Altering the Approach: Open Minimally Invasive Renal Transplant in Obese Patients Through the Anterior Rectus Sheath

Incisional hernias post renal transplant: a systematic review and meta-analysis

PURPOSE

Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT.

METHODS

PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported.

RESULTS

Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease.

CONCLUSIONS

IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis.

Wound related complications and the anterior rectus sheath versus Gibson approach to kidney transplantation: A single center randomized controlled trial

INTRODUCTION

Wound related complications (WRC) are a significant source of morbidity in kidney transplant recipients, and may be mitigated by surgical approach. We hypothesize that the anterior rectus sheath approach (ARS) may decrease WRC and inpatient opiate use compared to the Gibson Approach (GA).

METHODS

This double-blinded randomized controlled trial allocated kidney transplant recipients aged 18 or older, exclusive of other procedures, 1:1 to ARS or GA at a single hospital. The ARS involves a muscle-splitting paramedian approach to the iliopsoas fossa, compared to the muscle-cutting GA. Patients and data analysts were blinded to randomization.

RESULTS

Seventy five patients were randomized to each group between August 27, 2019 and September 18, 2020 with a minimum 12 month follow-up. There was no difference in WRC between groups (p = .23). Nine (12%) and three patients (4%) experienced any WRC in the ARS and GA groups, respectively. Three and one Clavien IIIb complications occurred in the ARS and GA groups, respectively. In a multiple linear regression model, ARS was associated with decreased inpatient opioid use (β = -58, 95% CI: -105 to -12, p = .016).

CONCLUSIONS

The ARS did not provide a WRC benefit in kidney transplant recipients, but may be associated with decreased inpatient opioid use.

Super-Minimal Incision Technique in Pediatric Kidney Transplantation: A Paired Kidney Analysis

BACKGROUND

Recently, the demand for minimally invasive techniques in kidney transplantation (MIKT) has increased. However, there is only a limited number of studies on MIKT, especially in pediatric kidney transplants. Hence, we evaluated whether there is a difference between the super-minimal incision technique in pediatric kidney transplantation (SMIPKT) and conventional kidney transplantation (CKT).

METHODS

Between December 2018 and November 2021, 34 patients who underwent pediatric kidney transplantation with a follow-up of 1 month were enrolled. A paired kidney analysis was performed to minimize donor variability and bias. The SMIPKT and CKT groups included 17 patients.

RESULTS

There was no difference in baseline clinical characteristics, including age, sex, the donor/ recipient weight ratio (DRWR), choice of dialysis modality, pretransplant dialysis time, BMI, renal artery number, cause of ESRD, DGF, length of the kidney and cold ischemic time, tacrolimus concentration at 3 and 7 days, serum creatinine at 1 month and postoperative complication rate between the SMIPKT and CKT groups (all P > 0.05). However, the length of the incision, operation time, intraoperative bleeding, postoperative drainage volume within 24 h and Vancouver scar scale at 1 month were statistically significant (all P < 0.05).

CONCLUSION

Compared with CKT, our results indicated that SMIPKT showed more satisfactory cosmetic results, shorter SMIPKT operating time, and reduced intraoperative bleeding and postoperative drainage volume within 24 h. There were also no statistical differences in postoperative complications. Hence, we suggest that SMIPKT is an appropriate method for pediatric kidney transplantation.

An Effective Cooling Device for Minimal-Incision Kidney Transplantation

BACKGROUND This study investigated the safety and efficacy of a new cooling device for use in minimal-incision kidney transplantation (MIKT). MATERIAL AND METHODS From June 2016 to December 2021, 9 patients underwent MIKT surgery in our hospitals using the new cooling device to maintain hypothermia. We recorded and analyzed information on the etiology, comorbid status, ongoing renal replacement assessment, BMI, HLA mismatching sites of donors and recipients, and perioperative and postoperative clinical data for recipients. RESULTS Kidney transplantation was successfully performed in all patients. The kidney surface temperature measurement results showed that the intraoperative renal anterior and posterior surface temperatures were stable at approximately 3.8±1.2°C and 5.2±1.3°C, respectively, during ice-water circulation. The mean operation time was 112±15 min, the artery anastomosis time was 16±6.0 min, and the vein anastomosis time was 14±4.5 min. All recipients recovered uneventfully. The patients were followed up for 6-30 months. Urinary and vascular complications were not found in any recipients. CONCLUSIONS The new cooling device can facilitate MIKT. It is safe and feasible to carry out MIKT using the new cooling device, which can reduce surgical trauma and improve the quality of vascular anastomosis with satisfactory cosmetic results.