Laparoscopic live donor nephrectomy

Laparoscopic management of chylous ascites following laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) is an established operation for organ procurement in living donor transplantation. Living donor renal transplantation is being performed more frequently and is associated with better graft function and survival. The minimal access approach for organ procurement from healthy individuals ensures early convalescence and improved patient participation. Here we describe a rare complication of LDN. Postoperative chylous ascites frequently occurs secondary to aortic surgery. Though previously described after LDN, its treatment remains contentious. Conventional strategies have adopted an expectant approach with medical management. These include parenteral feeding, bowel rest and somatostatin analogue usage. We report laparoscopic suture ligation as the principal management of postoperative chyle leak. We advocate surgical exploration in acute onset, high output chylous ascites. Pre-existing port site incisions were used for undertaking successful laparoscopic repair. This surgical approach enabled faster convalescence and reduced hospital stay-important considerations for our healthy living donor.

Non-invasive monitoring of tissue oxygenation during laparoscopic donor nephrectomy

Background

Standard methods for assessment of organ viability during surgery are typically limited to visual cues and tactile feedback in open surgery. However, during laparoscopic surgery, these processes are impaired. This is of particular relevance during laparoscopic renal donation, where the condition of the kidney must be optimized despite considerable manipulation. However, there is no in vivo methodology to monitor renal parenchymal oxygenation during laparoscopic surgery.

Methods

We have developed a method for the real time, in vivo, whole organ assessment of tissue oxygenation during laparoscopic nephrectomy to convey meaningful biological data to the surgeon during laparoscopic surgery. We apply the 3-CCD (charge coupled device) camera to monitor qualitatively renal parenchymal oxygenation with potential real-time video capability.

Results

We have validated this methodology in a porcine model across a range of hypoxic conditions, and have then applied the method during clinical laparoscopic donor nephrectomies during clinically relevant pneumoperitoneum. 3-CCD image enhancement produces mean region of interest (ROI) intensity values that can be directly correlated with blood oxygen saturation measurements (R² > 0.96). The calculated mean ROI intensity values obtained at the beginning of the laparoscopic nephrectomy do not differ significantly from mean ROI intensity values calculated immediately before kidney removal (p > 0.05).

Conclusion

Here, using the 3-CCD camera, we qualitatively monitor tissue oxygenation. This means of assessing intraoperative tissue oxygenation may be a useful method to avoid unintended ischemic injury during laparoscopic surgery. Preliminary results indicate that no significant changes in renal oxygenation occur as a result of pneumoperitoneum.

Contrast enhancement for in vivo visible reflectance imaging of tissue oxygenation

Results are presented illustrating a straightforward algorithm to be used for real-time monitoring of oxygenation levels in blood cells and tissue based on the visible spectrum of hemoglobin. Absorbance images obtained from the visible reflection of white light through separate red and blue bandpass filters recorded by monochrome charge-coupled devices (CCDs) are combined to create enhanced images that suggest a quantitative correlation between the degree of oxygenated and deoxygenated hemoglobin in red blood cells. The filter bandpass regions are chosen specifically to mimic the color response of commercial 3-CCD cameras, representative of detectors with which the operating room laparoscopic tower systems are equipped. Adaptation of this filter approach is demonstrated for laparoscopic donor nephrectomies in which images are analyzed in terms of real-time in vivo monitoring of tissue oxygenation.

Can magnetic resonance angiogram be a reliable alternative for donor evaluation for laparoscopic nephrectomy?

BACKGROUND

While hand-assisted laparoscopic donor nephrectomy (HLDN) is less invasive, which can encourage kidney donation, it requires more exact information about the renal vascular anatomy because of its limited visual field during nephrectomy. MRA is also an attractive choice because of its minimal invasiveness; further, it is an outpatient-based procedure, it uses non-nephrotoxic contrast material and it has no radiation. The aim of our study was to evaluate the effectiveness of gadolinium enhanced three-dimensional MRA (GdE-3D MRA) in a group of potential live donors who were candidates for HLDN.

METHODS

From September 2002 to December 2004, 40 potential live renal donors were evaluated prospectively with GdE-3D MRA, and this imaging modality was performed before the gold standard, the intra-arterial digital subtraction angiogram (IA-DSA), was carried out. All the images were reviewed in a blinded manner by the attending vascular radiologist. The MRA findings were compared with the DSA findings and the surgical findings as the reference methods. We evaluated the accuracy of MRA for imaging the renal architectures, and especially for imaging the renal accessory arteries and the early branching arteries that are important determinants for selection of the donor kidney.

RESULTS

Both the MRA and DSA images showed consistent findings with the surgical findings in 92.5% of the 40 donors. There were no discrepant cases in depicting the main renal artery. MRA showed 100% specificity for imaging both the renal accessory arteries and the early branching arteries, when compared with the surgical findings. The kappa values for the MRA and DSA for the accessory arteries were all 0.66 compared with the intraoperative findings. MRA also depicted one huge renal cyst in one donor and many small renal cysts in the other donors that could not be imaged by DSA. There were no adverse events during the MRA procedure. None of the findings missed by MRA resulted in deleterious consequences at laparoscopic nephrectomy for the donor and graft.

CONCLUSIONS

Our limited experience with GdE-3D MRA for imaging the renal structures in kidney donor evaluation for HLDN has been quite satisfactory.