Laparoscopic Live Donor Right Nephrectomy: A New Technique to Maximize the Length of the Renal Vein Using a Modified Endo GIA Stapler

Clip or staple in laparoscopic live donor nephrectomy? A systematic literature review

INTRODUCTION

Ligation of the renal pedicle is a crucial step in laparoscopic renal harvesting. Currently, two devices are widely used: Hem-o-Lok® clips and staplers. Each has its advantages and disadvantages.

METHODS

A systematic literature review was conducted following the PRISMA methodology on PubMed, EMBASE, and Cochrane databases with no time restrictions. Registered in the PROSPERO database (CRD42023460585), the study's primary outcome measures include the failure rate of the ligation tool, conversion to open surgery, rate of severe bleeding, and device-related death. Other secondary variables are also explored. An assessment of the quality of included comparative studies was performed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool.

RESULTS

Out of 393 articles identified using our keywords, 32 were included. Overall, clips have a lower failure rate during application, elongate graft vessel length, and are more cost-effective. Staples are associated with a shorter warm ischemia time and lower blood loss. There is no significant difference between the two devices in terms of conversion, severe bleeding, death, and blood transfusion.

CONCLUSION

There is no perfect modality for renal pedicle control during laparoscopic harvesting, as each instrument has its pros and cons. Hem-o-Lok® clips are a safe and cost-effective option, particularly suitable for right-sided harvesting or in cases of vascular variations. However, they are still associated with a risk of secondary displacement with potentially serious consequences. Certain technical tricks can mitigate this risk.

Safe transition from open to pure laparoscopic donor nephrectomy: Approach and results

Introduction

Laparoscopic living donor nephrectomy (LLDN) offers many advantages compared to open living donor nephrectomy. However, the perceived difficulty in learning LLDN has slowed its wider implementation. Herein, we describe the evolution of LLDN at a single center, emphasizing the approach and technical modifications and its impact on outcome.

Methods

The series included a 2½-year period and three different surgeons. We started with two-stage plan for establishing LLDN at the institute (introduction and consolidation). Data of laparoscopic donor nephrectomy performed at the institution were prospectively evaluated regarding donor and recipient outcome.

Results

From December 2016 to April 2019, 221 donors underwent LLDN. Three donors required conversion to open surgery. The mean operation time was 96.4 (62-158) min and the mean warm ischemia time was 186 (149-423) s. The complications were observed in 11.6% of donors from LLDN group and all complications were Class I and Class II only (Clavien-Dindo classification). No Class III and Class IV complications occurred. In the present study, there was some learning curve effect observed only in operative time (OT) with longer OT in initial cases. However, the overall operative complications were minimal, showing that this learning curve had no deleterious effects on donor safety.

Conclusion

The present study demonstrates that with proper planning, team approach, and a few technical modifications, the transition from open to LLDN could be safe and effective.

Experience With 15 Years of Laparoscopic Donor Nephrectomy: Review of 2500 Cases

BACKGROUND

Laparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events.

METHODS

The records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications.

RESULTS

The mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3).

CONCLUSIONS

LDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Laparoscopic living donor right nephrectomy: Assessment of outcome and association of BMI to length of right renal vein

AIMS

The aim of this study was to describe outcomes of laparoscopic living donor right nephrectomy (LLDRN) and study factors affecting the length of right renal vein from the donors.

MATERIAL AND METHODS

This study was conducted in 60 donors (48 males and 12 females) from January 2016 to December 2017. We performed a retrospective review of consecutive patients who underwent transperitoneal right laparoscopic living donor nephrectomy at our unit.

RESULTS

LLDRN was successfully performed in all subjects by the same surgeons. Among 60 cases, 47 donors had single renal artery and vein, 2 cases had one artery and 2 veins, and 5 donors had 2 arteries and one vein, and the rest had 2-3 arteries with 1-3 veins. Operative time was 142.60±33.73min. Warm ischemic time was 2.64±0.76min. The mean hospital stay was 6.69±0.63 days. The median length of right renal vein was 1.92±0.41cm. All transplanted kidneys showed immediate function. No graft losses were recorded. Almost no gender differences were found in study variables except BMI and warm ischemic time, that was higher BMI but shorter warm ischemic time in female versus male donors. Further analysis showed a negative correlation between BMI and right renal vein (r=-0.282, P<0.05), but a positive correlation between operative time and estimate blood loss (r=0.37, P<0.01).

CONCLUSIONS

LLDRN is a feasible safe procedure, less traumatic approach, and provides good outcomes kidney for recipients. Notably, in the study group the higher BMI was associated with resulting more difficult LLDRN and kidney transplantation.

Open Management of the Renal Vein Is a Safe Modification in Right-Sided Laparoscopic Living Donor Nephrectomy to Maximize Graft Vein Length

BACKGROUND

The primary objective in living donor kidney transplantation is donor safety. In laparoscopic living donor nephrectomy, most centers prefer the left kidney for donation given the shorter renal vein, higher rate of thromboses, and more difficult surgical procedure for right kidney retrieval. The goal of this study was to demonstrate the feasibility of a hybrid technique using a Satinsky clamp in right-sided living donor nephrectomy to obtain maximal renal vein and to compare the outcome with standard left-sided laparoscopic donor nephrectomies.

MATERIAL AND METHODS

Between 2005 and 2013, 77 patients underwent a left (group L) and 54 a right (group R) living donor nephrectomy. In group R, after laparoscopic dissection and mobilization of the right kidney, two 12-mm trocar incisions in the right upper quadrant were connected in a 5-7 cm subcostal incision. The caval vein was partially clamped under direct vision prior to dissection of the renal vein. The venotomy was then closed with a running 4-0 Prolene suture. The two groups were compared with regard to surgical complications, graft function, and graft survival.

RESULTS

Using this technique, no significant difference with regard to complications or graft function was observed. Serum creatinine at discharge in donor group L was 1.23 (±0.43) mg/dL and in donor group R 1.21 (±0.37) mg/dL (P = .71). Graft survival at one year was 100% in both groups.

CONCLUSION

Open management of the renal vein is a safe alternative in laparoscopic right-sided donor nephrectomy and ensures maximal length of the vein.

Transperitoneal laparoscopic left versus right live donor nephrectomy: Comparison of outcomes

Introduction:

Although laparoscopic donor nephrectomy (LDN) is being performed at many centers, there are reservations on the routine use of laparoscopy for harvesting the right kidney due to a perception of technical complexity and increased incidence of allograft failure, renal vein thrombosis and the need for more back-table reconstruction along with increased operative time.

Materials and Methods:

We performed a prospective non-randomized comparison of transperitoneal laparoscopic left donor nephrectomy (LLDN) with laparoscopic right donor nephrectomy (RLDN) from August 2008 to May 2013. The operative time, warm ischemia time, intraoperative events, blood loss and post-operative parameters were recorded. The renal recipient parameters, including post-operative creatinine, episodes of acute tubular necrosis (ATN)  and delayed graft function were also recorded.

Results:

A total of 188 LDN were performed between August 2008 and May 2013, including 164 LLDN and 24 RLDN. The demographic characteristics between the two groups were comparable. The operative duration was in favor of the right donor group, while warm ischemia time, estimated blood loss and mean length of hospital stay were similar between the two groups. Overall renal functional outcomes were comparable between the two donor groups, while the recipient outcomes including creatinine at discharge were also comparable.

Conclusions:

RLDN has a safety profile comparable with LLDN, even in those with complex vascular anatomy, and can be successfully performed by the transperitoneal route with no added morbidity. RLDN requires lesser operative time with comparable morbidity.

[Elongation of the right renal vein in 120 consecutive transplant patients. A comparative analysis]

OBJECTIVES

Shorter length of the right renal vein (RRV) may represent an additional difficulty for transplant. This paper has aimed to present our experience with RRV elongation in the kidney from a cadaveric donor and to compare the results with the rest of kidneys transplanted in the same period of time.

MATERIAL AND METHODS

We performed 377 kidneys transplants within the last 11 years. Of these, in 120, the RRV was elongated with the vena cava. The surgical technique is described and the results compared with the remaining transplants of the series. Renal function, graft survival and complications were assessed at 1, 3 and 12 months. Data were obtained retrospectively from the database of the Urology Department and Hospital medical records.

RESULTS

In the 377 transplants, there were 4 (1%) venous thrombosis, 2 (1.6%) of which concerned kidneys with elongation of the RRV and 2 (0.7%) in the rest of transplanted kidneys. There was no difference in postoperative bleeding, 11 (9.1%) occurred in kidneys with elongated RRV and 22 (8.5%) in the remaining kidney. In no case was the bleeding related to the elongated segment. Graft survival and renal function were similar for both groups.

CONCLUSIONS

Elongation of the RRV with the vena cava is a feasible, fast, and effective procedure that does not increase morbidity or affect renal function or graft viability. It facilitates vascular anastomosis and places the kidney in a less forced position, shortens the warm ischemia time and avoids the risk of kinking of the renal artery because it is equal to the length of the vein artery.

Renal vein lengthening using gonadal vein reduces surgical difficulty in living-donor kidney transplantation

BACKGROUND

During living-donor kidney transplantation, to maximally decrease donor injury, the right kidney with lower glomerular filtration rate often is selected as the donor kidney. However, the renal vein of the right kidney is relatively short for transplantation. The gonadal vein is essentially useless and is easily accessed during the donor nephrectomy.

METHODS

Seventeen live kidney donors received right kidney nephrectomy for living-donor kidney transplantation. Short renal veins were lengthened by circular anastomosis or spiral anastomosis of longitudinally cut gonadal veins. The renal function of receivers was evaluated using creatinine clearance.

RESULTS

The renal veins were extended by 2.0-2.7 cm with circular anastomosis and 4.1-4.5 cm with spiral anastomosis with an average of 2.5 ± 0.7 cm. Lengthening of renal veins averaged 20.4 ± 4.2 min. All surgeries were successful, significantly reducing difficulty of vascular anastomosis during transplantation. No poor early graft function occurred. No side effects were observed in donors.

CONCLUSIONS

When donor renal veins are too short for effective kidney transplantation and may affect reliability of vascular anastomosis, they can be lengthened by using gonadal veins without increasing injury to the donor. Successful extension of donor kidney renal veins expands the indication for right donor kidneys.

Retroperitoneal LESS donor nephrectomy

Donor nephrectomy with laparo-endoscopic single site (LESS) surgery has been reported via the transperitoneal approach. We describe a novel technique of retroperitoneal donor nephrectomy using a single surgical incision in the groin, below the abdominal skin crease or "bikini line". The LESS groin incision offers superior cosmesis, while the retroperitoneal approach has distinct advantages, such as the ability to identify the renal vessels early. The new procedure has been performed in two obese patients (body mass index 32 and 33 kg/m2, respectively). The operative times were 4 and 5 hours, warm ischemic times 135 and 315 seconds, blood loss 100 and 250 mL, and hospitalization 3 and 2 days, respectively. Retroperitoneal LESS donor nephrectomy through a single, inconspicuous groin incision is feasible and safe. Further evaluation of the technique in a larger patient cohort is indicated.

Laparoscopic-Assisted Recipient Nephrectomy and Recipient Kidney Procurement during Orthotopic Living-Related Kidney Transplantation

Advanced atherosclerosis or thrombosis of iliac vessels can constitute an absolute contraindication for heterotopic kidney transplantation. We report the case of a 42-year-old women with end-stage renal disease due to lupus nephritis and a history of bilateral thrombosis of iliac arteries caused by antiphospholipid antibodies. Occlusion had been treated by the bilateral placement of wall stents which precluded vascular anastomosis. The patient was transplanted with a right kidney procured by laparoscopic nephrectomy from her HLA semi-identical sister. The recipient had left nephrectomy after laparoscopical transperitoneal dissection. The donor kidney was orthotopically transplanted with end-to-end anastomosis of graft vessels to native renal vessels and of the graft and native ureter. Although, the patient received full anticoagulation because of a cardiac valve and antiphospholipid antibodies, she had no postoperative complication in spite of a short period of delayed graft function. Serum creatinine levels three months after transplantation were at 1.0 mg/dl. Our case documents that orthotopical transplantation of laparoscopically procured living donor kidneys at the site of recipient nephrectomy is a feasible procedure in patients with surgical contraindication of standard heterotopic kidney transplantation.

Right-sided transperitoneal hand-assisted laparoscopic donor nephrectomy: is there an issue with the renal vessels?

OBJECTIVE

Short right renal vessels might complicate kidney transplantation, thus causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy (HALDN) is presented.

PATIENTS AND METHODS

Eighty-two living kidney donors underwent HALDN between 2003 and 2008. Right-sided HALDN was performed in 46 living kidney donors. The operative technique of right-sided HALDN was modified to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were prospectively collected.

RESULTS

All procedures were laparoscopically completed with no conversion. Mean operative time was 127 minutes (vs. 138 minutes in left HALDN, p = 0.08). The mean warm ischemia time was 41 seconds (vs. 39 seconds in left HALDN, p = 0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p = 0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p = 0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation.

CONCLUSIONS

Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.

[Current value of laparoscopy for renal transplantation]

Laparoscopic techniques have not only become increasingly more important for patients on dialysis or after kidney transplantation, they also represent the operative standard procedures as almost all patients additionally suffer from concomitant diseases and do carry a higher operative risk. Therefore, these patients will derive special benefits from minimally invasive procedures offering lower morbidity and quick recovery. In centers with expertise in minimally invasive procedures, laparoscopic donor nephrectomy has already replaced open live donor nephrectomy as the standard procedure.

Evaluation of cadaveric renal vein lengths and their extension loss with three types of ligature and section

BACKGROUND AND PURPOSE

The right kidney has been less frequently used in live donor nephrectomy, because of the shorter length of the right renal vein (RRV) that is associated with technical difficulties and higher rates of venous thrombosis. In live open donor or deceased donor transplant nephrectomy, an additional cuff of the inferior vena cava is usually removed, but this is a more difficult and risky maneuver in laparoscopic nephrectomy. For this reason, laparoscopic right nephrectomy (LRN) for renal transplantation (RT) is not frequently performed in most medical institutions. We evaluate the difference between RRV and left renal vein (LRV) lengths in cadavers, as harvested for RT by three clamping methods. Our objective was to obtain information that could clarify when LRN for RT should be encouraged or avoided with regard to conventional surgery.

MATERIALS AND METHODS

Ninety adult fresh unfrozen cadavers were randomly divided into three groups of 30, according to the clamping device used: Satinsky, stapler, and Hem-o-lok clip. The abdominal viscera were removed through a median xyphopubic incision, and the veins were measured on the bench. Two lateral limits were used: The renal hilum and the tangential line of the renal poles. As for medial limits, the inferior vena cava or the laparoscopic clipping device on the RRV were used on the right side, while on the LRV, the medial border of the emergence of the adrenal vein was considered. After section of the renal vein, a slight traction of the extremity was applied for the measurement. All measurements were obtained three times using a metallic millimetric ruler, and the arithmetic mean was considered. The chi-square, one-way analysis of variance, and paired t tests were used for statistical analysis. Statistical significance was accepted at P <or= 0.05.

RESULTS

The groups of cadavers were homogeneous in demographic characteristics. Regardless of the clamping method and considering the useful length of the LRV, the RRV was statistically smaller. The evaluation of the vein length did not depend on the lateral limit considered. Independent of the clamping method, on both sides, the lengths after the vein section were larger than before the section, a fact attributed to traction. Use of a stapler and a single Hem-o-lok presented the same waste of vein length on the right side. On average, the RRV was 13.7% shorter than the LRV.

CONCLUSIONS

With the wide acceptance of laparoscopic live donor nephrectomy, the length difference between the veins of both kidneys is an important issue, and the right kidney is therefore used less than the left, compared with conventional surgery. This article represents the first step to quantify the anatomic length of renal veins in different situations. Certainly, more imagenologic or surgical studies should be carried out before decisions can be made for better selection of patients for LRN.

[Renal live donor. Open and laparoscopic experience at La Paz Hospital]

Laparoscopic live donor nephrectomy is a rare operation in our country because the complexity of the technique and the expansion of the cadaveric donor. We present our open and laparoscopic live donor nephrectomy from 1984.

MATERIAL AND METHODS

From 1984 to 2007 we have done 84 live donor nephrectomies; 64 open, 20 laparoscopic surgeries. The transperitoneal approach is preferred in laparoscopy and lumbotomy for the open surgery.

RESULTS

In the open technique the operating time is 112 min (70-155), ischaemia time 20 seconds (15-47) and postoperative hospital stay 4,8 days (3-9). Laparoscopic cases, the operating time is 146 min (90-210), ischaemia time 3 min 15 sec (2-3, 25 min) and postoperative hospital stay 3,4 days (2-9).

CONCLUSIONS

The laparoscopic live donor nephrectomy is a difficult and demanding technique. It should be done by experienced team in laparoscopic renal surgery. The kidney from a live donor is a very good alternative for the cronic renal failure. It should be offered in our main hospitals.

Renal vein extension using gonadal vein: a useful strategy for right kidney living donor harvested using laparoscopy

INTRODUCTION

Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. Based on experience in open donor nephrectomy, our unit has used the donor gonadal vein to obtain a longer renal vein in this setting.

METHODS

Four consecutive living related donors with the indication for laparoscopic right nephrectomy underwent this procedure. Three donors were females and the overall average age was 48.5 years. The renal vein was controlled with a 30-mm stapler and we included 5-6 cm of the ipsilateral gonadal vein during the harvest. The donor kidney was perfused and renal vessels prepared under cold conditions. The gonadal vein was opened longitudinally and sutured to the donor right renal vein as a wide tube in 3 cases and as a spiral tube in 1 case with 6-0 monofilament suture.

RESULTS

This procedure extended the bench work between 25 to 40 minutes permitting an 2.5- to 3.5-cm extension of the donor vein. The transplantations were performed in the usual mode and the vein enlargement enormously facilitated the implantation surgery. All recipients displayed immediate graft function; no complications were observed with this strategy.

CONCLUSIONS

Vein extension with the gonadal vein was a simple, safe method to enlarge the renal vein among right living donor kidneys procured using laparoscopy.

Living Donor Nephrectomy: Open versus Laparoscopic Technique

Background

The living donor nephrectomy has to be safe and effective, allowing a good graft function in the recipient. In the past, donor nephrectomy was performed only by open technique; more recently this nephrectomy has also been performed by laparoscopic technique. The best technique has not been established in literature. The purpose of this study is to report the results of open and laparoscopic nephrectomy in living donors.

Materials and Methods

From January 1992 to August 2008, 37 living donor nephrectomies were performed. 23 nephrectomies were achieved by laparoscopic procedure (LDN) and 14 by open technique (ODN). The 2 groups were comparable regarding both donor and recipient characteristics.

Results

All laparoscopic nephrectomies were successfully performed without conversion to open procedure. No donor deaths were reported in either groups. 3 complications (13%) in the LDN group and 1 (7.1%) in the ODN group (p=0.6) were observed. Mean operative time was higher in the LDN group (p<0.036). Mean warm and cold ischemia time, resumption of oral intake and hospital stay were shorter in the LDN group (p<0.04)(p<0.03) (p<0.0001), whereas the return to normal occupational life was similar (p<0.52). We had no significant differences in the surgical complication rates, graft and patient survival.

Conclusions

Our experience suggests that both procedures can be used safely and efficiently, and assure a good renal function in the recipient. Laparoscopic nephrectomy, although more difficult, provides post-operative advantages. However, laparoscopic procedure must be performed by experienced centres only to prevent serious complications in the donor.

Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique

OBJECTIVES

To report a novel approach to overcome the problems associated with a short right renal vein harvested by clipping the vein during right laparoscopic donor nephrectomy (RLDN).

PATIENTS AND METHODS

This prospective study included 32 donors and their recipients; all donors had transperitoneal RLDN. The right renal artery and vein were ligated by Hem-o-lok and titanium clips, which resulted in a very short renal vein (<1.5 cm). When the kidney was positioned inverted in the recipient, the renal vein was placed posteriorly, adjacent to the external iliac vein, making a safe and simple venous anastomosis possible.

RESULTS

All RLDN were completed with no conversion or re-operation. The mean (range) warm ischaemia time was 9.59 (3-17) min and there was no malfunction of the vascular clips on the major vessels. After a mean follow-up of 14 months the recipient survival rate was 97%. Graft function was excellent, with a mean (sd) serum creatinine level of 1.35 (0.31) mg/dL at 3 months after surgery, and there was no renal artery or vein thrombosis in any of the grafts. There were two ureteric complications (6%), i.e. one ureterocutaneous fistula resolved by secondary ureteroureterostomy, and one stricture at the site of ureteric anastomosis, which was managed by ureteroneocystostomy.

CONCLUSION

The right renal vein obtained by LDN, after clipping the renal vein, is quite short, but by placing the kidney upside-down in the right iliac fossa transplantation is possible with no increased incidence of vascular thrombosis. This simple modification might obviate the need for removing a patch from the inferior vena cava, which is a challenging procedure for laparoscopic surgeons during RLDN.