Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy: Experience from the First 75 Consecutive Cases

Chylous Ascites After Robot-Assisted Laparoscopic Donor Nephrectomy: Is Early Surgical Intervention Necessary?

OBJECTIVES

Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robotassisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites.

MATERIALS AND METHODS

We reviewed the medical records of 424 laparoscopic living donor nephrectomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy.

RESULTS

Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet.

CONCLUSIONS

Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robotassisted donor laparoscopic nephrectomy.

Management of Chylous Ascites After Laparoscopic Nephrectomy for Living Kidney Donor: A Case Report and Literature Review

Kidney transplant is currently the elective treatment of choice for end-stage renal disease. Laparoscopic living donor nephrectomy (LLDN) has substantial advantages over open nephrectomy. Chylous ascites (CA) is a rare surgical complication after the LLDN; there are few reports in the literature. We present a case report of a 58-year-old woman who started CA on the 21st day post operation. The recommended initial therapeutic approach to suspend the fat in the diet and place percutaneous drainage was not enough. It was decided to jointly introduce fasting and total parenteral nutrition with the administration of octreotide, resolving the complication completely in 15 days with no need for the patient to undergo surgery. The conservative management, during the first 4 to 8 weeks after the diagnosis is the best option. Surgery is generally recommended if conservative management fails. The prevalence of CA varied between 0% and 6.2% of LLDNs. In our experience of 87 LLDNs, we only presented 1.15% for this complication. There are 62 cases reported in the international literature. The mean presentation was 14 days after LLDN. All patients underwent conservative treatment, and only 15 patients (24%) went to surgery after the failure of conservative management. It would be highly useful, considering the disparity of the prevalence, if the bibliographic reports detail what hemostatic and sealing techniques are used in an LLDN. In this way it would be possible to identify which factor affects a complication like this one.

Preoperative assessment system for hand-assisted laparoscopic donor nephrectomy by discriminant analysis

We developed a preoperative assessment system to predict surgical workload in hand-assisted laparoscopic donor nephrectomy (HALDNx) using the normal-based linear discriminant rule (NLDR). A total of 128 cases of left HALDNx performed by a single operator were used as training data. Surgical workload was measured by operative time. The optimized model had 9 explanatory variables: age, total protein, total cholesterol, number of renal arteries (numberRA), 4 variables of perinephric fat (PNF), and thickness of subcutaneous fat. This model was validated using cross-validation and the .632 estimator to estimate discrimination rates with future test data. PNF and numberRA were the predominant factors affecting workload followed by the computed tomography value of PNF, body weight, and male sex. The estimated accuracy of the prediction system was 94.6%. The complication rate was 9.38% and did not correlate with surgical workload. We also made our program available online for constructing assessment functions from other cohort data. In conclusion, the surgical workload of HALDNx could be predicted with PNF and numberRA as the dominant risk factors.

Chylous Ascites: Complication of Laparoscopic Donor Nephrectomy. Case Report and Review of Literature

BACKGROUND

Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes the importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment.

METHODS

A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using "chyle," "complications," and "laparoscopic donor nephrectomy" as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described.

RESULTS

Fifty-four cases of chyle leak/ascites have been reported after LDN in literature to date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parenteral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large-volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up.

CONCLUSIONS

Chylous ascites is a rare complication after donor nephrectomy in experienced centers. Although conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.

Hand-assisted laparoscopic retroperitoneal donor nephrectomy: A single-institution experience of over 500 cases-Operative technique and clinical outcomes

OBJECTIVE

Although there are several variations of laparoscopic living-donor nephrectomies, there is no consensus as to the best technique. Our objective was to describe our technique and assess the outcomes of our approach to hand-assisted laparoscopic retroperitoneal donor nephrectomies.

METHODS

From July 2001 to October 2015, 507 consecutive hand-assisted laparoscopic retroperitoneal donor nephrectomies were performed. Their clinical information was retrospectively reviewed including warm ischemia time, skin incision to kidney ready time, estimated blood loss, adverse intraoperative events, and postoperative complications.

RESULTS

Mean incision time to kidney removal was 135 minutes (55-260), mean warm ischemia time was 125 seconds (30-390), and mean blood loss was 83 mL (20-500). Average length of stay was 3 days (1-6). There were no significant differences between left and right kidney donors based on demographics, length of hospital stay, or warm ischemia time. There were no conversions to open surgery. Complications occurred in 4.9% of patients (25/507), including 4 cases of perioperative bleeding.

CONCLUSIONS

This is a single-center series describing the safety and efficacy of the hand-assisted laparoscopic retroperitoneal donor nephrectomy for both right and left sides. It does not require intraperitoneal manipulation and allows for safe extraction of either kidney with minimal warm ischemia time.

A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature

OBJECTIVES

Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy.

MATERILAS AND METHODS

In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described.

RESULTS

Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition.

CONCLUSIONS

Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.

Should hand-assisted retroperitoneoscopic nephrectomy replace the standard laparoscopic technique for living donor nephrectomy? A meta-analysis

OBJECTIVE

We performed this meta-analysis to compare hand-assisted retroperitoneoscopic (HARP) and traditional laparoscopic (TLS) techniques for living donor nephrectomy.

METHODS

We searched PubMed, Cochrane Central, EMBASE, and Web of science for prospective studies, comparing HARP and TLS techniques. Data were extracted from eligible studies and pooled as risk ratios (RR) or standardized mean difference (SMD), using RevMan software (version 5.3 for windows). We performed a sensitivity analysis to test the robustness of our evidence and a subgroup analysis to stratify intraoperative complications on Clavien-Dindo score.

RESULTS

Seven studies (498 patients) were included in the final analysis. HARP was superior to TLS in terms of shortening the operative duration (SMD = -0.84, 95% CI [-1.18 to -0.50]) and warm ischemia time (SMD = -0.93, 95% CI [-1.13 to -0.72]). There was no significant difference between HARP and TLS in terms of blood loss (SMD = 0.13, 95% CI [-0.50 to 0.76]), hospital stay (SMD = -0.27, 95% CI [-0.70 to 0.15]) or graft survival (RR = 0.97, 95% CI [0.92 to 1.02]). The overall risk ratio of intraoperative complications did not differ significantly between the two groups (RR = 0.62, 95% CI [0.31 to 1.21]).

CONCLUSION

Our meta-analysis shows that HARP was associated with a shorter surgery duration and less warm ischemia time than TLS. However, no significant differences were found between the two groups in terms of graft survival or intraoperative complication rates. We recommend HARP over TLS for living donor nephrectomy; however, future studies with larger sample sizes are recommended to compare both techniques in terms of operative safety and quality of life outcomes.

Implantation of Autologous Selected Renal Cells in Diabetic Chronic Kidney Disease Stages 3 and 4-Clinical Experience of a "First in Human" Study

Introduction

Animal models of chronic kidney disease demonstrate that a redundant population of therapeutically bioactive selected renal cells (SRCs) can be delivered to the kidney through intraparenchymal injection and arrest disease progression. Direct injection of SRCs has been shown to attenuate nuclear factor-κB, which is known to drive tissue inflammation, as well as the transforming growth factor-β-mediated plasminogen activator inhibitor-1 response that drives tissue fibrosis.

Methods

We present experience from the first-in-human clinical study with SRCs. Seven male type 2 diabetic patients (63 ± 2 years of age) with chronic kidney disease stage 3 to 4 (estimated glomerular filtration rate 25 ± 2 ml/min) were recruited. After blood and urine sampling, iohexol clearance, magnetic resonance imaging, and renal scintigraphy, patients underwent ultrasound-guided renal biopsy. Two cores of renal tissue were shipped to the manufacturing plant for cell isolation, culture, and product preparation. Formulated SRCs were transported back to study sites (range 59-87 days after biopsy) for intracortical injection using a retroperitoneoscopic technique.

Results

Laparoscopically assisted implantation of SRCs was uneventful in all patients. However, postoperative complications were common and suggest that other techniques of SRC delivery should be used. Kidney volume, split function, and glomerular filtration rate did not change during 12 months of follow-up. An extended 24-month follow-up in 5 of the patients showed a decline in estimated glomerular filtration rate (cystatin C).

Discussion

Postoperative complications following retroperitoneoscopic implantation of SRC in the kidney cortex seem to be related to the surgical procedure rather than to injection of the cell product. No changes in renal function were observed during the original 12-month protocol. Beyond the first 12 months after cell implantation, individual renal function began to deteriorate during further follow-up.

Can right-sided hand-assisted retroperitoneoscopic donor nephrectomy be advocated above standard laparoscopic donor nephrectomy: a randomized pilot study

Endoscopic techniques have contributed to early recovery and increased quality of life (QOL) of live kidney donors. However, laparoscopic donor nephrectomy (LDN) may have its limitations, and hand-assisted retroperitoneoscopic donor nephrectomy (HARP) has been introduced, mainly as a potentially safer alternative. In a randomized fashion, we explored the feasibility and potential benefits of HARP for right-sided donor nephrectomy in a referral center with longstanding expertise on the standard laparoscopic approach. Forty donors were randomly assigned to either LDN or HARP. Primary outcome was operating time, and secondary outcomes included QOL, complications, pain, morphine requirement, blood loss, warm ischemia time, and hospital stay. Follow-up time was 1 year. Skin-to-skin time did not significantly differ between both groups (162 vs. 158 min, P = 0.98). As compared to LDN, HARP resulted in a shorter warm ischemia time (2.8 vs. 3.9 min, P < 0.001) and increased blood loss (187 vs. 50 ml, P < 0.001). QOL, complication rate, pain, or hospital stay was not significantly different between the groups. Right-sided HARP is feasible but does not confer clear benefits over standard right-sided LDN yet. Further studies should explore the value of HARP in difficult cases such as the obese donor and the value of HARP for transplantation centers starting a live kidney donation program (Dutch Trial Register number: NTR3096). Nevertheless, HARP is a valuable addition to the surgical armamentarium in live donor surgery.

Retroperitoneal hand-assisted laparoscopic nephrectomy and partial nephrectomy

The purpose of the present paper is to describe our technique and experience with retroperitoneal hand-assisted laparoscopic (HAL) nephrectomies as an alternative to the transperitoneal approach. Eight retroperitoneal HAL nephrectomies and one partial nephrectomy were performed. Several excisional techniques were employed incorporating the Harmonic scalpel or Ligasure device. Hemostatic agents were used to cover the renal defect. Surgical bolsters were sutured to the renal capsule with pleget reinforcements to aid in hemostasis. The average operative time was 210 min and estimated blood loss 110 mL. Mean change in hematocrit was 3 units and creatinine was 1 point. No patient required a transfusion. There were no major complications, with a mean follow-up of fourteen months. On average, patients resumed oral intake in 2 days, and were discharged in 3 days. Pathological examination revealed that two lesions were benign and seven malignant. Tumor diameter averaged 3 cm. There were no positive surgical margins. In conclusion, we have demonstrated the feasibility of retroperitoneal laparoscopic hand-assisted nephrectomy and partial nephrectomy surgery for solid renal masses.

Chylous ascites after laparoscopic hand-assisted donor nephrectomy: Is it specific for the left-side?

We describe a case-report of a chylous ascites after laparoscopic donor nephrectomy, summarize the current literature, and hypothesize on the etiology of this complication.

[Surgical aspects of living donor nephrectomy]

CONTEXT

Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication.

OBJECTIVE

To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication.

EVIDENCE ACQUISITION

A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy.

CONCLUSIONS

Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.

Comparing Surgical Complications of Donors and Recipients in Retroperitoneoscopic versus Mini-Incision Donor Nephrectomy: A Single-Center Experience

Anterior vertical mini-incision donor nephrectomy (MIDN) has been used as the standard retrieval procedure in our center. Though the MIDN approach was tolerated very well with low complication rates, there were especially cosmetic reasons, to consider a change of procedure. Hence we switched to a total retroperitoneoscopic donor nephrectomy (RPDN) in 2011. We compared the outcome and surgical complications of donors and recipients of the first 30 RPDNs performed with 30 consecutive MIDN procedures. In both techniques, right and left nephrectomies were carried out. After a very short learning curve, the mean RPDN operation times were shorter compared to the MIDN (109 versus 171 min, P<0.01) and donors were discharged earlier. No major complications occurred in the RPDN group and complications were less frequent compared to MIDN (17% versus 40%). The renal function in the recipients was equivalent in both groups at the time of discharge and after one year. We conclude that RPDN is easy to learn for a surgical team experienced in open retroperitoneal donor nephrectomy. The change of the retrieval technique is safe for the donor and the recipient regarding surgical complications and recipients’ renal function. Donors benefit from RPDN due to earlier hospital discharge and faster recovery.

Chyle Leak following Open Donor Nephrectomy: A Rare Complication-A Case Report

Introduction. Donor workup in renal transplantation is extensive. Despite this, chyle leakage following donor nephrectomy, a rare complication, has been reported in the literature. We encountered two cases of chyle leak in kidney donors in our series of open donor nephrectomies. Summary of Cases. After complete workup, standard open retroperitoneal donor nephrectomy with drain placement was performed in 684 living renal donors. We encountered chyle leak in two cases. The first case was a 33-year-old female who underwent an otherwise uneventful left donor nephrectomy but continued to have high drain output (upto 300–400 mL/24 hrs) in the postoperative period. The drain fluid was milky, raising the suspicion of chyle which was confirmed on biochemical analysis. The second case was a 42-year-old female with a similar case history. Both were managed conservatively with low-fat diet. The leak subsided spontaneously in three weeks and one week in the first and second patients, respectively. The drain was removed, and the patients remained symptom-free on followup. Conclusions. Both of our cases of chyle leak following open donor nephrectomy were managed successfully with conservative management. The management options and the experience of other centers are reviewed and discussed.

Technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy: a single-center experience

OBJECTIVES

To report a single-center experience and technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy (HARLDN).

METHODS

A total of 78 living donors underwent HARLDN from June 2004 to November 2009. We used a three-port, finger-dissecting, routine retroperitoneal approach. After almost complete mobilization of the kidney, the renal pedicle was dissected to expose the renal vessels. The ureter was dissected and divided at the level of the iliac vessels. An approximately 7-cm Gibson incision was made as the hand-assisted port. The surgeon's hand was introduced through this incision directly. With hand assistance, the renal artery was clipped using two Hem-o-lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. Then the kidney was rapidly removed through the incision by hand.

RESULTS

HARLDN was effectively and safely completed in 78 (100%) donors. No conversion to an open operation was necessary. The mean operative time and mean warm ischemic time were 121 minutes (range, 90-134) and 146 seconds (range, 112-247) respectively. The mean blood loss was 61 mL (range, 32-85). Clavien 1 complications including subcutaneous emphysema in 5.1% (4/78). The mean visual analog scales on postoperative days 1 to 5 were: 2.5, 1.2, 0.8, 0.5, and 0.1, respectively. The mean time to resume oral diet was 1.5 days. The mean hospital stay was 4.5 days (range, 4-5). The mean level of postoperative serum creatinines of the donors at 7 days and 1 month thereafter were 1.06 mg/dL (range, 0.74-1.43) and 1.15 mg/dL (range, 0.79-1.61) mg/dL, respectively. The mean level of postoperative serum creatinines of the recipients at 7 days and 1 month were 1.40 mg/dL (range 0.81-1.67) and 1.52 mg/dL (range, 0.76-1.83), respectively. The mean incision length was 6.5 cm (range, 6.0-7.2).

CONCLUSIONS

The modified HARLDN combines the purely laparoscopic technique with quicker, safer organ retrieval by the open access.

Efficacy and safety of continuous local infusion of ropivacaine after retroperitoneoscopic live donor nephrectomy

Morphine-based analgesia is effective but can compromise donor safety. We investigated whether continuous infusion of local anesthetics (CILA) can provide sufficient pain control and reduce morbidity related to opiate analgesics after hand-assisted retroperitoneoscopic (HARS) live donor nephrectomy. Forty consecutive live kidney donors underwent HARS and were treated with the ON-Q system providing CILA with 0.5% ropivacaine through two SilvaGard catheters placed in the retroperitoneal cavity and the rectus sheath, respectively. The case control group consisted of 40 donors matched with regard to sex, age, BMI and surgical technique. All donors were maintained on standardized multimodal analgesia combining nurse-controlled oxycodone treatment and acetaminophen. CILA donors had lower median cumulative consumption of morphine equivalents (CCME) (7 mg [0-56] vs. 42 mg [15-127]; p < 0.0000001), lower incidence of nausea (18 [45%] vs. 35 [87.5%] donors; p < 0.001), shorter time in postoperative care unit (160 vs. 242.5 min; p < 0.001) and shorter hospital stay (4 [4-7] vs. 6 [4-11] days; p < 0.001). In 32.5% of CILA donors the CCME was 0 mg (0% in matched control group, p < 0.001). CILA with 0.5% ropivacaine provides effective postoperative pain relief, reduces the need for opioid treatment and promotes postoperative recovery.

Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand-assisted approach

The retroperitoneoscopic (RP) approach to live donor nephrectomy (LDN) may be advantageous for the donor because it avoids mobilization of peritoneal organs and provides direct access to the renal vessels. Notwithstanding, this approach is not popular, likely because of the steeper learning curve. We feel that hand-assistance (HA) can reduce the learning curve and in this study, we present our experience with a novel hand-assist approach to retroperitoneoscopic live donor nephrectomy (HARP-LDN). Over a one-yr period, 10 consecutive patients underwent left HARP-LDN with a mean body mass index of 29 and three with prior left abdomen surgery. The surgical technique utilizes a 7 cm, muscle-sparing incision for the hand-port with two endoscopic ports. Operative time was an average of 155 min., with no open conversions. Mean blood loss was 68 mL, and warm ischemia time was 2.5 min. Hospital stay averaged 2.7 d with postoperative complications limited to one urinary retention. Our modified HARP approach to left LDN is safe, effective and can be performed expeditiously. Our promising initial results require a larger patient cohort to confirm the advantages of the hand-assisted retroperitoneal technique.

Hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy: HARP-trial

Background

Transplantation is the only treatment offering long-term benefit to patients with chronic kidney failure. Live donor nephrectomy is performed on healthy individuals who do not receive direct therapeutic benefit of the procedure themselves. In order to guarantee the donor's safety, it is important to optimise the surgical approach. Recently we demonstrated the benefit of laparoscopic nephrectomy experienced by the donor. However, this method is characterised by higher in hospital costs, longer operating times and it requires a well-trained surgeon. The hand-assisted retroperitoneoscopic technique may be an alternative to a complete laparoscopic, transperitoneal approach. The peritoneum remains intact and the risk of visceral injuries is reduced. Hand-assistance results in a faster procedure and a significantly reduced operating time. The feasibility of this method has been demonstrated recently, but as to date there are no data available advocating the use of one technique above the other.

Methods/design

The HARP-trial is a multi-centre randomised controlled, single-blind trial. The study compares the hand-assisted retroperitoneoscopic approach with standard laparoscopic donor nephrectomy. The objective is to determine the best approach for live donor nephrectomy to optimise donor's safety and comfort while reducing donation related costs.

Discussion

This study will contribute to the evidence on any benefits of hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy.

Trial Registration

Dutch Trial Register NTR1433

Chylous ascites requiring surgical intervention after donor nephrectomy: case series and single center experience

Chylous ascites as a result of laparoscopic donor nephrectomy (LDN) is a rare complication that carries significant morbidity, including severe protein-calorie malnutrition and an associated immunocompromised state. We report a patient who underwent hand-assisted left LDN and subsequently developed chylous ascites. He failed conservative therapy including low-fat diet with medium-chain triglycerides (LFD/MCT) and oral protein supplementation as well as strict NPO status with intravenous (IV) total parenteral nutrition (TPN) and subcutaneous (SQ) somatostatin analogue administration. Laparoscopic re-exploration and intracorporeal suture ligation and clipping of leaking lymph channels successfully sealed the chyle leak. We review the literature to date including diagnosis, incidence, management options, psychosocial aspects and clinical outcomes of chylous ascites after LDN.

Chylous ascites requiring surgical intervention after donor nephrectomy: case series and single center experience

Chylous ascites as a result of laparoscopic donor nephrectomy (LDN) is a rare complication that carries significant morbidity, including severe protein-calorie malnutrition and an associated immunocompromised state. We report a patient who underwent hand-assisted left LDN and subsequently developed chylous ascites. He failed conservative therapy including low-fat diet with medium-chain triglycerides (LFD/MCT) and oral protein supplementation as well as strict NPO status with intravenous (IV) total parenteral nutrition (TPN) and subcutaneous (SQ) somatostatin analogue administration. Laparoscopic re-exploration and intracorporeal suture ligation and clipping of leaking lymph channels successfully sealed the chyle leak. We review the literature to date including diagnosis, incidence, management options, psychosocial aspects and clinical outcomes of chylous ascites after LDN.

Randomized clinical trial of laparoscopic versus open donor nephrectomy

Background

This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short-incision open donor nephrectomy (ODN).

Methods

Eighty-four live kidney donors were randomized in a 2 : 1 ratio to LDN (56 patients) or short-incision ODN without rib resection (28). Primary endpoints were pain relief and duration of inpatient stay.

Results

There was no donor death or allograft thrombosis in either group. The first warm ischaemic time median (range) 4 (2–7) versus 2 (1–5) min; P = 0·001) and the duration of operation (160 (110–250) versus 150 (90–200); P = 0·004) were longer for LDN. LDN led to a reduction in parenteral morphine requirement 59 (6–136) versus 90 (35–312) mg; P = 0·001) and hospital stay (4 (2–6) versus 6 (2–9) days; P = 0·001), and earlier return to employment (42 (14–84) versus 66·5 (14–112) days; P = 0·004). Postoperative respiratory function was improved after LDN. There were more postoperative complications per donor in the ODN group (0·6(0·7) versus 0·3(0·5); P = 0·033). At a median follow-up of 74 months, there were no differences in renal function or allograft survival between the groups.

Conclusion

LDN removes some of the disincentives to live donation without compromising the outcome of the recipient transplant.

Comparative study of in vivo lymphatic sealing capability of the porcine thoracic duct using laparoscopic dissection devices

PURPOSE

Sealing the lymphatic vessels during abdominal and pelvic surgery is important to prevent the leakage of lymphatic fluid and its resultant sequelae. To our knowledge we compared for the first time the quality of lymphatic sealing by each of 4 commonly used laparoscopic dissection devices.

MATERIALS AND METHODS

A total of 12 domestic pigs were used to test dissecting devices, including monopolar scissors (Ethicon Endo-Surgery, Cincinnati, Ohio), Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector. A midline incision was made from mid sternum to umbilicus, the diaphragm was divided and the porcine thoracic duct was isolated. In all animals each device was used to seal an area of the duct and each seal was placed at least 2 cm from the prior seal. In group 1 the thoracic duct of 6 pigs was cannulated with a 5Fr catheter and the seal was subjected to burst pressure testing using a burst pressure measuring device (Cole-Parmer, Vernon Hills, Illinois). In the 6 pigs in group 2 each seal was immediately sent for histopathological evaluation. Specimens were given a score for the extent of cautery damage, including 0-none, 1-minimal, 2-moderate, 3-severe and 4-extreme.

RESULTS

A total of 64 seals were created, of which 35 were subjected to burst pressure testing. Mean size of the thoracic duct was 2.6 mm. No acute seal failures were observed with any bipolar device or the harmonic shears. However, 2 immediate failures (33%) were seen with monopolar scissors. Mean burst pressure for monopolar scissors, Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector was 46 (range 0 to 165), 540 (range 175 to 795), 258 (range 75 to 435), 453 (range 255 to 825) and 379 mm Hg (range 175 to 605), respectively (p <0.05). Trissector, Harmonic ACE Scalpel and EnSeal generated seals with significantly higher burst pressure than that of monopolar scissors (p <0.05). Histopathological evaluation revealed that LigaSure caused less thermal damage than Trissector and EnSeal (p <0.05).

CONCLUSIONS

Each device tested except monopolar scissors consistently produced a supraphysiological seal and should be suitable for sealing lymphatic vessels during laparoscopic surgery.

Comparison of Intraoperative Parameters and Perioperative Complications of Retroperitoneal and Transperitoneal Approaches to Laparoscopic Partial Nephrectomy: Support for a Retroperitoneal Approach in Selected Patients

BACKGROUND AND PURPOSE

Retroperitoneal laparoscopy (RP) may have some intrinsic advantages over transperitoneal laparoscopy (TP) in certain patients undergoing partial nephrectomy. We reviewed our experience with RP and TP partial nephrectomy to identify differences in intraoperative and postoperative parameters.

PATIENTS AND METHODS

The records of 72 patients (45 TP, 27 RP) undergoing laparoscopic partial nephrectomy without hand assistance between January 2003 and August 2005 were reviewed. The two groups were similar demographically; tumors were smaller in RP patients (2.1 v 2.7 cm; P = 0.03), and the RP approach was used more frequently on right kidneys (70.4% v 37.8%; P = 0.01).

RESULTS

The operative time (mean 160 v 192 minutes; P = 0.008) and length of stay (LOS; median 1.0 days [range 1-10 days] v 2.0 days [range 1-64 days]; P = 0.001) were shorter in RP patients. Rates of collecting system entry (22% v 38%), positive-margin rate (0% v 6.7%; P = 0.29), and complications (19% v 22%; P = 0.77) were similar in RP and TP patients. Hemorrhage was the most common complication in both groups. Bowel-related complications occurred in three TP patients, but in no RP patients. Overall, the median estimated blood loss (EBL) was lower in RP patients (100 mL [range 25-3500 mL] v 225 mL [range 25-1900 mL]; P = 0.06). Among patients with complications, EBL was similar in both groups (median 325 mL [50-1500 mL] v 200 mL [50-3500 mL] for RP and TP; P = 0.86).

CONCLUSIONS

The RP approach reduces operative time, LOS, and some types of complications without compromising the quality of tumor resection. Complications in the retroperitoneal space are not associated with higher EBL. Anatomic considerations and surgeon experience may improve outcomes.

Reluctance Over Right-Sided Retroperitoneoscopic Living Donor Nephrectomy: Justified or Not?

We retrospectively compared perioperative donor outcomes and early complication rate of right- and left-sided retroperitoneoscopic living donor nephrectomy (RLDN).

METHODS

From November 2001 to April 2006, we performed 118 RLDN. Including 24% (n = 28) right-sided RLDN and 76% (n = 90) left-sided RLDN. Perioperative results and the rate of adverse events were compared for both sides.

RESULTS

We observed no significant difference in operation time, blood loss, warm ischemia time, or postoperative creatinine levels between right- and left-sided kidney donors. RLDN was successfully performed in 116 of 118 donors. One donor in each group had to be converted to an open approach. We observed one graft loss due to renal artery kinking in one recipient after left-sided RLDN. Two right donations needed a saphenous venous patch due to a short right renal vein (<2 cm). Overall, intraoperative and postoperative complications were comparable between the two donor groups.

CONCLUSION

Right-sided RLDN provides comparable perioperative and postoperative results to those of left-sided RLDN. Our results demonstrated that groups with significant experience in RLDN can perform right living donor nephrectomy safely and efficiently with minimal invasiveness.

Obtaining Cuff of Inferior Vena Cava by Use of the Endo-TA Stapler in Retroperitoneoscopic Right-Side Donor Nephrectomy

OBJECTIVES

To determine the feasibility of obtaining an adequate cuff of the inferior vena cava (IVC) for vascular anastomosis during retroperitoneoscopic donor nephrectomy.

METHODS

Between September 2004 and May 2005, a total 100 retroperitoneoscopic donor nephrectomies were performed. Fifteen cases were performed on the right side. The Endo-TA stapler was used to obtain the cuff of IVC in all cases of right-side donor nephrectomy.

RESULTS

Mean warm ischemia time was 4.9 minutes (range, 2.96 to 8.0 minutes). Mean length of the cuff of IVC was 4 mm (range, 3 to 6 mm) at the upper end and 6 mm (range, 4 to 8 mm) at the lower end of the vein. All grafts functioned immediately, and there was one graft loss due to vascular rejection.

CONCLUSIONS

Control of the renal vein by use of the Endo-TA stapler during retroperitoneoscopic donor nephrectomy helps in obtaining a good vascular cuff of the IVC.

The Current Practice of Live Donor Nephrectomy in Europe

BACKGROUND

The increasing number of live kidney donors in the last decade has stimulated interest in the surgical technique of donor nephrectomy. In this study, we evaluated the current status of the surgical approach in European transplant centers.

METHODS

A questionnaire was sent to 131 centers in 12 European countries. Questions included the number of donors, the technique used, and the inclusion and exclusion criteria for a technique.

RESULTS

Ninety-two replies (70%) were included. In the responding centers, approximately 1450 live donor nephrectomies were performed in 2004 (more than 80% of all live kidney donations in these countries). The number of living donors ranged from 0 to 95 per center. Nineteen institutions (21%) removed kidneys using endoscopic techniques only. Twenty-two centers (24%) performed both open and laparoscopic donor nephrectomy. Vessel length, difficult anatomy and right-sided donor nephrectomy were common reasons to choose an open technique. Twelve centers had performed laparoscopic donor nephrectomy but quit their program for various reasons. In 51 centers (55%), only open donor nephrectomy was carried out. Lack of evidence that endoscopic techniques provide better results was the main reason for these centers to stick to an open approach. Incisional hernias occurred after all types of open surgery in up to 30% of the donors per center. Twenty-nine clinics still carry out the classic flank incision.

CONCLUSION

The surgical technique of live donor nephrectomy varies greatly between transplant centers in European countries. To define the optimal surgical approach a European registration of donor nephrectomies would be helpful.

Introduction of Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy at Karolinska University Hospital Huddinge

Living donor kidney transplantation accounts for about 50% of the total number of renal transplantations at our center. From 1999 through 2005, 75 out of 220 living donor nephrectomies were performed with a laparoscopic technique (LLDN). In June 2005, we introduced the technique of hand-assisted retroperitoneoscopic nephrectomy (HARS) for living donors. Since the introduction until the end of 2005, 11 out of 18 living donor nephrectomies (LDN) were performed with HARS. Reduced operation time was observed for the HARS group (mean, 166 minutes) compared with the LLDN (mean, 244 minutes). Two grafts showed delayed function, one in the LLND group and one in the HARS group. No major perioperative or postoperative complications were observed in the HARS group, whereas one patient who underwent LLDN developed severe pancreatitis. So far in our hands HARS is a fast and safe procedure with results comparable with open LDN. Compared to LLDN, we experienced reduced operation time together with the advantage of retroperitoneal access.

Living Kidney Donation: Evolution and Technical Aspects of Donor Nephrectomy

For more than 40 years, living donor nephrectomy was performed through a flank incision drawn on the urologic experience with nephrectomy for cancer. Since its introduction one decade ago, laparoscopic donor nephrectomy has gained widespread acceptance and popularity; currently over one-half of donor nephrectomies in the United States are performed with this technique. The changing practice of donor nephrectomy resembles in many ways the evolution of minimally invasive in other subspecialties. The lessons learned from these technical developments are valuable and can be adapted by general surgeons and urologists when called upon to perform nephrectomy for organ donation or kidney disease.

Pararektale Miniinzision zur streng retroperitonealen Nephrektomie in der Lebendspende

PURPOSE

In this study we present the technique of a strictly retroperitoneal donor nephrectomy via a pararectal mini-incision.

MATERIAL AND METHODS

Data of 34 living kidney donations were analyzed. All donors underwent a pararectal mini-incision and strictly retroperitoneal nephrectomy (MIDN).

RESULTS

Total operation time, perioperative use of pain medication, length of hospital stay after successful mobilization, and return to full enteral nutrition and regular digestion were evaluated retrospectively. Total operation time for MIDN was 132+/-26 min. The total average application was 22.2+/-19.4 mg of opioid in morphine equivalent dosage (MED), 7.7+/-6.1 g metamizol, and 512+/-325 mg NSAR during hospital stay, which was 4.9+/-1.4 days. Patients were mobilized primarily 2.9+/-8.0 h after surgery. Mobility was achieved 33.8+/-15.8 h after surgery. Enteral nutrition with fluids was started after 1.9+/-7.0 h, full enteral nutrition was accomplished after 37.4+/-19.0 h, and normal digestion returned 58.6+/-23.0 h after the procedure.

CONCLUSIONS

The strictly retroperitoneal nephrectomy via a mini-incision is an elegant, minimally traumatic, safe, and quickly learnable method, resulting in short hospital stays, good cosmetic results, and a low grade of complications.

Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial

OBJECTIVES

To determine the best approach for live donor nephrectomy to minimise discomfort to the donor and to provide good graft function.

DESIGN

Single blind, randomised controlled trial.

SETTING

Two university medical centres, the Netherlands.

PARTICIPANTS

100 living kidney donors.

INTERVENTIONS

Participants were randomly assigned to either laparoscopic donor nephrectomy or to mini incision muscle splitting open donor nephrectomy.

MAIN OUTCOME MEASURES

The primary outcome was physical fatigue using the multidimensional fatigue inventory 20 (MFI-20). Secondary outcomes were physical function using the SF-36, hospital stay after surgery, pain, operating times, recipient graft function, and graft survival.

RESULTS

Conversions did not occur. Compared with mini incision open donor nephrectomy, laparoscopic donor nephrectomy resulted in longer skin to skin time (median 221 v 164 minutes, P < 0.001), longer warm ischaemia time (6 v 3 minutes, P < 0.001), less blood loss (100 v 240 ml, P < 0.001), and a similar number of complications (intraoperatively 12% v 6%, P = 0.49, postoperatively both 6%). After laparoscopic nephrectomy, donors required less morphine (16 v 25 mg, P = 0.005) and shorter hospital stay (3 v 4 days, P = 0.003). During one year's follow-up mean physical fatigue was less (difference - 1.3, 95% confidence interval - 2.4 to - 0.1) and physical function was better (difference 6.2, 2.0 to 10.3) after laparoscopic nephrectomy. Function of the graft and graft survival rate of the recipient at one year censored for death did not differ (100% after laparoscopic nephrectomy and 98% after open nephrectomy).

CONCLUSIONS

Laparoscopic donor nephrectomy results in a better quality of life compared with mini incision open donor nephrectomy but equal safety and graft function.