Handport-assisted laparoscopic live-donor nephrectomy
Article Outline
The accumulated benefits of laparoscopic live donor nephrectomy (LLDN) increased the acceptance of donation and expanded the pool of potential kidney donors.1 The initial experience of using handport-assisted LLDN in Taiwan is reported herein.
Materials and methods
Ten serial patients underwent handport-assisted LLDN in the Surgical Department of National Taiwan University Hospital from January 2001 through January 2002. Laboratory evaluation included the determination of human leukocyte antigen and a lymphocytotoxic crossmatch before the transplantation. Magnetic resonance angiography was performed to visualize the renal vascular and ureteral anatomy, to determine the presence of two functional kidneys. Body mass index, operation time, warm ischemia time of graft, hospital stay, and short- term graft function of donors and recipients were evaluated.
Surgical technique
The patient is placed in the modified flank position. A pneumo-peirtoneum of 15 mm Hg was established via a periumbilical incision. The kidney was approached via a transperitoneal access using four ports. The umbilical port site was enlarged to 7 cm at the end of the procedure for hand-port placement and for removal of the graft. The left colon was reflected medially to expose Gerota’s fascia. The hilum of the kidney was dissected to reveal the renal vein and its tributes. The gonadal vein and suprarenal vein were clipped and divided. The ureter and gonadal vein were dissected together to the level of pelvic brim and the bifurcation of common iliac artery. To minimize the risk of ischemic necrosis of the ureter, the gonadal vein and the ureter were dissected as a unit to preserve the adventitia and arterial plexus of the ureter. No ureteral complications developed in our series. During the dissection, the patient was given crystalloid together with mannitol and furosemide to maintain diuresis.
The periumbilical port site was enlarged to a 7-cm incision to allow the placement of the hand-port (Pneumo Sleeve device, Dexterity, Roswell, GA). With the assistance of a bare hand, the kidney was freed from surrounding attachments and from the adrenal gland. The renal artery was dissected from its root at the aorta from the posterior aspect of kidney. The lumbar veins were clipped and divided. The renal artery was divided between clips to begin the warm ischemia time. An endoscopic gastrointestinal anastomosis stapler was used subsequently to divide the renal vein. The graft was removed via the hand port and put into an ice bath, flushed, and prepared for transplantation. The wounds were closed in a standard manner. The harvested graft was immersed immediately in iced saline solution and transferred to the back bench for renal perfusion.
Results
The demographics of donors are listed in Table 1. Handport-assisted LLDN was successfully performed in all 10 patients. Mean ischemic time was 3.7 minutes. There were no major complications. Short-term graft functions were all well.
Table 1. Demographics of Patients Undergoing LLDN
| Case | Age (y) | Sex | Body Mass Index | Operation Time (min) | Warm Ischemia (min) | Hospital Stay (d) | Blood Urea Nitrogen/Creatinine POD#30 (Donor) | Blood Urea Nitrogen/Creatinine POD#7 (Recipient) |
|---|---|---|---|---|---|---|---|---|
| 1 | 55 | Female | 27.7 | 270 | 3 | 8 | 11.9/0.9 | 21.2/1.2 |
| 2 | 53 | Female | 20.5 | 290 | 3 | 7 | 13.6/1.3 | 38.9/1.3 |
| 3 | 33 | Male | 31.1 | 473 | 8 | 4 | 21.8/1.6 | 20.8/0.9 |
| 4 | 46 | Male | 25.7 | 330 | 5 | 6 | 14.8/0.9 | 23.1/0.9 |
| 5 | 47 | Female | 26.2 | 275 | 4 | 6 | 20.1/0.9 | 20.6/0.8 |
| 6 | 37 | Male | 22.1 | 235 | 4 | 6 | 14.2/1.4 | 18.0/0.8 |
| 7 | 21 | Female | 21.3 | 127 | 2.5 | 5 | 9.7/0.7 | 20.1/0.8 |
| 8 | 55 | Female | 26.2 | 203 | 3 | 5 | 21.7/1.3 | 18.3/1.0 |
| 9 | 38 | Female | 21.1 | 265 | 3 | 5 | 10.3/1.1 | 18.7/1.0 |
| 10 | 58 | Female | 26.3 | 222 | 1.5 | 5 | 21.8/1.1 | 16.6/0.7 |
| Mean | 44.3 ± 11.8 | Male:Female = 3:7 | 24.8 ± 3.4 | 269 ± 90.5 | 3.7 ± 1.8 | 5.7 ± 1.2 |
Discussion
Hand-assisted laparoscopic surgery (HALS) is suitable for living donor nephrectomy for it allows tactile feedback, hand-eye coordination, gentle traction on tissue, and removal of the graft via the incision necessary anyway. It could shorten the learning curve for surgeons beginning this stressful operation. In addition, HALS is believed to decrease the warm ischemia time2 and gain more vessel length at the time of dividing renal vein and artery.3
HALS has its drawbacks. First, it limits the liberal placement of camera port. Second, the handedness of the surgeon might limit the placement of the pneumosleeve. In our series, we inserted the pneumosleeve after the ureter and gondal vein dissections were completed, and we could finish the rest of the procedure without the need of changing camera position. In this way, we felt comfortable to handle the vessels and saved a lot of time in dissection.
Conclusion
LLDN is a technically demanding approach. With the handport assistance, surgeons could shorten their learning curve. Cosmesis and hospital stay were improved by the laparoscopic approach. Longer follow-up and larger patient numbers are needed to confirm these initial results. More importantly, we hope the new method will stimulate live kidney donation in Taiwan.
References
PII: S0041-1345(02)03795-8
doi:10.1016/S0041-1345(02)03795-8
© 2003 Elsevier Science Inc. All rights reserved.
