Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2012  |  Volume : 23  |  Issue : 6  |  Page : 1274--1277

Laparoscopic live donor nephrectomy: Our experience


Punit Tiwari, MK Bera, S Kumar 
 Department of Urology, Institute of Post-Graduate Medical Education and Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Kolkata, India

Correspondence Address:
Punit Tiwari
Department of Urology, Institute of Post-Graduate Medical Education and Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Kolkata
India




How to cite this article:
Tiwari P, Bera M K, Kumar S. Laparoscopic live donor nephrectomy: Our experience.Saudi J Kidney Dis Transpl 2012;23:1274-1277


How to cite this URL:
Tiwari P, Bera M K, Kumar S. Laparoscopic live donor nephrectomy: Our experience. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2023 Feb 4 ];23:1274-1277
Available from: https://www.sjkdt.org/text.asp?2012/23/6/1274/103575


Full Text

To the Editor,

Laparoscopic procedures in urology are gaining popularity, with an increasing number of centers performing advanced surgeries like live laparoscopic donor nephrectomy (LLDN) that was started in the year 1995. [1] As the donor nephrectomy should ensure the safety of the healthy voluntary donors and must obtain a viable kidney, the procedure requires a careful and safe learning curve. We in our institution are now regularly performing laparoscopic donor nephrectomy for the last two years.

Here, we are presenting our experience, how we switched over from open surgery to laparoscopic assisted and then finally to total laparoscopic live donor nephrectomy.

Renal transplantation was started in our institution in the early '70s. Since then, donor nephrectomy was done through the 12 th rib or the 11 th rib bed flank incision [Figure 1]. But, approach through those incisions and even through open sub-costal incisions are considered inferior to laparoscopic live donor nephrectomy because of less pain, early convalescence and better quality of life. [2],[3]{Figure 1}

In the initial phase of our learning curve, we started laparoscopic-assisted mini sub-costal approach. After an "as much as possible" laparoscopic dissection of donor kidney, the kidney was removed through sub-costal mini incision (6-7 cm) [Figure 2]. We performed many cases by that approach, which is suitable for the developing world. [3] Following complete mobilization of kidney laparoscopically, we retrieved the graft through a very small sub-costal incision after ligation and transection of renal vessels. This approach was found to be better than flank incision transcostal approach. [4] Finally, we started complete LLDN and retrieval of kidney through Pfannenstiel incision [Figure 3] and [Figure 4].{Figure 2}{Figure 3}{Figure 4}

In the Western countries, the number of live donor nephrectomy has increased over the last ten years, and LLDN has played a great role for that. [5] The same is true about our institution.

When starting LLDN, one should be careful not to harm the donor or compromise the viability of the graft. Leventhal and colleagues reported that all their complications with that procedure occurred in the first 30 cases. [6] Jacobs et al reported significant higher blood loss and complications in their first 100 cases of LLDN. [7] On the other hand, Bergman et al reported safe introduction of LLDN in their institute without significant negative outcome because of an organized team approach and taking due precautions. [8]

During the early learning curve, a surgeon should select easy cases like left kidney with single artery and vein. Thin-built patients have little perinephric fat, making the dissection comparatively easy. Before operation, it is prudent to examine the computerized tomography angiography carefully and plan the procedure.

Various positions have been described by different authors. [5] We follow a 45 degree lateral position with elevation of kidney bridge. Initially, we introduce a 5 mm trocar in the iliac fossa or sub-costal region depending on the build, abdominal scar and size of the liver or spleen on ultrasonographic finding. Other trocars were introduced under vision (left side = [Table 1], right side = [Table 2]). Later on, the 5 mm trocar at iliac fossa is converted to 10 mm for left donor nephrectomy and, for the right side, 5 mm subcostal trocar is converted to 10 mm. For most of the soft tissue dissection, we use harmonic scalpel liberally as it is user friendly and helps faster dissection with least thermal dissipation. [9] After reflection of the colon, we cut as usual the spleno-colic and spleno-renal ligaments as well as open the fascia gerota at the upper pole. Then, mobilize the upper pole followed by dissection of the gonodal vein with ureter over the psoas muscle. Next, hilar dissection is performed; the gonodal and adrenal veins are clipped and transected. The lumbar vein in the left side is clipped and transected to exposé the renal artery.{Table 1}{Table 2}

On the right side, the inferior venacava (IVC) is primary land mark for dissection. The gonadal vein is identified and dissected up to its junction with the IVC. Then, full mobilization of IVC is performed by reflecting the duodenum medially and dissecting the vena cava superiorly and inferiorly of renal vein. [10] The renal artery is exposed at the inter-aortocaval region if necessary. [11]

Cautery hook is very much helpful to transect the periarterial lymphatics tissue. Larger lymphatic vessels may require clipping, but harmonic scalpel also obliterate the lympho-vascular lumen. If liga-sure is available, the adrenal vein can be transected, the adrenal glands can be dissected easily, the large lymphatic vessels can be blocked and transected. [5],[12]

After transection of ureter and gonadal veins at the level of iliac vessels, the whole assembly is mobilized cephalad and the kidney is made free from the lateral wall. The kidney is rotated medially and left over extreme medial lymphatic tissue are transected from the posterior side. During the procedure, it is preferable to maintain pneumo-peritonium pressure within 12 mmHg for better perfusion of kidney. [13] A 5-6 cm Pfannenstiel incision is made and, through the rectus muscle split approach, the kidney is retrieved. We found that clipping and transection of the renal artery after introducing the hand through the Pfannenstiel incision and removal of kidney at the same time is very easy. It also causes less warm ischemic time (2-3 min) than retrieval with a bag as well as by two fingers method (3-5 min). [4],[5],[14] Moreover, on the right side, the surgeon can introduce his own hand and help in clipping and transection of the vessels. Thus, it is possible to push the venacava downward to get a good length of artery and vein, off course. If venacava cuff is required, the mini sub-costal incision approach will be more helpful. [15]

In few centers, LLDN, particularly on the right side, is performed through retroperitoneal approach but working space is limited and sub-capsular hematomas may occur due to prolonged pressure by fan retractor. [15]

LLDN is now the standard of care and is being performed at many centers world wide, [16] and many are preparing to start it to reduce morbidity and to improve the outcome of this procedure with acceptable cosmetics.

In pioneer centers, transplant surgeons are constantly engaged to refine the technique and to improve the instruments for LLDN. In our center, with limited resources, we are also trying to simplify and improve our technique.

References

1Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995; 60:1047-9.
2Mitre A, Denes FT, Nahas WC, Simoes FA, Colombo JR, Piovesanac. Comparative and prospective approach for Live Donor Nephrectomy. Clinics 2009;64:23-8.
3Perry KT, Freedland SJ, Hu JC, et al. Quality of life, pain and return to normal activities following Laparoscopic Donor Nephrectomy versus open Mini-Incision Donor Nephrectomy. J Urol 2003;169:2018-21.
4Kumara A, Dubey D, Gogoi S, Arvind NK. Laparoscopy Assisted live donor nephrectomy: A modified cost effective approach for developing countries. J Endourol 2002;16:155-9.
5Peter AP, Gary WC, Arieh LS. Laparoscopic Live Donor Nephrectomy. Smith's text book of endourology. 2 nd ed. 2007 .p. 533-7.
6Leventhal JR, Deeik RK, Joehl RJ, et al. Laparoscopic live donor nephrectomy - is it safe? Transplantation 2000;70:602-6.
7Jacobs SC, Cho E, Foster C, Liao P, Bartlett ST. Laparoscopic live donor nephrectomy: The University of Meryland 3 years experience. J Urol 2000;164:1494.
8Bergman S, Feldman LS, Anidjar M, et al. "First do no harm" monitoring outcomes during the transition form open to laparoscopic live donor nephrectomy in a Canadian. Centre.Can J Surg 2008;51:103-10.
9Manohart T, Wani K, Gupta R, Debai MR. Risk reduction strategies in laparoscopic donor nephrectomy: A comparative study. Indian J Urol 2006;22:201-4.
10Buell JF, Edye M, Johanson M, Li C, Koffron A, Cho E, et al. Are concerns over Right laparoscopic donor nephrectomy unwarranted. Annals of Surg 2001;233:645-51.
11Turk IA, Deger RS, Davis JW, et al. Laparoscopic live right donor nephrectomy: A new technique with preservation of vascular length. J Urol 2002;167:630-3.
12Sartori PV, Romano F, Uggeri F, et al. Energy-based hemostatic devices in laparoscopic adrenalectomy. Langenbecks Arch Surg 2010;395: 111-4.
13Hazebroek EJ, Gommers D, Schreve MA, et al. Impact of intraoperative donor management on short-term renal function after laparoscopic donor nephrectomy. Annals Surg 2002;236: 127-32.
14Waller JR, Hiley AL, Mullin EJ, Veitch PS, Nicholson ML. Living kidney donation: A comparison of laparoscopic and conventional open operations. Postgrad Med J 2002;78:153-7.
15Gupta N, Raina P, Kumar A. Laparoscopic donor nephrectomy. J Min Accesssary 2005;1: 155-64.
16Kim FJ, Ratner LE, Kavoussi LR. Renal transplantation: Laparoscopic live donor nephrectomy. Urol Clin North Am 2000;27:777-85.