- Email: [email protected]
A Consecutive Series of 70 Laparoscopic Donor Nephrectomies Demonstrates the Safety of This New Operation
A Consecutive Series of 70 Laparoscopic Donor Nephrectomies Demonstrates the Safety of This New Operation N.R. Brook, S.J. Harper, J.R. Waller, and M.L. Nicholson ABSTRACT Laparoscopic donor nephrectomy (LDN) has the potential to overcome some of the disincentives to living kidney donation. This study presents the results of a consecutive series of 70 LDN from a single center with an emphasis on postoperative complication rates and donor recovery times. There was no selection bias based on donor body mass index or because of difficult vascular anatomy. All donors received postoperative analgesia using a patient-controlled system and returned to activities and employment at their discretion. There was no donor mortality and no episode of thromboembolic disease. One operation was converted from open to LDN because of renal artery bleeding. Postoperative complications encompassed chest infection (6%), unilateral pulmonary edema (3%), ileus (3%), wound infection (3%), paraesthesia of L1 (4%), testicular pain (3%), persistent wound pain (1.4%), and reoperation for division of adhesions (3%). In conclusion, LDN is a safe procedure with low postoperative morbidity. There were some unexpected complications, but recovery time was short.
T
HE SHORTAGE OF KIDNEYS available for transplantation has stimulated the expansion of living donor programs. However, the number of kidney donors may be limited by concerns regarding postoperative pain, prolonged recovery, and the cosmetic implications of a large wound. Laparoscopic donor nephrectomy (LDN) was introduced in an attempt to reduce such disincentives.1 It is hoped that the advantages of minimal access techniques appreciated in other branches of surgery can be applied to renal transplantation. Some concerns still surround the application of this technique for renal donation. The procedure is technically demanding, takes longer than open nephrectomy, and involves a transperitoneal approach with attendant potential complications. The laparoscopic approach takes longer than the open operation, with potential for an increase in the incidence of respiratory and thromboembolic complications. The pneumoperitoneum may reduce renal perfusion before explantation. This study presents the results of 70 laparoscopic donor nephrectomy procedures from a single center, with an emphasis on postoperative complication rates and donor recovery times. METHODS Seventy living kidney donors underwent transperitoneal LDN. Two consultant surgeons working together performed all operations. © 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 37, 627– 628 (2005)
There was no selection based on donor body mass index (range 18 to 45 kg/m2) or because of difficult vascular anatomy. Patients were placed in a modified lateral decubitus position. A CO2 pneumoperitoneum was established using a Veress needle. In general, four laparoscopic ports were required: the videolaparoscope was introduced through a 12-mm umbilical port, and two further 12-mm ports were placed in the epigastrium and left iliac fossa for the main dissecting instruments. A retractor for the colon can be passed through a 5-mm port placed in the midaxillary line. The procedure for left nephrectomy has been described in detail by other authors.1 For right transperitoneal donor nephrectomy, the positioning of the patient and placement of the ports was a mirror image of the left side. The peritoneal reflection was cut at the border of the liver exposing the adrenal gland and the superior edge of the kidney. The duodenum was partially Kocherized, and displaced medially with the pancreas, exposing the inferior vena cava. Gerota’s fascia was opened and the remainder of the dissection is as described for the left side. We used a subcostal transverse muscle cutting incision, with control of the IVC using a Satinsky side-biting clamp to permit harvesting of maximum vessel length. Kidney extraction was through this incision. From the Transplant Surgery Group, Leicester General Hospital, University of Leicetser, Leicetser, UK. Address reprint requests to Nicholas R. Brook, BSc, MSc, BM, MRCS, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, Leicestershire LE5 4PW, United Kingdom. 0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2004.12.149 627
628 All patients received postoperative analgesia using a patientcontrolled analgesia system. Donors resumed normal activities and return to work at their discretion.
RESULTS
Thirty-nine women and 31 men (mean age 46 years) underwent LDN. Sixty-two left and eight right donor nephrectomies were performed. One donor operation was converted from laparoscopic to open because of bleeding from the renal artery stump. A few of the renal artery staples were dislodged when the renal vein was stapled; the bleeding could not be controlled laparoscopically. Four patients (6%) developed clinical postoperative chest infection requiring antibiotic treatment. Unilateral pulmonary edema developed in the dependent lung of two patients (3%) early in our experience. At this time, patients were given large volumes of intravenous fluid during the procedure in an attempt to maintain renal artery and vein perfusion in the presence of pneumoperitoneum. The pioneers of LDN commonly use 8 to 10 L of crystalloid pre- and intraoperatively2 to maintain renal perfusion. These two episodes have led us to change this practice; we now volume-load patients with 2 L of crystalloid the night before surgery, and use only replacement fluids during the operation. There has been no apparent detriment to renal function. Wound infection developed in two patients (3%), resolving with oral antibiotic treatment. Self-limiting small bowel ileus occurred in two patients, and late laparoscopic division of abdominal adhesions was required in two sepa-
BROOK, HARPER, WALLER ET AL
rate patients. There were no clinically detected episodes of thromboembolic disease. No donor mortality occurred. Three patients (4%) suffered persistent paresthesia in the L1 dermatome, and two others suffered persistent testicular pain. We believe this is due to damage to the femoral and genital branches of the genitofemoral nerve, respectively, during dissection of the ureter. One patient has persistent, undiagnosed port-site wound pain. Recipient transplantation was complicated by ureteric stenosis in two cases, but there were no vascular thromboses. Laparoscopic donor recovery times (mean ⫾ SD) were as follows: in-patient stay 4 ⫾ 1 days, duration of patientcontrolled analgesia 44 ⫾ 12 hours, time to return to driving 2 ⫾ 2 weeks, and time to return to employment 5 ⫾ 2 weeks. In conclusion, this study demonstrates that LDN is a safe procedure with low postoperative morbidity for the donor. Nevertheless, some unexpected complications such as L1 paraesthesia, testicular pain, and pulmonary edema were recorded. Recovery times for the laparoscopic procedure are short. These findings address some of the concerns surrounding LDN and support its potential for reducing living donor disincentives. REFERENCES 1. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60:1047, 1995 2. Ratner LE, Smith P, Montgomery RA, et al: Laparoscopic live donor nephrectomy: preoperative assessment of technical difficulty. Clin Transplant 14:427, 2000
T
HE SHORTAGE OF KIDNEYS available for transplantation has stimulated the expansion of living donor programs. However, the number of kidney donors may be limited by concerns regarding postoperative pain, prolonged recovery, and the cosmetic implications of a large wound. Laparoscopic donor nephrectomy (LDN) was introduced in an attempt to reduce such disincentives.1 It is hoped that the advantages of minimal access techniques appreciated in other branches of surgery can be applied to renal transplantation. Some concerns still surround the application of this technique for renal donation. The procedure is technically demanding, takes longer than open nephrectomy, and involves a transperitoneal approach with attendant potential complications. The laparoscopic approach takes longer than the open operation, with potential for an increase in the incidence of respiratory and thromboembolic complications. The pneumoperitoneum may reduce renal perfusion before explantation. This study presents the results of 70 laparoscopic donor nephrectomy procedures from a single center, with an emphasis on postoperative complication rates and donor recovery times. METHODS Seventy living kidney donors underwent transperitoneal LDN. Two consultant surgeons working together performed all operations. © 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 37, 627– 628 (2005)
There was no selection based on donor body mass index (range 18 to 45 kg/m2) or because of difficult vascular anatomy. Patients were placed in a modified lateral decubitus position. A CO2 pneumoperitoneum was established using a Veress needle. In general, four laparoscopic ports were required: the videolaparoscope was introduced through a 12-mm umbilical port, and two further 12-mm ports were placed in the epigastrium and left iliac fossa for the main dissecting instruments. A retractor for the colon can be passed through a 5-mm port placed in the midaxillary line. The procedure for left nephrectomy has been described in detail by other authors.1 For right transperitoneal donor nephrectomy, the positioning of the patient and placement of the ports was a mirror image of the left side. The peritoneal reflection was cut at the border of the liver exposing the adrenal gland and the superior edge of the kidney. The duodenum was partially Kocherized, and displaced medially with the pancreas, exposing the inferior vena cava. Gerota’s fascia was opened and the remainder of the dissection is as described for the left side. We used a subcostal transverse muscle cutting incision, with control of the IVC using a Satinsky side-biting clamp to permit harvesting of maximum vessel length. Kidney extraction was through this incision. From the Transplant Surgery Group, Leicester General Hospital, University of Leicetser, Leicetser, UK. Address reprint requests to Nicholas R. Brook, BSc, MSc, BM, MRCS, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, Leicestershire LE5 4PW, United Kingdom. 0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2004.12.149 627
628 All patients received postoperative analgesia using a patientcontrolled analgesia system. Donors resumed normal activities and return to work at their discretion.
RESULTS
Thirty-nine women and 31 men (mean age 46 years) underwent LDN. Sixty-two left and eight right donor nephrectomies were performed. One donor operation was converted from laparoscopic to open because of bleeding from the renal artery stump. A few of the renal artery staples were dislodged when the renal vein was stapled; the bleeding could not be controlled laparoscopically. Four patients (6%) developed clinical postoperative chest infection requiring antibiotic treatment. Unilateral pulmonary edema developed in the dependent lung of two patients (3%) early in our experience. At this time, patients were given large volumes of intravenous fluid during the procedure in an attempt to maintain renal artery and vein perfusion in the presence of pneumoperitoneum. The pioneers of LDN commonly use 8 to 10 L of crystalloid pre- and intraoperatively2 to maintain renal perfusion. These two episodes have led us to change this practice; we now volume-load patients with 2 L of crystalloid the night before surgery, and use only replacement fluids during the operation. There has been no apparent detriment to renal function. Wound infection developed in two patients (3%), resolving with oral antibiotic treatment. Self-limiting small bowel ileus occurred in two patients, and late laparoscopic division of abdominal adhesions was required in two sepa-
BROOK, HARPER, WALLER ET AL
rate patients. There were no clinically detected episodes of thromboembolic disease. No donor mortality occurred. Three patients (4%) suffered persistent paresthesia in the L1 dermatome, and two others suffered persistent testicular pain. We believe this is due to damage to the femoral and genital branches of the genitofemoral nerve, respectively, during dissection of the ureter. One patient has persistent, undiagnosed port-site wound pain. Recipient transplantation was complicated by ureteric stenosis in two cases, but there were no vascular thromboses. Laparoscopic donor recovery times (mean ⫾ SD) were as follows: in-patient stay 4 ⫾ 1 days, duration of patientcontrolled analgesia 44 ⫾ 12 hours, time to return to driving 2 ⫾ 2 weeks, and time to return to employment 5 ⫾ 2 weeks. In conclusion, this study demonstrates that LDN is a safe procedure with low postoperative morbidity for the donor. Nevertheless, some unexpected complications such as L1 paraesthesia, testicular pain, and pulmonary edema were recorded. Recovery times for the laparoscopic procedure are short. These findings address some of the concerns surrounding LDN and support its potential for reducing living donor disincentives. REFERENCES 1. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60:1047, 1995 2. Ratner LE, Smith P, Montgomery RA, et al: Laparoscopic live donor nephrectomy: preoperative assessment of technical difficulty. Clin Transplant 14:427, 2000