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。     

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     

自制单孔多通道设备行后腹腔镜活体供肾切取术（附4例报告）

目的：探讨单孔后腹腔镜活体供肾切取术的安全性和可行性。方法：对4例亲属活体供肾者取腰部7cm切口,采用自制单孔多通道设备、常规腹腔镜操作器械完成单孔后腹腔镜活体供肾切取术。结果：本组平均手术时间160min,出血30-350ml,热缺血时间2～4min。开放血流后,4例供肾均在1min内泌尿,移植肾功能术后3天内均恢复正常;供者术后肾功能正常,5～6天出院,无手术并发症。结论：自制单孔多通道设备行后腹腔镜活体供肾切取术临床可行,安全可靠,费用低,可进一步减轻供者创伤,是一种有广阔应用前景的手术方式;能否替代传统腹腔镜活体供肾切取术还需进行前瞻、随机、对照研究。     

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。     

手助腹腔镜活体供肾摘取术在肾移植中的应用

目的 为减轻对话体供者的损伤，探讨腹腔镜在供肾切取中的应用。方法 对3名亲属活体供肾者采用腹腔镜切取肾脏，术前行磁共振、静脉尿路造影和数字减影血管造影检查，以了解供者双侧肾脏的血管情况，取肾术在全身麻醉下进行，先行腹腔穿刺，注入CO2气体，以形成气腹，供肾通过脐上腹中线切口取出。结果 2例取左肾，l例取右肾，3例取肾手术均获成功，手术历时5、4和3．5h，失血100～400ml，供肾热缺血时间分别为8、5、5min，血管吻合完毕开放血流后，移植肾均在1min内泌尿，移植肾功能良好。结论 活体供者采用腹腔镜取肾可减轻供者的手术创伤，术后伤口疼痛轻，住院时间短，身体恢复快。     

活体亲属肾移植手术的17例报告

目的总结活体亲属肾移植的临床经验。方法对供、受者进行全面的免疫学检查，对供者行IVU检查了解分侧肾功能，行DSA或MRA、螺旋CT血管三维成像检查了解血管的变异情况之后，开放式手术摘取供肾13例，经后腹腔镜活体供肾摘取4例，按常规方法移植给受者。免疫抑制方案为环孢素A（或FK506）、霉酚酸酯（或硫唑嘌呤、雷帕鸣）、强的松三联免疫抑制剂。结果13例开放式手术时间1．5～3．0h，平均2．0h；热缺血时间1．0～1．5min，平均1．2min；术中出血量60～200ml，平均140ml，术中及术后均未输血；术后住院7～10d，平均8d。4例后腹腔镜手术时间3．0～4．5h，平均3．5h；热缺血时间2．5～3．5min，平均2．8min；术中出血量60～100ml，平均75ml，术中及术后均未输血；术后3～5d出院。移植肾血液循环恢复后10～40s泌尿，平均20s。1例受者术后45d发生轻微的急性排斥反应，应用激素冲击3d后逆转，其余受者均无并发症。随访4～60个月，人／肾存活率为100％，移植肾功能良好。结论活体亲属肾移植安全可行，取左肾尽量靠近腹主动脉壁切断肾动脉，取右肾切取少许下腔静脉片。     

手助腹腔镜肾切取术在活体供肾移植中的应用体会(附30例报告)

目的:评价手助腹腔镜活体供肾切取术的安全性及临床效果。方法:分析2013年8月至2016年8月采用手助腹腔镜活体供肾切取术获取30例活体供肾的临床资料。供者男7例,女23例,均取左肾,供受体关系为:父—子5例,母—子13例,母—女2例,兄弟2例,兄—妹4例,妻—夫3例,叔—侄1例。供肾者32~63岁,平均(51.8±8.5)岁。血型相同29例,相容1例,群体反应性抗体、淋巴毒均为阴性。30例患者均行手助腹腔镜活体供肾切取,切取后常规移植给受者,记录手术时间、出血量、供体冷热缺血时间、供者住院时间、术中副损伤及供受者术后恢复情况。结果:供者均切取左肾,手术成功,无一例中转开腹,供肾切取时间105~160 min,平均(100.4±19.5)min;失血量50~110 ml,平均(52.5±24.5)ml;供肾热缺血时间2.0~3.8 min,平均(2.4±0.5)min;冷缺血时间60~90 min,平均(68.2±26.7)min。供者术后1~3 d即可进食并下床活动,平均(2.5±0.6)d;住院3~6 d,平均(4.0±1.6)d。供受体无任何手术并发症发生,受者手术均获成功。随访3个月~3年,供体肾功能均正常。2例受者分别于肾移植术后1年8个月、1年2个月因自行减药,发生排斥反应,导致移植肾肾功能丢失,恢复透析,其余受体肾功能均正常。结论:手助腹腔镜活体供肾切取术结合了腹腔镜活体供肾切取术与开放手术的优点,既减轻了手术对供者的创伤,又保证了供肾质量,是安全、可靠的手术方法。     

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。     

后腹腔镜下亲属活体右侧供肾切取术经验总结

目的探讨后腹腔镜下亲属活体右侧供肾切取术的安全性,并总结相关临床经验。 方法回顾性分析2010年2月至2019年6月解放军总医院第八医学中心实施的14例亲属活体右侧供肾切取术临床资料,其中8例为后腹腔镜下供肾切取(腹腔镜组),6例为经腰部开放供肾切取(开放手术组)。腹腔镜组供者常规采取左侧卧位,腰部采用三套管法穿刺。采用成组t检验比较两组供者手术时间、腔静脉切口缝合时间、供肾动脉长度、供肾静脉长度、供肾热缺血时间、手术出血量和术后住院时间。P<0.05为差异有统计学意义。 结果14例亲属活体右侧供肾切取术均成功,两组供者术中均未输血,腹腔镜组供肾切取术中均未中转开腹。腹腔镜组与开放手术组供肾静脉长度分别为(2.2±0.4)和(1.2±0.3)cm,术中出血量分别为(45±12)和(80±10)mL,差异均有统计学意义(t＝1.042和5.781,P均<0.05)。两种术式手术时间、腔静脉切口缝合时间、供肾动脉长度、供肾热缺血时间及术后住院时间差异均无统计学意义(P均>0.05)。截至2019年8月,开放手术组和腹腔镜组供者中位随访时间分别为6个月(3～18个月)和8个月(3～24个月),均健康。受者术前及术后应用巴利昔单抗行免疫诱导治疗,术后免疫抑制方案为CNI＋抗代谢类药物＋糖皮质激素。移植肾功能均于术后2周内恢复,术后均顺利摆脱透析。截至2019年8月,14例受者随访时间3～12个月,期间受者及移植肾功能均正常。 结论亲属活体右侧供肾获取过程中采用腹腔镜联合Satinsky钳技术安全、可行,可较大限度地延长供肾静脉,且术中出血量更少。     

机器人辅助腹腔镜活体供肾切取术(附2例报告)

目的:探讨机器人辅助腹腔镜活体供肾切取术的安全性和可行性。方法:对2例亲属活体供肾者行机器人辅助腹腔镜活体供肾切取术。结果:术前机器人定位时间28min,平均手术时间80min,出血约50ml,热缺血时间3min。开放血流后,2例移植肾脏均在1 min内开始分泌尿液。2例受者术后1周内血肌酐均降至正常,无手术并发症,无排斥反应。2例供者术后复查肾功能正常,住院5~6d,无手术并发症。结论:机器人精细的解剖分离和高效的止血提高了术者手术技巧,机器人辅助腹腔镜活体供肾切取术安全可行。     

后腹腔镜下肾切除术的关键——肾蒂处理的体会

目的总结后腹腔镜下肾切除术中肾蒂处理的经验。方法根治性肾切除术66例,单纯性肾切除术52例,活体供肾切取术2例,术中注意肾蒂的快速寻找、及早控制和适当的处理方法三要点。结果116例后腹腔镜手术成功,4例中转开放手术。手术时间65～180min,平均103min。术中出血量50～150ml,平均70ml,病人均未输血。术后2～3d拔除引流管,3～5d下床活动,恢复顺利,无并发症。105例随访2年未发现异常。结论肾蒂快速寻找、及早控制和适当的处理方法是后腹腔镜下肾脏切除手术成功的关键。     

Nephrectomy in a living donor by retroperitoneal laparoscopy or lomboscopy

INTRODUCTION: The advantages of laparoscopic live donor nephrectomy are now well documented. This new approach can lower donor morbidity and could stimulate living related organ donation. We described our original operative technique and report our preliminary results. MATERIAL AND METHODS: Since 1998, we have used the retroperitoneal laparoscopy in tree related living donors. Advantages and inconvenient of this new surgical procedure were discussed with each donors and inform consent obtained. The left kidney was harvested in the three cases. RESULTS: The operative time was inferior to 280 minutes, warm ischemia less than five minutes and bleeding less than 150 mL. Patients were discharged between the 2nd and 3rd post-operative days. CONCLUSION: Retroperitoneal laparoscopy is a valuable alternative in transplant centres with skilled laparoscopic surgeons.     

改良后腹腔镜下活体供肾切取术八例报告

目的 介绍后腹腔镜下活体供肾切取术的初步经验，探讨其临床价值及可行性。方法 术前对供受体进行血型、HLA配型及群体反应性抗体（PRA）检查，并对供体行IVU、彩超检查了解双肾功能、肾血管情况。采用经后腹腔途径对8例活体亲属供。肾者行腹腔镜取肾术。右侧卧位，后腹腔操作通过腰部置入的3个套管完成，阻断。肾血管前延长腋前线穿刺孔至6～7cm，左手伸入后腹腔内，手助下离断。肾血管并迅速取出供肾标本。结果 8例手术均取得成功。手术时间96～128min，平均112min；术中出血25～56ml，平均42ml；热缺血时间126—245s，平均152s；肾动脉长度2.8～3．2cm，平均3.0cm；。肾静脉长度3．2—3．5cm，平均3．3cm；输尿管长15—18cm，平均16cm。血管吻合顺利，开放血流后供。肾均在1min内开始泌尿。受体肾功能均在5d内恢复正常．住院时间14—15d。供体伤口引流管2～3d内拔除，住院时间4—5d。供受体均无外科并发症。结论 后腹腔镜活体供肾切取术对患者创伤小、恢复快、供肾质量好、扩大了供肾来源。在离断肾血管及取出供肾时辅以手助可缩短热缺血时间，增加动静脉长度，提高取肾的安全性。     

Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation

PURPOSE: We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation. MATERIALS AND METHODS: A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation. RESULTS: All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks. CONCLUSIONS: In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.     

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE: A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts. MATERIALS AND METHODS: The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy. RESULTS: The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature. CONCLUSIONS: We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.     

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。     

The way to establish laparoscopic donor nephrectomy as the method of choice in live kidney donation--a single centre experience

INTRODUCTION: In contrast to the USA, laparoscopic donor nephrectomy is rarely practised in German transplant centres. Safety concerns and difficulties with the learning curve of this advanced laparoscopic procedure are the main obstacles to the establishment of this operation. PATIENTS AND METHODS: From 1998-2005, we performed laparoscopic kidney procurement in 50 live kidney donors on an intention to treat basis harvesting a total of 29 left and 21 right kidneys for transplantation. RESULTS: Negative adverse effects on the donor side were temporary nerve irritation (2 patients) and postoperative retroperitoneal hematoma. Reasons to convert to open nephrectomy were bleeding (2 patients) and adhesions (1 patient). On the recipient side, one kidney was lost due to renal vein thrombosis. Three patients required short-time dialysis after transplantation. All other kidney transplants worked without any problems. CONCLUSION: Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our hospital.     

Laparoscopic live donor nephrectomy. A review of the first 5 years.

Laparoscopic live donor nephrectomy is technically feasible. The operation has evolved over the last 5 years and is greatly improved compared with the procedure originally described. Advantages to the donor when compared with the standard open operation are decreased postoperative pain, shorter hospitalization, a quicker recuperation, an earlier return to driving, and an earlier return to employment. These improvements have resulted in fewer lost wages and a lower financial burden for donors. Live donor nephrectomy also provides improved cosmetic results. It successfully removes many of the disincentives to live kidney donation and has resulted in an increased willingness of individuals to donate their kidneys. The operative risk seems to be equivalent to that of the open donor operation performed through a flank approach. Although there is no financial advantage of the laparoscopic operation in terms of hospital costs, the increase seen in live donor transplantation may result in long-term cost savings overall. Kidneys procured laparoscopically function well in recipents in the short and long term. There is no increased risk for rejection or technical complications, and the recipent's length of hospitalization is unaffected. The laparoscopic donor operation does not have any apparent deleterious effect on the recipient. The procedure is being adopted rapidly by transplant centers around the world and has been performed at more than 100 centers on five continents. The authors believe that laparoscopic live donor nephrectomy will become the standard of care in the not too distant future.     

Learning laparoscopic donor nephrectomy safely: a report on 100 cases

HYPOTHESIS: There is concern that learning laparoscopic live donor nephrectomy (LLDN) is associated with increased morbidity. We propose that with a team approach LLDN can be learned safely, without increased donor morbidity or graft failure, even during the early portion of a learning curve. DESIGN: Case series with cohort comparison. SETTING: Tertiary referral center. PATIENTS: The laparoscopic group consisted of 100 donors and 100 recipients; the open group, 50 donors and 50 recipients. INTERVENTIONS: A team approach that combines laparoscopic and urologic expertise was used to perform 100 cases of LLDN. MAIN OUTCOME MEASURES: Donor morbidity and graft function in the laparoscopic group were compared with those in the open group. RESULTS: Laparoscopic live donor nephrectomy was completed in 99 patients. One patient required conversion to open donor nephrectomy because of intraoperative hemorrhage. Minor complications occurred in 6 laparoscopic group donors (6%) and 3 open group donors (6%). Laparoscopic and open group donors were of similar age. Operative times were longer for laparoscopic group donors (231 vs 209 minutes). Mean hospital stay was shorter for laparoscopic group donors (3.3 vs 4.7 days). Graft function was comparable between the laparoscopic and open groups, with equivalent postoperative creatinine levels. Graft survival was comparable. Recipient ureteral complications occurred with less frequency (2% vs 6%) in the laparoscopic group. CONCLUSIONS: By forming an operative team that combines expertise in laparoscopy with expertise in live donor nephrectomy, surgeons can learn LLDN safely. Adoption of the techniques developed by those who pioneered the procedure can further minimize the morbidity associated with a learning curve.