Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy

Evolution of laparoscopic live donor nephrectomy: a single-center experience with 1510 cases over 14 years

OBJECTIVE

This study evaluated the outcomes of laparoscopic donor nephrectomy (LDN) and proposed modifications for kidney donation surgery. From February 1997 to February 2011, 1510 LDNs were performed.

PATIENTS AND METHODS

Surgical modifications included a modified open access technique for entry into the abdominal cavity, using vascular clips for safe and cost-effective control of the renal pedicle, control of the lumbar veins, and adrenal vein using bipolar cautery instead of clips, and leaving the gonadal vein intact with the ureter. Kidneys were extracted by hand through a Pfannenstiel incision. Heparin was not used after the first 300 cases to prevent potential hemorrhagic complications.

RESULTS

Although three major vascular injuries occurred using the closed access method that were managed successfully, no access-related complications occurred using the modified open access technique. Clip failure did not happen in any cases. Patient and graft survival at 1 year post-transplantation were 96.5% and 95.5%, respectively, and at 5 years post-transplantation were 95.3% and 89.5%, respectively.

CONCLUSION

The proposed surgical modifications are based on 14 years of experience and 1510 cases, and make LDN simple, safe, and cost-effective. The excellent recipient and graft outcomes with minimal morbidity obtained further confirm that LDN can be considered as the gold standard for kidney donation surgery.

Laparoscopic donor nephrectomy

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

[Laparoscopic nephrectomy in a living donor]

Kidney transplantation is the therapeutic option of choice for patients with end-stage renal disease. With the advent of safer harvesting techniques and immunosuppression, both donor and recipient outcomes have markedly improved in recent years. Kidney donation from Living donors remains the single most important factor responsible for improving patient and graft survival. The laparoscopic donor nephrectomy has revolutionized renal transplantation, allowing expansion of the donor pool by diminishing surgical morbidity while maintaining equivalent recipient outcome. This technique is now becoming the gold-standard harvesting procedure in transplant centres worldwide, despite its technical challenge and ongoing procedural maturation, especially early in the learning curve. Previous contraindications to laparoscopic donor nephrectomy are no longer absolute. In the following analysis, the procedural aspects of the laparoscopic donor nephrectomy are detailed including pre-operative assessment, operative technique and a review of the current literature delineating aspects of both donor and recipient morbidity and mortality compared with open harvesting techniques.

Outcome of Renal Transplantation with Multiple Versus Single Renal Arteries After Laparoscopic Live Donor Nephrectomy: A Comparative Study

OBJECTIVES

To compare donor morbidity and recipient outcomes in patients with a single artery versus multiple arteries undergoing laparoscopic donor nephrectomy.

METHODS

A total of 303 consecutive laparoscopic donor nephrectomies were performed. Data from the group with multiple arteries (n = 27) (group I) were compared with those from the groups with single renal artery (n = 245) (group IIA) and early branching renal artery resulting in two artery recipient anastomoses (n = 31) (group IIB), in terms of donor and recipient outcomes.

RESULTS

Laparoscopic donor nephrectomy was technically successful in all 303 patients without need for open conversion. The graft retrieval time was higher in group I and group IIB compared with group IIA (3.9 +/- 1.4 and 3.9 +/- 0.8 versus 3.5 +/- 1.0 minutes). Similarly, warm ischemia time was significantly higher in groups I and IIB versus group IIA (7.2 +/- 1.9 and 6.7 +/- 1.9 versus 5.6 +/- 1.8 minutes). Creatinine level at day 1 was higher in group I compared with group IIA (2.4 +/- 1.4 versus 1.9 +/- 0.7 mg/dL). However, there was no significant difference in creatinine levels at 1 month and 1 year among the three groups. Overall graft survival in groups I, IIA, and IIB was 92%, 94.4%, and 94%, respectively.

CONCLUSIONS

Laparoscopic donor nephrectomy in the presence of multiple renal arteries is feasible and safe. Additionally, long-term graft survival and graft function at 1 month and 1 year are not adversely impacted by the presence of multiple renal arteries in grafts procured laparoscopically.

Hand port use for extraction during laparoscopic donor nephrectomy

OBJECTIVES

To report our technique of laparoscopic donor nephrectomy using the hand port for specimen extraction. In 1999, our institution began a kidney transplant program. Donor nephrectomies have since been exclusively performed laparoscopically. Early in our experience, we used a specimen extraction bag to assist in graft removal, but encountered some complications. We subsequently changed our technique to include a hand port for specimen extraction.

METHODS

A database of our experience was kept prospectively. The records of both donors and recipients were reviewed. We describe our technique of laparoscopic donor nephrectomy, including our new method of specimen extraction using a hand port.

RESULTS

A total of 230 consecutive procedures were reviewed. We had excellent donor outcomes, including a mean operative time of 107.9 minutes and an estimated blood loss of 112.4 mL. In addition, the complication (12.6%) and open conversion (1.3%) rates were low. The time needed for specimen extraction decreased from 3.16 minutes to 1.16 minutes (P <0.05) after implementation of the hand port.

CONCLUSIONS

The hand port modification decreased the extraction time and allowed for a safer method of extraction. We believe that the hand port facilitates a procedure that contains a small margin of error.

A cost-effective technique for pure laparoscopic live donor nephrectomy

OBJECTIVE

Compare two different techniques for laparoscopic live donor nephrectomy (LDN), related to the operative costs and learning curve.

MATERIALS AND METHODS

Between April/2000 and October/2003, 61 patients were submitted to LDN in 2 different reference centers in kidney transplantation. At center A (CA), 11 patients were operated by a pure transperitoneal approach, using Hem-O-Lok clips for the renal pedicle control and the specimens were retrieved manually, without using endobags. At center B (CB), 50 patients were also operated by a pure transperitoneal approach, but the renal pedicles were controlled with endo-GIA appliers and the specimens were retrieved using endobags.

RESULTS

Operative time (231 +/- 39 min vs. 179 +/- 30 min; p < 0.000), warm ischemia time (5.85 +/- 2.85 min vs. 3.84 +/- 3.84 min; p = 0.002) and blood loss (214 +/- 98 mL vs. 141 +/- 82 mL; p = 0.02) were statistically better in CB, when compared to CA. Discharge time was similar in both centers. One major complication was observed in both centers, leading to an open conversion in CA (9.1%). One donor death occurred in CB (2%). Regarding the recipients, no statistical difference was observed in all parameters analyzed. There was an economy of US$1.440 in each procedure performed in CA, when compared to CB.

CONCLUSIONS

Despite the learning curve, the technique adopted by CA, showed no deleterious results to the donors and recipients when compared with the CB. On the other hand, this technique was cheaper than the technique performed in the CB, representing an attractive alternative for LDN, mainly in developing centers.

Laparoscopic donor nephrectomy: an update

PURPOSE OF REVIEW

Laparoscopic donor nephrectomy is considered the gold standard for renal donation. In the hands of experienced laparoscopists it provides a safe and equally effective alternative to open nephrectomy, and recipient graft function has been shown to be equivalent regardless of the procurement method utilized. Complication rates and postoperative donor renal function are equivalent to that of open nephrectomy, whereas recovery time is significantly shorter and surgical scars more cosmetic with the laparoscopic approach.

RECENT FINDINGS

Advances in preoperative imaging and laparoscopic technique have enabled surgeons to broaden the patient population considered for donor nephrectomy. Improved three-dimensional imaging facilitates operative planning and intraoperative dissection, and the retroperitoneoscopic approach has decreased operative time. Acquisition of laparoscopic skills has also enabled surgeons to perform donor nephrectomies on kidneys that previously would have been considered less desirable for donation (e.g. right-sided or with anomalous vasculature).

SUMMARY

End-stage renal disease and the need for renal transplantation continue to be major medical concerns in the United States and worldwide. Advances in donor nephrectomy have reduced the demand for organs by increasing the potential organ pool while limiting risk to donors. As imaging and laparoscopic techniques continue to advance, it is anticipated that minimally invasive donor nephrectomy will continue to evolve. This review summarizes the developments to date.

Terminal hand-assist for laparoscopic donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices.

METHOD

The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible.

RESULTS

Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 +/- 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days.

CONCLUSIONS

Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.

HALS Devices and Operating Room Set-Up: Pearls and Pitfalls

Although some surgeons maintain that such devices are not necessary, most prefer a hand-assist device for the performance of hand-assisted laparoscopy. The three devices now available are the Gelport, LapDisc, and Omniport. None is perfect, and the choice depends in part on surgeon preference and patient body habitus. Each has advantages and disadvantages, and there is room for improvement, especially in the ease of hand removal and reinsertion, sturdiness and reliability, and ability to maintain the pneumoperitoneum. Beginning laparoscopic surgeons are advised to try all three devices and formulate their own opinions. As important as the hand-assist device is the operating room set-up. The authors provide a checklist covering the imaging system, insufflation equipment, hemostatic generators, and instrumentation.

Prospective experience with a second-generation hand-assisted laparoscopic device and comparison with first-generation devices

BACKGROUND AND PURPOSE

The GelPort Hand-Assisted Laparoscopy (HAL) device was licensed for use in the U.K. in September 2001. We compared our experience with this second-generation device with that of first-generation devices; i.e., the Handport, launched in 1999, and the Intromit, first marketed in 1998.

MATERIALS AND METHODS

We prospectively compared a number of parameters for operations performed using the GelPort (13 radical nephrectomies, 4 nephroureterectomies) with those performed using the Handport (3 radical nephrectomies, 2 nephroureterectomies, 2 simple nephrectomies) and the Intromit (2 radical nephrectomies, 1 nephroureterectomy, 2 simple nephrectomies). The main outcome measures were ease of application, time required to place the device, and perioperative complications specific to the device.

RESULTS

The device requiring the longest time to place was the Intromit (average 15 minutes) followed by the HandPort (average 10 minutes) and then the GelPort (average 5 minutes). There were two leaks with the Intromit (one major and one minor). Pop-outs were a frequent issue with the HandPort, necessitating repeated replacement and resufflation. There was also a need to resufflate every time the hand was removed for a change of swab. None of these problems was noted with the GelPort, which was also found to be the easiest to use. The major disadvantage of the GelPort was its price, which was about a third more than that of the first-generation devices.

CONCLUSION

The GelPort is currently a more user-friendly and robust HAL device. It is, however, more expensive than first-generation devices.

[Laparoscopic transperitoneal donor nephrectomy. Technique and results]

Living donor kidney transplantation is one possibility to meet the growing demand for organs in patients with chronic renal failure. In 1995 the first laparoscopic living donor nephrectomy (LDN) was performed in the United States. More than 100 transplant centers worldwide perform LDN. The expectations of a larger number of willing organ donors were fulfilled due to the less traumatic operation. Meanwhile, several techniques exist to retrieve a kidney laparoscopically, including the trans- or retroperitoneal, strictly laparoscopic, or hand-assisted approach. From February 1999 to September 2002, 63 strictly laparoscopic, transperitoneal LDNs were performed at the Department of Urology of the Charité University Hospital, Berlin. Warm ischemic time was 148 s (105-360) and operating time was 203 min (110-305). Intraoperative complications were due to insufficient closure of the vessels in four patients. Mean postoperative hospital stay was 5.7 days (3-9). One year after LDN, renal function as well as creatinine levels of the recipient showed no difference compared to the organs harvested via the approach at our department prior to implementation of LDN. Strictly laparoscopic transperitoneal donor nephrectomy is a safe method for kidney retrieval and ensures excellent graft function.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience

PURPOSE

We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions.

MATERIALS AND METHODS

We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures.

RESULTS

Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions).

CONCLUSIONS

Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience

PURPOSE

We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions.

MATERIALS AND METHODS

We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures.

RESULTS

Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions).

CONCLUSIONS

Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.