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Hand-assisted laparoscopic live donor nephrectomy: a single center experience in Japan
Hand-Assisted Laparoscopic Live Donor Nephrectomy: A Single Center Experience in Japan I. Nakajima, T. Tojimbara, S. Sato, T. Kawase, S. Fuchinoue, and S. Teraoka
S
TANDARD laparoscopic live donor nephrectomy has been described since 1995,1 and first hand-assisted laparoscopic live donor nephrectomy (HALapNx) was reported in 1998.2 On the contrary, these procedures have not yet been widely used in Japan. After our first HALapNx in 2001, we report 30 cases and examine the possibility of making this technique widely available in Japan. PATIENTS AND METHODS From April 2001 through February 2002, hand-assisted laparoscopic live donor left nephrectomy was performed in 30 cases at our institution. Operative data and postoperative courses were reviewed, including operative time, graft volume, blood loss, conversion to laparotomy, and complications. The analysis focused on the influence on operating time of the learning curve.
Donor Characteristics HALapNx was performed in 30 healthy donors (10 men and 20 women). The mean age was 52.0 ⫾ 10.5 years, mean height was 162.6 ⫾ 9.1 cm, and mean weight was 61.1 ⫾ 13.1 kg.
Laparoscopic Operative Technique The operative procedure for HALapNx is briefly described as follows. The donor was placed in a lateral decubitus position. Two laparoscopic ports and the hand port device were introduced. Two 12-mm ports were placed in the left midaxillary line at the superior and inferior level of the umbilicus. A 5-cm incision was made in the midline periumbilicus and the Hand Port System (Smith & Nephew, USA) was fitted through the abdominl incision. After 10 mm Hg pneumoperitoneum, HALapNx was begun with mobilization of the left colon. Finally, the ureter was divided cephalad to the clip, and an endo-stapling device was applied to the renal artery and renal vein. The kidney was removed through the Hand Port System.
Statistical Analysis All data are expressed as group mean values and standard deviation’s. Comparisons between groups were performed using Student’s t test for parametric data and the regression analysis for learning curve. P ⬍ .05 was considered statistically significant.
RESULTS
HALapNx was performed successfully in all of cases, and no patients required conversion to laparotomy. The estimated © 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 43– 44 (2003)
Table 1. Influence on the Operative Time (1) Age, sex, height, weight: not significant (2) Number of renal arteries and veins: not significant (3) Graft volume: Mean operative time (min) 308.3 ⫾ 18.9g (n ⫽ 3) 281.3 ⫾ 19.6* 162.9 ⫾ 36.1g (n ⫽ 17) 202.6 ⫾ 44.7* (4) Experience in HALapNx: Mean operative time (min) 1st period (No. 1⬃10) 238.6 ⫾ 39.6* 2nd period (No. 11⬃20) 190.2 ⫾ 50.2*
(P ⫽ .0086)
(P ⫽ .0278)
*Significant.
blood loss was under 100 mL; no patients required blood transfusion. HALapNx offered less postoperative pain and minimal cosmetic disfigurement to all donors. There was no complication in a donor, but one recipient (No. 4) had a ureteral complication requiring surgical repair. The mean operative time of 200.5 ⫾ 51.6 minutes was significantly shorter in the second period (Nos. 11 through 20) than in the first period (Nos 1 through 10) (P ⫽ .0278; Table 1). Graft volume also influenced the operative time; that is, the mean operative time being longer in the big graft group (308.3 ⫾ 18.9 g, n ⫽ 3) than in the normal graft group (162.9 ⫾ 36.1 g, n ⫽ 17) (P ⫽ .0086; Table 1). The learning curve between operative time and number of cases showed a negative correlation (Y ⫽ ⫺4.269X ⫹ 259.226, R2 ⫽ 0.25, P ⫽ .0248; Fig 1). DISCUSSION
Compared with the standard open donor nephrectomy, our study documented considerable advantages of the laparoscopic approach for live donor nephrectomy with regards to postoperative pain and cosmetic disfigurement. Most published data regarding laparoscopic donor nephrectomy have been derived from standard laparoscopic live donor nephrectomy.3– 6 However, of the centers that have started to offer laparoscopic donor nephrectomy only From the Department of Surgery, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan. Address reprint requests to Ichiro Nakajima, Department of Surgery, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(02)03932-5 43
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NAKAJIMA, TOJIMBARA, SATO ET AL
Fig 1.
Learning curve between operative time and number of cases.
recently, many have adopted the hand-assisted technique because it is perceived to be faster, easier, and safer than the standard technique.7 Our mean operative time was 200.5 ⫾ 51.6 minutes and learning curve showed the negative correlation. Moreover, no patients required conversion to laparotomy or blood transfusion. These findings suggest that HALapNx is the best way to make this technique widely available in Japan. In conclusion, HALapNx is technically feasible and may offer several advantages over the standard open donor nephrectomy in terms of less blood loss, less postoperative pain, and minimal cosmetic disfigurement. In Japan, these procedures have not yet spread, possibly due to the need for surgical laparoscopic skills. We believe that the best way to
make this technique widely available is through the handassisted laparoscopic surgery. REFERENCES 1. Ratner LE, Ciseck LJ, Moore RG, et al: Transplantation 60:1047, 1995 2. Wolf JS, Tchetgen MB, Merion RM: Urology 52:885, 1998 3. Flowers JL, Jacobs S, Cho E, et al: Ann Surg 226:483, 1997 4. Philosophe B, Kuo PC, Schweitzer EJ, et al: Transplantation 68:497, 1999 5. Fabrizio MD, Ratner LE, Montgomery RA, et al: Urol Clin North Am 26:247, 1999 6. Ratner LE, Montgomery RA, Kavoussi LR, et al: Nephrol Dial Transplant 14:2090, 1999 7. Wolf JS, Merion RM, Leichtman AB, et al: Transplantation 72:284, 2001
S
TANDARD laparoscopic live donor nephrectomy has been described since 1995,1 and first hand-assisted laparoscopic live donor nephrectomy (HALapNx) was reported in 1998.2 On the contrary, these procedures have not yet been widely used in Japan. After our first HALapNx in 2001, we report 30 cases and examine the possibility of making this technique widely available in Japan. PATIENTS AND METHODS From April 2001 through February 2002, hand-assisted laparoscopic live donor left nephrectomy was performed in 30 cases at our institution. Operative data and postoperative courses were reviewed, including operative time, graft volume, blood loss, conversion to laparotomy, and complications. The analysis focused on the influence on operating time of the learning curve.
Donor Characteristics HALapNx was performed in 30 healthy donors (10 men and 20 women). The mean age was 52.0 ⫾ 10.5 years, mean height was 162.6 ⫾ 9.1 cm, and mean weight was 61.1 ⫾ 13.1 kg.
Laparoscopic Operative Technique The operative procedure for HALapNx is briefly described as follows. The donor was placed in a lateral decubitus position. Two laparoscopic ports and the hand port device were introduced. Two 12-mm ports were placed in the left midaxillary line at the superior and inferior level of the umbilicus. A 5-cm incision was made in the midline periumbilicus and the Hand Port System (Smith & Nephew, USA) was fitted through the abdominl incision. After 10 mm Hg pneumoperitoneum, HALapNx was begun with mobilization of the left colon. Finally, the ureter was divided cephalad to the clip, and an endo-stapling device was applied to the renal artery and renal vein. The kidney was removed through the Hand Port System.
Statistical Analysis All data are expressed as group mean values and standard deviation’s. Comparisons between groups were performed using Student’s t test for parametric data and the regression analysis for learning curve. P ⬍ .05 was considered statistically significant.
RESULTS
HALapNx was performed successfully in all of cases, and no patients required conversion to laparotomy. The estimated © 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 43– 44 (2003)
Table 1. Influence on the Operative Time (1) Age, sex, height, weight: not significant (2) Number of renal arteries and veins: not significant (3) Graft volume: Mean operative time (min) 308.3 ⫾ 18.9g (n ⫽ 3) 281.3 ⫾ 19.6* 162.9 ⫾ 36.1g (n ⫽ 17) 202.6 ⫾ 44.7* (4) Experience in HALapNx: Mean operative time (min) 1st period (No. 1⬃10) 238.6 ⫾ 39.6* 2nd period (No. 11⬃20) 190.2 ⫾ 50.2*
(P ⫽ .0086)
(P ⫽ .0278)
*Significant.
blood loss was under 100 mL; no patients required blood transfusion. HALapNx offered less postoperative pain and minimal cosmetic disfigurement to all donors. There was no complication in a donor, but one recipient (No. 4) had a ureteral complication requiring surgical repair. The mean operative time of 200.5 ⫾ 51.6 minutes was significantly shorter in the second period (Nos. 11 through 20) than in the first period (Nos 1 through 10) (P ⫽ .0278; Table 1). Graft volume also influenced the operative time; that is, the mean operative time being longer in the big graft group (308.3 ⫾ 18.9 g, n ⫽ 3) than in the normal graft group (162.9 ⫾ 36.1 g, n ⫽ 17) (P ⫽ .0086; Table 1). The learning curve between operative time and number of cases showed a negative correlation (Y ⫽ ⫺4.269X ⫹ 259.226, R2 ⫽ 0.25, P ⫽ .0248; Fig 1). DISCUSSION
Compared with the standard open donor nephrectomy, our study documented considerable advantages of the laparoscopic approach for live donor nephrectomy with regards to postoperative pain and cosmetic disfigurement. Most published data regarding laparoscopic donor nephrectomy have been derived from standard laparoscopic live donor nephrectomy.3– 6 However, of the centers that have started to offer laparoscopic donor nephrectomy only From the Department of Surgery, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan. Address reprint requests to Ichiro Nakajima, Department of Surgery, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(02)03932-5 43
44
NAKAJIMA, TOJIMBARA, SATO ET AL
Fig 1.
Learning curve between operative time and number of cases.
recently, many have adopted the hand-assisted technique because it is perceived to be faster, easier, and safer than the standard technique.7 Our mean operative time was 200.5 ⫾ 51.6 minutes and learning curve showed the negative correlation. Moreover, no patients required conversion to laparotomy or blood transfusion. These findings suggest that HALapNx is the best way to make this technique widely available in Japan. In conclusion, HALapNx is technically feasible and may offer several advantages over the standard open donor nephrectomy in terms of less blood loss, less postoperative pain, and minimal cosmetic disfigurement. In Japan, these procedures have not yet spread, possibly due to the need for surgical laparoscopic skills. We believe that the best way to
make this technique widely available is through the handassisted laparoscopic surgery. REFERENCES 1. Ratner LE, Ciseck LJ, Moore RG, et al: Transplantation 60:1047, 1995 2. Wolf JS, Tchetgen MB, Merion RM: Urology 52:885, 1998 3. Flowers JL, Jacobs S, Cho E, et al: Ann Surg 226:483, 1997 4. Philosophe B, Kuo PC, Schweitzer EJ, et al: Transplantation 68:497, 1999 5. Fabrizio MD, Ratner LE, Montgomery RA, et al: Urol Clin North Am 26:247, 1999 6. Ratner LE, Montgomery RA, Kavoussi LR, et al: Nephrol Dial Transplant 14:2090, 1999 7. Wolf JS, Merion RM, Leichtman AB, et al: Transplantation 72:284, 2001