Transition From Hand-Assisted to Pure Laparoscopic Donor Nephrectomy

Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder: IDEAL stage 2a study

BACKGROUND

Solo-surgery can be defined as a practice of a surgeon operating alone using a camera holder, without other surgical members except for a scrub nurse. This study was designed to evaluate the feasibility and safety of solo-surgeon pure laparoscopic donor nephrectomy.

METHODS

The study protocol was approved by the Institutional Review Board of Asan Medical Center, Seoul, Korea. The brief study protocol was registered on the Clinical Research Information Service site of the Korea Centers for Disease Control and Prevention. Candidates fulfilling all inclusion and exclusion criteria were enrolled in the clinical trial and underwent solo-surgeon pure laparoscopic donor nephrectomy. The feasibility was assessed by the proportion of subjects who could undergo solo-surgeon pure laparoscopic donor nephrectomy without difficulty. The perioperative complications were identified to assess the safety of solo-surgeon pure laparoscopic donor nephrectomy.

RESULTS

Of the 47 potential candidates from November 2018 to August 2019, 40 were enrolled in the clinical trial and seven excluded due to declining participation. The feasibility of solo-surgeon pure laparoscopic donor nephrectomy was 100%, without an occasion of any difficulty requiring conversion to the human assisted pure laparoscopic donor nephrectomy. Fourteen intraoperative complications occurred in 10 patients. The most common intraoperative complication was spleen injury. Two of three cases classified as the Satava classification grade II were due to the incomplete stapling of endoscopic stapler. Seventy-eight postoperative complications occurred in 34 patients. The most common postoperative complication was nausea/vomiting and followed by aspartate aminotransferase/alanine aminotransferase elevation. Most postoperative complication was independent of the solo-surgery itself.

CONCLUSIONS

Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder is technically feasible. In terms of safety, it is necessary to adjust the scope of surgery performed alone. Trial Registration CRIS, KCT0003458. Registered 30/01/2019, Retrospectively registered, https://cris.nih.go.kr/cris/search/detailSearch.do/15868 .

Procedure: Laparoscopic Donor Nephrectomy

Minimally invasive approaches for laparoscopic donor nephrectomy are necessary to limit surgical morbidity, and technical challenges differ from those encountered during other laparoscopic renal surgeries. Presented here is a step-by-step guide for laparoscopic donor nephrectomy-focusing on pure laparoscopic and hand-assisted techniques. Both straight laparoscopic and hand-assisted nephrectomies were performed in healthy donors who met transplantation criteria in terms of global health and psychologic well-being. Patient positioning, trocar placement, surgical steps, incision closure, and postoperative care are reviewed. Standard equipment used to complete this procedure is itemized. This guide outlines indications, preoperative preparation, and procedural steps for laparoscopic donor nephrectomy. The techniques and the evolution thereof represent our experience since 2002 for 510 cases. The attached videos demonstrate a high-volume surgeon's typical approach while factoring in anatomical variation. In both cases, the donor nephrectomies were without incident and the patient's postoperative courses were without complication. A basic framework for donor nephrectomy is presented highlighting surgical steps we believe to be essential for graft preservation and ultimately effective transplantation. Although no two cases are the same, systematic approaches will allow for timely case completion, fewer complications, and better donor/recipient outcomes.

Pure laparoscopic donor nephrectomy without routine drainage does not increase postoperative morbidity

Purpose

We aimed to define the feasibility of the omission of routine insertion of a drain after pure laparoscopic donor nephrectomy (PLDN). We compared the outcomes between those with and without routine drain insertion.

Materials and Methods

From July 2014 to October 2018, 178 PLDN were consecutively performed by a single surgeon. Since October 2016, we stopped routine insertion of a drain after PLDN. Thus, the former 80 drained routinely were defined as the Drainage group and the latter 98 were defined as the Non-drainage group. One patient drained non-routinely in the Non-drainage group was excluded from the final analysis. Operative and convalescence parameters and intra- and postoperative complications were compared between the groups. Intra- and postoperative complications within 90 days of surgery were graded using the Satava and Clavien–Dindo classifications, respectively.

Results

Baseline characteristics were similar between the groups, except for concomitant surgery, American Society of Anesthesiologists score, and preoperative glomerular filtration rate. All operative and convalescence parameters were similar between the groups, except for postoperative glomerular filtration rate. The rates of overall intra- (22.5% versus 28.9%, p=0.337) and postoperative (62.5% versus 59.8%, p=0.713) complications were similar between the groups. The rates of potentially drain-related postoperative complications were also similar between the groups (36.3% versus 33.0%, p=0.650). Two patients per group suffered from major drain-related complications (2.5% versus 2.1%).

Conclusions

PLDN without routine drainage can be performed safely without an increase in postoperative morbidity.