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Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia
ADULT UROLOGY
HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY MINIMIZES WARM ISCHEMIA KENT KERCHER, DOUGLAS DAHL, ROBERT HARLAND, ROBERT BLUTE, KAREN GALLAGHER, AND DEMETRIUS LITWIN
ABSTRACT Objectives. Traditional open donor nephrectomy is associated with good donor outcomes and excellent allograft function. Laparoscopic donor nephrectomy may accomplish these same goals with less morbidity. We report our initial experience with hand-assisted laparoscopic living donor nephrectomy using a commercially available hand-assist device. Methods. Donor and allograft outcomes for the first 30 patients undergoing hand-assisted laparoscopic live donor nephrectomy in our institution were prospectively analyzed. Results. Hand-assisted laparoscopic donor nephrectomy was successfully completed in 29 (97%) of 30 donors. Organ dissection was carried out purely laparoscopically. Vessel division and allograft extraction were performed using a hand-assisted technique. The average operative time was 275 minutes (range 193 to 360), with an estimated blood loss of 99 mL (range 50 to 300). Pneumoperitoneum was consistently maintained during the hand-assisted portion of the procedure. The mean warm ischemic time was 72.5 seconds (range 30 to 165). On average, the regular diet was resumed after 2.2 days (range 1 to 3), and patients were discharged home 3.4 days (range 2 to 5) after surgery. Eight minor complications occurred in the donor group. Immediate graft function occurred in all 30 cases. No ureteral complications occurred. The recipient creatinine levels ranged from 0.6 to 2.4 mg/dL at an average follow-up of 11.5 months (range 1 to 23). Conclusions. Laparoscopic donor nephrectomy is technically feasible and can be performed with minimal morbidity. Hand-assisted kidney extraction may help to facilitate immediate allograft function by minimizing the warm ischemic time. UROLOGY 58: 152–156, 2001. © 2001, Elsevier Science Inc.
T
he laparoscopic approach to live donor nephrectomy decreases postoperative pain, shortens hospitalization, hastens patient recovery, and improves the cosmetic results.1,2 However, graft function may be compromised by the longer warm ischemic times. The use of a hand-assisted technique for vascular division and kidney extraction may decrease the warm ischemic time and
This study was partially funded through an unrestricted educational grant from Smith & Nephew Endoscopy Inc. Upon submission of this article, K. Kercher was the recipient of a fellowship funded by the sponsor of this study. D. Litwin receives research funding from the sponsor of this study. From the Department of Surgery and Section of Urology, University of Massachusetts Medical School, Worcester, Massachusetts; and Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina Reprint requests: Douglas Dahl, M.D., Department of Urology, University of Massachusetts Medical School, 55 Lake Avenue North, Room S4-860, Worcester, MA 01655-0333 Submitted: July 27, 2000, accepted (with revisions): March 29, 2001
152
© 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
help to maximize the donor vessel length. Our initial experience with hand-assisted laparoscopic donor nephrectomy is presented. MATERIAL AND METHODS PATIENT SELECTION All potential living kidney donors presenting to the transplant clinic at the University of Massachusetts Medical School between October 1998 and August 2000 were considered for laparoscopic donor nephrectomy. Standard immunologic and medical evaluations were performed in each case to confirm the suitability of each potential donor. Helical computed tomography (CT) arteriography with three-dimensional reconstruction was used to delineate the renal vascular anatomy preoperatively. Patients with multiple renal arteries or a contraindication to removal of the left kidney were offered traditional (open) donor nephrectomy.
SURGICAL TECHNIQUE Hand-assisted laparoscopic live donor nephrectomy was performed under general anesthesia with the patient in the right lateral decubitus position. The pneumoperitoneum was 0090-4295/01/$20.00 PII S0090-4295(01)01194-3
FIGURE 2. Hand-assist device allowing insertion of surgeon’s right hand into abdomen while maintaining pneumoperitoneum.
FIGURE 1. (1) Left-hand working port (11-mm), (2) camera port/linear stapler port (12-mm), (3) right-hand working port (11-mm)—extended to 9 cm for handassist device and kidney extraction, and (4) assistant port (5-mm).
established using a Veress needle. Three (11/12-mm) ports were placed along the lateral border of the rectus muscle (Fig. 1). One additional 5-mm assistant port was inserted in the flank. The surgeon and camera operator stood on the right side of the table, with the assistant on the left side. After mobilization of the splenic flexure, spleen, and pancreatic tail, Gerota’s fascia was incised and the renal vessels were identified. The adrenal, gonadal, and lumbar veins were individually ligated with clips and divided close to the renal vein. Intravenous mannitol (12.5 g) was given before dissection of the renal artery and vein. The renal artery was dissected to its origin from the aorta. The renal vein was circumferentially exposed 1 to 2 cm below the entry point of the adrenal vein. The ureter and investing tissues were dissected to the level of the iliac bifurcation. The posterior attachments of the kidney were then divided. The most inferior trocar site was extended into an oblique 9-cm left lower quadrant muscle-splitting incision. The base ring retractor of the HandPort device (Smith & Nephew Endoscopy, Andover, Mass) was positioned within the wound. A plastic sleeve attaches the surgeon’s wrist to the device. The surgeon’s right hand was placed into the abdomen and the pneumoperitoneum re-established (Fig. 2). Under laparoscopic visualization, the distal ureter was transected using an endoscopic linear stapler. The hand elevates the kidney and presents the renal vessels for rapid, proximal division by the linear stapler. Two vascular staplers (one for the artery and one for the vein) were used to minimize the time required for instrument exchange. To ensure adequate vessel length for transplantation, the vein was transected approximately 5 to 10 mm below the entry point of the adrenal vein, and the artery was divided flush with the aorta. The kidney was then extracted through the base ring retractor of the hand-assist device (Fig. 3). The warm ischemic time was measured from the moment of arterial stapler application to placement of the kidney on ice. UROLOGY 58 (2), 2001
FIGURE 3. Kidney can be easily extracted through the base ring retractor of the hand-assist device.
RESULTS Thirty hand-assisted laparoscopic live donor nephrectomies were attempted using the technique described. All were single-artery left kidneys. One case was electively converted because of obesity and extensive adhesions. The average donor age was 41 years (range 21 to 59). The mean patient weight was 74 kg (range 43 to 116). All operations were performed by one of three laparoscopic surgeons. For the 29 cases completed laparoscopically, the operative time ranged from 193 to 360 minutes (mean 275). The average blood loss was 99 mL (range 50 to 300). All warm ischemic times were less than 3 minutes (average 72.5 seconds, range 30 to 165). Vascular staple loads (2.0 mm) were used for vessel division in all cases. There were no instances of staple-line bleeding. The incision used for hand insertion and kidney extraction ranged from 8.5 to 10 cm (mean 9.0). Postoperatively, patients were allowed clear liquids on the first postoperative day. The time to resump153
TABLE I. Results for open, laparoscopic, and hand-assisted donor nephrectomy Flowers et al.1 (1997) Cases (n) Mean operative time (min) Mean warm ischemic time (min) Mean estimated blood loss (mL) Conversions (%) Delayed graft function (%) Mean length of stay (days)
Odland et al.7 (1999)
Present Series (2000)
Open
Laparoscopic
Open
Laparoscopic
HALDN
65 213 NR 408 — 2 4.5
69 226 3.0 122 5.7 3 2.2
30 148 1.7 192 — 3 3.8
30 183 5.0 116 23 12 2.7
30 275 1.2 99 3 0 3.4
KEY: HALDN ⫽ hand-assisted laparoscopic donor nephrectomy; NR ⫽ not reported.
tion of a regular diet averaged 2.2 days (range 1 to 4). Pain control with oral analgesics was achieved at a mean of 1.7 days (range 1 to 4) after surgery. The average length of stay was 3.4 days (range 2 to 5). All patients had resumed regular activity by 1 month after surgery. No intraoperative complications occurred. Postoperatively, 1 patient developed multiple skin blisters from an allergy to the silk tape, and 1 developed subcutaneous emphysema related to carbon dioxide insufflation. Two patients had transient fever related to atelectasis. Two patients required postoperative antibiotics for wound cellulitis. Transient urinary retention requiring catheterization occurred in 1 patient. No vascular, renal parenchymal, or ureteral injuries occurred during the procurement process. In all cases, the harvested renal artery, vein, and ureter provided adequate length for transplantation. Immediate graft function occurred in all 30 recipients. One recipient required re-exploration for bleeding on the first postoperative day. One transplanted kidney developed transient cyclosporine toxicity. A third recipient with pre-existing aortoiliac occlusive disease developed renovascular hypertension 7 months after transplantation. A stenosis at the external iliac anastomosis was identified and successfully bypassed. At a mean follow-up of 11.5 months (range 1 to 23), the recipient creatinine levels ranged from 0.6 to 2.4 mg/dL. No ureteral complications occurred. COMMENT Although the hand-assisted technique for laparoscopic donor nephrectomy is not new, the use of the HandPort device for this procedure has not been previously reported. In other reports, handassist devices have been time-consuming to place and have been associated with the loss of the pneumoperitoneum.3–5 In our experience, this device is easy to use, requires no adhesives for fixation to the abdominal wall, and has been associated with no significant air leakage.6 At the time of organ re154
moval, the surgeon’s hand and donor kidney can be rapidly extracted through the base of the device. Importantly, the edges of the base retractor are soft, and there is no valve mechanism that could traumatize the kidney during organ extraction. Although it is feasible to use hand-assistance for the entire case, we have not found this strategy to be useful. Since mobilization of the kidney and dissection of the vessels can be performed expeditiously with standard laparoscopic techniques, we have found that the hand may impede visualization when used at the outset of the case. Rather, its value appears to be related to the critical steps of vessel division and kidney extraction. When comparing our results with those of other laparoscopic series not using hand-assistance, no appreciable differences have been noted with regard to operative time, blood loss, or length of stay.1,7 At the same time, the warm ischemic times with the handassisted technique have been lower than those reported for both open and laparoscopic extraction, and no instances of delayed graft function have occurred (Table I). Although many factors may influence the immediate graft function, we believe that these results are related in part to the rapid, atraumatic extraction allowed by the hand-assisted technique. We have found that a muscle-splitting left lower quadrant (Gibson) incision for hand insertion is an attractive approach. With the patient in the full lateral position, lateral placement of the handassist incision allows the surgeon comfortable access to the kidney. This incision incorporates the most inferior of the three trocar sites, thus minimizing the number of incisions required. In our experience, the postoperative disability has been minimal, patients have returned rapidly to regular activities, and we have had no significant wound complications related to this incision. In contrast, upper midline placement of this incision (while allowing insertion of the nondominant hand) can make elevation of the kidney more difficult, provides less comfortable access for the surgeon, and is less cosmetically appealing. For UROLOGY 58 (2), 2001
left-sided nephrectomy, the surgeon’s right hand is used for kidney extraction, and the linear stapler is operated with the left hand. Although the surgeons in our series are all right-hand dominant, we have found that kidney extraction and stapler application can be performed rapidly and easily with either the dominant or nondominant hand. By performing vessel transection under laparoscopic guidance with the hand already in the abdomen, the kidney does not have to be manipulated into an extraction bag. We believe that this avoids the longer warm ischemic times (range 1.9 to 6.9 minutes) that have been associated with the laparoscopic approach.1 In this series, the average extraction time was just slightly longer than 1 minute and never exceeded 3 minutes. In previous reports, laparoscopic donor nephrectomy has been associated with major vascular injuries during both ureteral and renal vascular transection.1 Although introduction of the hand into the abdomen during these critical maneuvers may not prevent all injuries, it may reduce their risk. By providing valuable tactile feedback and allowing for atraumatic retraction of the vessels and ureter, we believe that injuries to the surrounding structures are less likely to occur. When bleeding does occur, the hand can provide rapid control. Failure of the staple line has the potential to result in massive hemorrhage from either the aorta or vena cava. In this situation, if an extraction bag is being used to remove the kidney, it may take several minutes to remove the kidney, extend the incision, and control the bleeding. With the hand already in the abdomen, immediate vascular control can be obtained with local compression. Although this complication is rare and was not encountered in our series, substantial hemorrhage from stapler failure may occur in up to 2% of cases and has been associated with blood loss as high as 1200 mL.8 The hand-assisted approach also allows for maximization of the vessel and ureter length by placing these structures “on stretch” before stapler application. With the use of the hand, these maneuvers can be performed accurately and atraumatically. The result is a viable, undamaged kidney that is ready for immediate transplantation. CONCLUSIONS Hand-assisted laparoscopic donor nephrectomy is safe, technically feasible, provides a high quality kidney, and can be accomplished with minimal morbidity. A detailed review of the short-term and long-term outcomes for all laparoscopic and open donor nephrectomies performed at our institution is currently underway. UROLOGY 58 (2), 2001
REFERENCES 1. Flowers JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226: 483– 490, 1997. 2. Ratner LE, Hiller J, Sroka M, et al: Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 29: 3402–3403, 1997. 3. Wolf JS, Tchetgen M, Meron R, et al: Hand-assisted laparoscopic donor nephrectomy. Urology 52: 885– 887, 1998. 4. Wolf JS, Moon TD, Nakada SY, et al: Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy. J Urol 160: 22–27, 1998. 5. Meyers WC, Foley DP, Sandor A, et al: Handoscopic surgery: a prospective multicenter trial of a minimally invasive technique for complex abdominal surgery. Arch Surg 134: 477– 486, 1999. 6. Litwin D, Kercher K, Novitsky Y, et al: New device for hand-assisted laparoscopic surgery. Surg Tech Int IX: 113– 116, 2000. 7. Odland MD, Ney AL, Jacobs DM, et al: Initial experience with laparoscopic live donor nephrectomy. Surgery 126: 603– 607, 1999. 8. Chan D, Bishoff JT, Ratner L, et al: Endovascular gastrointestinal stapler device malfunction during laparoscopic nephrectomy: early recognition and management. J Urol 164: 319 –321, 2000.
EDITORIAL COMMENT Laparoscopic live donor nephrectomy (LLDN) was introduced clinically in February 1995 with the intent of decreasing disincentives to live kidney donation.1 Subsequent series have demonstrated that LLDN provides significant advantages to the donor compared with open donor nephrectomy in terms of decreased postoperative pain, shorter hospitalization, quicker recuperation, and earlier return to activities, including employment.2–5 A number of centers have now reported significant increases in live kidney donation since introducing LLDN. Over 3000 LLDNs have been performed at more than 100 centers on six continents. It appears that LLDN is evolving as the new “standard of care.” Controversy exists regarding the ideal technique for LLDN. A recent survey of 77 centers performing LLDN revealed that 44% use a hand-assisted transperitoneal approach and the remainder a purely laparoscopic technique. In a departure from the open operation, only about 2% of centers perform the laparoscopic operation as a retroperitoneal procedure. The authors report their series of 30 hand-assisted LLDNs, with excellent donor and recipient results. They demonstrate that the renal warm ischemic time can be limited to 72.5 seconds (range 30 to 165) using this approach. However, it is important to note that minimizing the warm ischemic time, although important, is not the only factor that affects recipient allograft renal function. London et al.6 have demonstrated that the pneumoperitoneum decreases both renal blood flow and urine output. This effect can be abrogated by volume loading. Thus, laparoscopic donors generally require large volumes of crystalloid (7 to 10 L) intraoperatively to ensure a brisk recipient diuresis. In my opinion, this is of greater importance than several additional minutes of warm ischemia. Advocates of the hand-assisted technique generally cite several advantages in addition to the quicker kidney extraction time. First, it may decrease the learning curve for those surgeons with limited laparoscopic experience. Second, mobilization of the upper pole of the kidney is much easier manually. This usually reduces the operative time. Third, the intra-abdominal hand can be used to tamponade any major bleeders while converting to an open operation. Finally, it restores tactile sense to the surgeon. The hand-assisted technique has several disadvantages. The 155
HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY MINIMIZES WARM ISCHEMIA KENT KERCHER, DOUGLAS DAHL, ROBERT HARLAND, ROBERT BLUTE, KAREN GALLAGHER, AND DEMETRIUS LITWIN
ABSTRACT Objectives. Traditional open donor nephrectomy is associated with good donor outcomes and excellent allograft function. Laparoscopic donor nephrectomy may accomplish these same goals with less morbidity. We report our initial experience with hand-assisted laparoscopic living donor nephrectomy using a commercially available hand-assist device. Methods. Donor and allograft outcomes for the first 30 patients undergoing hand-assisted laparoscopic live donor nephrectomy in our institution were prospectively analyzed. Results. Hand-assisted laparoscopic donor nephrectomy was successfully completed in 29 (97%) of 30 donors. Organ dissection was carried out purely laparoscopically. Vessel division and allograft extraction were performed using a hand-assisted technique. The average operative time was 275 minutes (range 193 to 360), with an estimated blood loss of 99 mL (range 50 to 300). Pneumoperitoneum was consistently maintained during the hand-assisted portion of the procedure. The mean warm ischemic time was 72.5 seconds (range 30 to 165). On average, the regular diet was resumed after 2.2 days (range 1 to 3), and patients were discharged home 3.4 days (range 2 to 5) after surgery. Eight minor complications occurred in the donor group. Immediate graft function occurred in all 30 cases. No ureteral complications occurred. The recipient creatinine levels ranged from 0.6 to 2.4 mg/dL at an average follow-up of 11.5 months (range 1 to 23). Conclusions. Laparoscopic donor nephrectomy is technically feasible and can be performed with minimal morbidity. Hand-assisted kidney extraction may help to facilitate immediate allograft function by minimizing the warm ischemic time. UROLOGY 58: 152–156, 2001. © 2001, Elsevier Science Inc.
T
he laparoscopic approach to live donor nephrectomy decreases postoperative pain, shortens hospitalization, hastens patient recovery, and improves the cosmetic results.1,2 However, graft function may be compromised by the longer warm ischemic times. The use of a hand-assisted technique for vascular division and kidney extraction may decrease the warm ischemic time and
This study was partially funded through an unrestricted educational grant from Smith & Nephew Endoscopy Inc. Upon submission of this article, K. Kercher was the recipient of a fellowship funded by the sponsor of this study. D. Litwin receives research funding from the sponsor of this study. From the Department of Surgery and Section of Urology, University of Massachusetts Medical School, Worcester, Massachusetts; and Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina Reprint requests: Douglas Dahl, M.D., Department of Urology, University of Massachusetts Medical School, 55 Lake Avenue North, Room S4-860, Worcester, MA 01655-0333 Submitted: July 27, 2000, accepted (with revisions): March 29, 2001
152
© 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
help to maximize the donor vessel length. Our initial experience with hand-assisted laparoscopic donor nephrectomy is presented. MATERIAL AND METHODS PATIENT SELECTION All potential living kidney donors presenting to the transplant clinic at the University of Massachusetts Medical School between October 1998 and August 2000 were considered for laparoscopic donor nephrectomy. Standard immunologic and medical evaluations were performed in each case to confirm the suitability of each potential donor. Helical computed tomography (CT) arteriography with three-dimensional reconstruction was used to delineate the renal vascular anatomy preoperatively. Patients with multiple renal arteries or a contraindication to removal of the left kidney were offered traditional (open) donor nephrectomy.
SURGICAL TECHNIQUE Hand-assisted laparoscopic live donor nephrectomy was performed under general anesthesia with the patient in the right lateral decubitus position. The pneumoperitoneum was 0090-4295/01/$20.00 PII S0090-4295(01)01194-3
FIGURE 2. Hand-assist device allowing insertion of surgeon’s right hand into abdomen while maintaining pneumoperitoneum.
FIGURE 1. (1) Left-hand working port (11-mm), (2) camera port/linear stapler port (12-mm), (3) right-hand working port (11-mm)—extended to 9 cm for handassist device and kidney extraction, and (4) assistant port (5-mm).
established using a Veress needle. Three (11/12-mm) ports were placed along the lateral border of the rectus muscle (Fig. 1). One additional 5-mm assistant port was inserted in the flank. The surgeon and camera operator stood on the right side of the table, with the assistant on the left side. After mobilization of the splenic flexure, spleen, and pancreatic tail, Gerota’s fascia was incised and the renal vessels were identified. The adrenal, gonadal, and lumbar veins were individually ligated with clips and divided close to the renal vein. Intravenous mannitol (12.5 g) was given before dissection of the renal artery and vein. The renal artery was dissected to its origin from the aorta. The renal vein was circumferentially exposed 1 to 2 cm below the entry point of the adrenal vein. The ureter and investing tissues were dissected to the level of the iliac bifurcation. The posterior attachments of the kidney were then divided. The most inferior trocar site was extended into an oblique 9-cm left lower quadrant muscle-splitting incision. The base ring retractor of the HandPort device (Smith & Nephew Endoscopy, Andover, Mass) was positioned within the wound. A plastic sleeve attaches the surgeon’s wrist to the device. The surgeon’s right hand was placed into the abdomen and the pneumoperitoneum re-established (Fig. 2). Under laparoscopic visualization, the distal ureter was transected using an endoscopic linear stapler. The hand elevates the kidney and presents the renal vessels for rapid, proximal division by the linear stapler. Two vascular staplers (one for the artery and one for the vein) were used to minimize the time required for instrument exchange. To ensure adequate vessel length for transplantation, the vein was transected approximately 5 to 10 mm below the entry point of the adrenal vein, and the artery was divided flush with the aorta. The kidney was then extracted through the base ring retractor of the hand-assist device (Fig. 3). The warm ischemic time was measured from the moment of arterial stapler application to placement of the kidney on ice. UROLOGY 58 (2), 2001
FIGURE 3. Kidney can be easily extracted through the base ring retractor of the hand-assist device.
RESULTS Thirty hand-assisted laparoscopic live donor nephrectomies were attempted using the technique described. All were single-artery left kidneys. One case was electively converted because of obesity and extensive adhesions. The average donor age was 41 years (range 21 to 59). The mean patient weight was 74 kg (range 43 to 116). All operations were performed by one of three laparoscopic surgeons. For the 29 cases completed laparoscopically, the operative time ranged from 193 to 360 minutes (mean 275). The average blood loss was 99 mL (range 50 to 300). All warm ischemic times were less than 3 minutes (average 72.5 seconds, range 30 to 165). Vascular staple loads (2.0 mm) were used for vessel division in all cases. There were no instances of staple-line bleeding. The incision used for hand insertion and kidney extraction ranged from 8.5 to 10 cm (mean 9.0). Postoperatively, patients were allowed clear liquids on the first postoperative day. The time to resump153
TABLE I. Results for open, laparoscopic, and hand-assisted donor nephrectomy Flowers et al.1 (1997) Cases (n) Mean operative time (min) Mean warm ischemic time (min) Mean estimated blood loss (mL) Conversions (%) Delayed graft function (%) Mean length of stay (days)
Odland et al.7 (1999)
Present Series (2000)
Open
Laparoscopic
Open
Laparoscopic
HALDN
65 213 NR 408 — 2 4.5
69 226 3.0 122 5.7 3 2.2
30 148 1.7 192 — 3 3.8
30 183 5.0 116 23 12 2.7
30 275 1.2 99 3 0 3.4
KEY: HALDN ⫽ hand-assisted laparoscopic donor nephrectomy; NR ⫽ not reported.
tion of a regular diet averaged 2.2 days (range 1 to 4). Pain control with oral analgesics was achieved at a mean of 1.7 days (range 1 to 4) after surgery. The average length of stay was 3.4 days (range 2 to 5). All patients had resumed regular activity by 1 month after surgery. No intraoperative complications occurred. Postoperatively, 1 patient developed multiple skin blisters from an allergy to the silk tape, and 1 developed subcutaneous emphysema related to carbon dioxide insufflation. Two patients had transient fever related to atelectasis. Two patients required postoperative antibiotics for wound cellulitis. Transient urinary retention requiring catheterization occurred in 1 patient. No vascular, renal parenchymal, or ureteral injuries occurred during the procurement process. In all cases, the harvested renal artery, vein, and ureter provided adequate length for transplantation. Immediate graft function occurred in all 30 recipients. One recipient required re-exploration for bleeding on the first postoperative day. One transplanted kidney developed transient cyclosporine toxicity. A third recipient with pre-existing aortoiliac occlusive disease developed renovascular hypertension 7 months after transplantation. A stenosis at the external iliac anastomosis was identified and successfully bypassed. At a mean follow-up of 11.5 months (range 1 to 23), the recipient creatinine levels ranged from 0.6 to 2.4 mg/dL. No ureteral complications occurred. COMMENT Although the hand-assisted technique for laparoscopic donor nephrectomy is not new, the use of the HandPort device for this procedure has not been previously reported. In other reports, handassist devices have been time-consuming to place and have been associated with the loss of the pneumoperitoneum.3–5 In our experience, this device is easy to use, requires no adhesives for fixation to the abdominal wall, and has been associated with no significant air leakage.6 At the time of organ re154
moval, the surgeon’s hand and donor kidney can be rapidly extracted through the base of the device. Importantly, the edges of the base retractor are soft, and there is no valve mechanism that could traumatize the kidney during organ extraction. Although it is feasible to use hand-assistance for the entire case, we have not found this strategy to be useful. Since mobilization of the kidney and dissection of the vessels can be performed expeditiously with standard laparoscopic techniques, we have found that the hand may impede visualization when used at the outset of the case. Rather, its value appears to be related to the critical steps of vessel division and kidney extraction. When comparing our results with those of other laparoscopic series not using hand-assistance, no appreciable differences have been noted with regard to operative time, blood loss, or length of stay.1,7 At the same time, the warm ischemic times with the handassisted technique have been lower than those reported for both open and laparoscopic extraction, and no instances of delayed graft function have occurred (Table I). Although many factors may influence the immediate graft function, we believe that these results are related in part to the rapid, atraumatic extraction allowed by the hand-assisted technique. We have found that a muscle-splitting left lower quadrant (Gibson) incision for hand insertion is an attractive approach. With the patient in the full lateral position, lateral placement of the handassist incision allows the surgeon comfortable access to the kidney. This incision incorporates the most inferior of the three trocar sites, thus minimizing the number of incisions required. In our experience, the postoperative disability has been minimal, patients have returned rapidly to regular activities, and we have had no significant wound complications related to this incision. In contrast, upper midline placement of this incision (while allowing insertion of the nondominant hand) can make elevation of the kidney more difficult, provides less comfortable access for the surgeon, and is less cosmetically appealing. For UROLOGY 58 (2), 2001
left-sided nephrectomy, the surgeon’s right hand is used for kidney extraction, and the linear stapler is operated with the left hand. Although the surgeons in our series are all right-hand dominant, we have found that kidney extraction and stapler application can be performed rapidly and easily with either the dominant or nondominant hand. By performing vessel transection under laparoscopic guidance with the hand already in the abdomen, the kidney does not have to be manipulated into an extraction bag. We believe that this avoids the longer warm ischemic times (range 1.9 to 6.9 minutes) that have been associated with the laparoscopic approach.1 In this series, the average extraction time was just slightly longer than 1 minute and never exceeded 3 minutes. In previous reports, laparoscopic donor nephrectomy has been associated with major vascular injuries during both ureteral and renal vascular transection.1 Although introduction of the hand into the abdomen during these critical maneuvers may not prevent all injuries, it may reduce their risk. By providing valuable tactile feedback and allowing for atraumatic retraction of the vessels and ureter, we believe that injuries to the surrounding structures are less likely to occur. When bleeding does occur, the hand can provide rapid control. Failure of the staple line has the potential to result in massive hemorrhage from either the aorta or vena cava. In this situation, if an extraction bag is being used to remove the kidney, it may take several minutes to remove the kidney, extend the incision, and control the bleeding. With the hand already in the abdomen, immediate vascular control can be obtained with local compression. Although this complication is rare and was not encountered in our series, substantial hemorrhage from stapler failure may occur in up to 2% of cases and has been associated with blood loss as high as 1200 mL.8 The hand-assisted approach also allows for maximization of the vessel and ureter length by placing these structures “on stretch” before stapler application. With the use of the hand, these maneuvers can be performed accurately and atraumatically. The result is a viable, undamaged kidney that is ready for immediate transplantation. CONCLUSIONS Hand-assisted laparoscopic donor nephrectomy is safe, technically feasible, provides a high quality kidney, and can be accomplished with minimal morbidity. A detailed review of the short-term and long-term outcomes for all laparoscopic and open donor nephrectomies performed at our institution is currently underway. UROLOGY 58 (2), 2001
REFERENCES 1. Flowers JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226: 483– 490, 1997. 2. Ratner LE, Hiller J, Sroka M, et al: Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 29: 3402–3403, 1997. 3. Wolf JS, Tchetgen M, Meron R, et al: Hand-assisted laparoscopic donor nephrectomy. Urology 52: 885– 887, 1998. 4. Wolf JS, Moon TD, Nakada SY, et al: Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy. J Urol 160: 22–27, 1998. 5. Meyers WC, Foley DP, Sandor A, et al: Handoscopic surgery: a prospective multicenter trial of a minimally invasive technique for complex abdominal surgery. Arch Surg 134: 477– 486, 1999. 6. Litwin D, Kercher K, Novitsky Y, et al: New device for hand-assisted laparoscopic surgery. Surg Tech Int IX: 113– 116, 2000. 7. Odland MD, Ney AL, Jacobs DM, et al: Initial experience with laparoscopic live donor nephrectomy. Surgery 126: 603– 607, 1999. 8. Chan D, Bishoff JT, Ratner L, et al: Endovascular gastrointestinal stapler device malfunction during laparoscopic nephrectomy: early recognition and management. J Urol 164: 319 –321, 2000.
EDITORIAL COMMENT Laparoscopic live donor nephrectomy (LLDN) was introduced clinically in February 1995 with the intent of decreasing disincentives to live kidney donation.1 Subsequent series have demonstrated that LLDN provides significant advantages to the donor compared with open donor nephrectomy in terms of decreased postoperative pain, shorter hospitalization, quicker recuperation, and earlier return to activities, including employment.2–5 A number of centers have now reported significant increases in live kidney donation since introducing LLDN. Over 3000 LLDNs have been performed at more than 100 centers on six continents. It appears that LLDN is evolving as the new “standard of care.” Controversy exists regarding the ideal technique for LLDN. A recent survey of 77 centers performing LLDN revealed that 44% use a hand-assisted transperitoneal approach and the remainder a purely laparoscopic technique. In a departure from the open operation, only about 2% of centers perform the laparoscopic operation as a retroperitoneal procedure. The authors report their series of 30 hand-assisted LLDNs, with excellent donor and recipient results. They demonstrate that the renal warm ischemic time can be limited to 72.5 seconds (range 30 to 165) using this approach. However, it is important to note that minimizing the warm ischemic time, although important, is not the only factor that affects recipient allograft renal function. London et al.6 have demonstrated that the pneumoperitoneum decreases both renal blood flow and urine output. This effect can be abrogated by volume loading. Thus, laparoscopic donors generally require large volumes of crystalloid (7 to 10 L) intraoperatively to ensure a brisk recipient diuresis. In my opinion, this is of greater importance than several additional minutes of warm ischemia. Advocates of the hand-assisted technique generally cite several advantages in addition to the quicker kidney extraction time. First, it may decrease the learning curve for those surgeons with limited laparoscopic experience. Second, mobilization of the upper pole of the kidney is much easier manually. This usually reduces the operative time. Third, the intra-abdominal hand can be used to tamponade any major bleeders while converting to an open operation. Finally, it restores tactile sense to the surgeon. The hand-assisted technique has several disadvantages. The 155