December 2001, we started using the technique of hand-assisted transperitoneal laparoscopic living donor nephrectomy (HLDN) in 10 cases. The procedure utilizes a hand-assisted device to increase safety and control of the laparoscopic technique. RESULTS: Only left nephrectomy was performed. The mean total operating and the warm ischemia times were 130 minutes and 3.0 minutes, respectively. Average lengths of renal artery and vein were 1.95 cm and 2.8 cm, respectively. There were no intraoperative or postoperative complications. CONCLUSIONS: HLDN is an easier procedure than the traditional laparoscopic living donor nephrectomy and can greatly mitigate the learning curve. HLDN has shortened warm ischemia time and operating time. It is also good for trocar placement, prevention of torsion of the kidney, control of potential bleeding at the final stage of vascular stapling, and kidney removal. Therefore, HLDN is a promising method for living donor nephrectomy.     

Visual impairment after laparoscopic donor nephrectomy

Loss of vision after surgery is rare and has never been reported after a laparoscopic procedure. We describe a case of visual deficits secondary to posterior ischemic optic neuropathy after a laparoscopic donor nephrectomy. The potential etiologies of postoperative visual loss are reviewed, and recommendations for avoiding this complication are discussed.     

Chylous ascites after laparoscopic donor nephrectomy

Laparoscopic living-donor nephrectomy has decreased the disincentives to live renal donation with a risk of complications similar to that of open donor nephrectomy. We report a patient who developed chylous ascites after an otherwise-uneventful laparoscopic donor nephrectomy. On MEDLINE search, we could find only two other cases with similar complications. This condition has the potential to cause significant morbidity in the donor, which may reduce the advantages of the minimally invasive approach. We suggest that meticulous dissection of the renal hilum and clipping of lymphatic tissue around the renal vessels could prevent this untoward complication.     

Terminal hand-assist for laparoscopic donor nephrectomy

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices. METHOD: The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible. RESULTS: Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 +/- 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days. CONCLUSIONS: Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.     

经腹腔手辅助腹腔镜活体供肾摘取术

目的：介绍经腹腔手辅助腹腔镜活体供肾摘取术（HLDN）。方法：供肾者5例，行经腹腔的手辅助腹腔镜活体供肾摘取术，总结手术方法。结果：平均手术时间116min，供肾平均热缺血时间2．8min，平均供肾动脉长度1．8cm，平均供肾静脉长度2．7cm。未发生任何手术并发症。术后7d供者恢复出院，3例受者术后第3－12天血肌酐恢复正常，2例受者发生肾功能延迟恢复（DGF）。结论：HLDN结合了单纯腹腔镜供肾摘取术（LDN）和开放供肾摘取术（ODN）的优点。既有切口小，痛苦小和恢复快的微创手术特点，又减少了单纯腹腔镜器械操作的难度，使外科医师更易掌握，显著缩短了手术时间和供肾热缺血时间，保证了供肾质量；同时有利于迅速处理一些紧急情况，减少并发症，提高了供者安全性和手术成功率。     

Ipsilateral orchialgia after laparoscopic donor nephrectomy

BACKGROUND AND PURPOSE: Complications related to laparoscopic donor nephrectomy (LDN) have been similar to those associated with open renal donor nephrectomy (ODN). However, during clinical follow-up, we noted a group of male patients who developed acute ipsilateral orchialgia after LDN. In an effort to assess the incidence of this problem, determine the etiology, and adapt preventive measures, we reviewed our experience. PATIENTS AND METHODS: A retrospective chart review was performed on 381 consecutive LDNs performed between February 1995 and November 2001 to assess for postoperative orchialgia. There were 157 male patients (41.2%) in our series. Our technique involves ligation of the gonadal vessels, periureteral tissue, and ureter over the iliac artery using either surgical clips or a linear laparoscopic GIA stapler. RESULTS: Left-sided nephrectomy was performed in 145 (92.3%) male patients, of whom 14 (9.6%) complained of ipsilateral orchialgia. Statistical analysis (t-test) of the orchialgia and non-orchialgia groups with respect to operative time, estimated blood loss, warm ischemia time, and ureteral length revealed no statistical differences (P>0.1). Onset of testicular pain occurred on average at postoperative day 5 (range days 1-14). The mean follow-up was 24.4 +/- 14.8 months (range 6-52 months). Ten patients were evaluated with transcrotal duplex ultrasonography. One patient with decreased flow and was managed conservatively, while one patient without detectable testicular flow underwent surgical exploration. One patient underwent spermatocelectomy and had improvement but not resolution of pain. The remaining patients were treated conservatively with nonsteroidal anti-inflammatory medication and empiric antibiotics. Seven patients (50%) had complete spontaneous resolution of orchialgia on average 6.3+/-7.2 months after LDN. CONCLUSION: Laparoscopic donor nephrectomy has proven to be an effective and safe surgical procedure. However, further evaluation has demonstrated a complication not previously reported, namely ipsilateral orchialgia. The etiology remains unclear but may be injury to the sensory nerves of the testicle during dissection of the periureteral tissue or transection of the spermatic cord. Further anatomic and physiological studies are needed to elucidate the pathophysiology of this problem.     

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.