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Hand port use for extraction during laparoscopic donor nephrectomy
ADULT UROLOGY
HAND PORT USE FOR EXTRACTION DURING LAPAROSCOPIC DONOR NEPHRECTOMY COSTAS D. LALLAS, ERIK P. CASTLE,
AND
PAUL E. ANDREWS
ABSTRACT Objectives. To report our technique of laparoscopic donor nephrectomy using the hand port for specimen extraction. In 1999, our institution began a kidney transplant program. Donor nephrectomies have since been exclusively performed laparoscopically. Early in our experience, we used a specimen extraction bag to assist in graft removal, but encountered some complications. We subsequently changed our technique to include a hand port for specimen extraction. Methods. A database of our experience was kept prospectively. The records of both donors and recipients were reviewed. We describe our technique of laparoscopic donor nephrectomy, including our new method of specimen extraction using a hand port. Results. A total of 230 consecutive procedures were reviewed. We had excellent donor outcomes, including a mean operative time of 107.9 minutes and an estimated blood loss of 112.4 mL. In addition, the complication (12.6%) and open conversion (1.3%) rates were low. The time needed for specimen extraction decreased from 3.16 minutes to 1.16 minutes (P ⬍0.05) after implementation of the hand port. Conclusions. The hand port modification decreased the extraction time and allowed for a safer method of extraction. We believe that the hand port facilitates a procedure that contains a small margin of error. UROLOGY 67: 706–708, 2006. © 2006 Elsevier Inc.
L
aparoscopic donor nephrectomy (LDN) is the emerging standard for procurement of live donor kidneys. The reasons for this phenomenon are less postoperative pain, a shorter hospital stay, a shorter convalescence, and better cosmesis. Moreover, the appeal of these clear benefits to the donor has been credited with increasing the willingness of individuals to undergo live kidney donation.1 We began our renal transplant program in 1999 and have since performed all our donor nephrectomies laparoscopically. Early in our series, specimen extraction was noted to be a particularly stressful portion of the procedure, and we encountered one episode of a small cortical fracture in a graft while trying to capture it in a laparoscopic entrapment bag. We accordingly converted from a laparoscopic entrapment bag to a hand port for specimen extraction and believe this modification has had an extremely positive impact on our experience. Although our dissection continues to be From the Department of Urology, Mayo Clinic, Scottsdale, Arizona Reprint requests: Paul E. Andrews, M.D., Department of Urology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85257. E-mail: [email protected] Submitted: June 7, 2005, accepted (with revisions): October 19, 2005 © 2006 ELSEVIER INC. 706
ALL RIGHTS RESERVED
performed purely laparoscopically, we have found that the hand port facilitates a procedure with a notoriously small margin of error. We reviewed our experience and report it here. MATERIAL AND METHODS The records of all patients who underwent LDN at our institution from June 1999 to April 2005 were reviewed after obtaining approval from our institutional review board. All cases were performed exclusively by, or under the tutelage of, one surgeon (P.E.A.). We used a transperitoneal approach for both left and rightsided LDN. The hand port was placed through either a lower midline or Pfannenstiel incision at the beginning of each case (Fig. 1). The pneumoperitoneum was established through the hand port at 15 mm Hg. LDN dissection was performed purely laparoscopically. Once the ureter and renal hilum were secured, the surgeon placed his arm (right arm for left-sided and left arm for right-sided procedures) through the hand port to extract the specimen swiftly and hand it off to the transplant team, who had prepared the recipient in an adjacent room.
RESULTS During the period of interest, we performed 230 LDNs. Consistent with prior reports, we had significantly more women donors than men.2 More than 13% (31 total) of the kidneys that we used 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.10.065
FIGURE 2. Mean extraction time before and after use of hand port (P ⬍0.05).
TABLE II. Recipient serum creatinine measurements during first year after transplant Serum Creatinine (mg/dL) 1 wk 6 mo 1 yr
Recipients 1–68
Recipients 69–230
2.2 ⫾ 2.0 1.4 ⫾ 0.6 1.3 ⫾ 0.4
2.1 ⫾ 1.6 1.4 ⫾ 0.4 1.5 ⫾ 0.4
No P values were statistically significant.
FIGURE 1. Diagram of Pfannenstiel incision for (A) placement of hand port and (B) standard setup for left LDN.
TABLE I. Donor (n ⴝ 230) and perioperative details Characteristic Mean age (yr) Sex (n) Male Female Side (n) Right Left Multiple renal arteries Average OR time (min) EBL (mL) Open conversions (n) Complications (n) LOS (days)
Donors 1–68 39.8 ⫾ 11.7
Donors 69–230 40.9 ⫾ 11.2
29 39
53 109
6 62 5 (7.4) 143.9 ⫾ 38.7 110.8 ⫾ 38.1 3 10 (14.7) 2.4 ⫾ 1.1
25 137 18 (11.1) 98.6 ⫾ 25.9 85.3 ⫾ 72.9 0 19 (11.7) 2.2 ⫾ 0.66
KEY: OR ⫽ operating room; EBL ⫽ estimated blood loss; LOS ⫽ length of stay. Data in parentheses are percentages.
were right sided and about 10% of the total donor grafts had multiple renal arteries. In addition, we also calculated our overall open conversion and complication rates (1.3% and 12.6%, respectively). UROLOGY 67 (4), 2006
It should be noted that none of our open conversions and 1 of 29 of our complications were related to specimen extraction (a small cortical fracture with no permanent damage to the transplanted kidney). The mean total operative time was a little less than 2 hours. These data are presented in Table I and have been divided between our first 68 and last 162 cases, without and with the hand port, respectively. We noted a decreased operative time, estimated blood loss, open conversion rate, and complication rate with increased experience, despite undertaking more challenging cases (ie, more rightsided LDNs and kidneys with multiple vessels). Starting with our 69th case, we converted to a hand port for specimen extraction. We immediately noted a difference in our mean extraction time, which was essentially halved (Fig. 2). We evaluated this decrease in warm ischemic time and its relation to both short and long-term graft survival but found no difference between the two methods of extraction (Table II). However, although the one cortical fracture on extraction was related to capturing the donor kidney in a laparoscopic entrapment bag, we have encountered no such difficulty with the hand port. COMMENT Although laparoscopy has reinvigorated living renal transplantation, the procedure itself can be 707
taxing. As a result, we consider any procedural modification that can broaden the diminutive margin of error of LDN as beneficial. Several groups who considered more traditional methods suboptimal have revised the extraction portion of the case.3–5 In addition, other institutions have noted the benefits of hand-assisted laparoscopy with regard to specimen extraction.6 – 8 Admittedly, we are not the first group to propose terminal manual extraction after a pure laparoscopic dissection.3,5 These two groups also turned to manual extraction after encountering complications with the laparoscopic entrapment bag. We believe that placing the hand port at the beginning of the case facilitates establishment of the pneumoperitoneum and port placement, in addition to its benefits in extraction. Additionally, we maintain a purely laparoscopic dissection because of our efficiency with this technique; this is how we have performed all our laparoscopic renal surgery for the past 6 years. Moreover, the cost difference between the hand port and the laparoscopic entrapment bag has been negligible at $84 more for the hand port according to the respective manufacturers’ quoted prices to our institution (Applied Medical, Rancho Santa Margarita, Calif and U.S. Surgical, Norwalk, Conn). Thus, this modification significantly increased the margin of error of LDN at an insignificant cost. The efficiency that the hand port imparts to extraction is due largely to the surgeon’s ability to break any residual fascial attachments between the donor kidney and the surrounding retroperitoneal structures. These attachments can be problematic when using an entrapment bag but are nothing but a nuisance with a hand port. It should be noted that the entire extraction is performed under direct vision; thus, these residual attachments are examined before manipulating them to prevent any untoward outcomes. Hand-assisted LDN has a shorter warm ischemic time than pure LDN, and this is largely a result of the method of extraction.6,7,9 This advantage, however, conveys questionable clinical significance, and it has been suggested that the shorter warm ischemic times associated with hand-assisted LDN, and even open donor nephrectomy, do not offer a measurable advantage in recipient graft function when considering the serum creatinine trends during 1 year.10 Correspondingly, we could not dem-
708
onstrate a significant difference when comparing the recipients from our first 68 donors and those for our last 162. Nonetheless, we believe that the extraction is a more controlled process when using the hand port, and we have been more satisfied because we have not caused any further damage to a graft since enacting this change. CONCLUSIONS We report our experience with hand port extraction after pure LDN. Although we found no demonstrable change in recipient renal function, the warm ischemic time was essentially halved after this procedural modification. In addition, we encountered no additional complications in relation to extraction after converting to the hand port. In all, we believe that using the hand port eases some of the burden of this anxiety-ridden procedure. REFERENCES 1. Ratner LE, Montgomery RA, and Kavoussi LR: Laparoscopic live donor nephrectomy: a review of the first 5 years. Urol Clin North Am 28: 709 –719, 2001. 2. Troppmann C, Ormond DB, and Perez RV: Laparoscopic (vs open) live donor nephrectomy: a UNOS database analysis of early graft function and survival. Am J Transplant 3: 1295–1301, 2003. 3. Bhat HS, Sanjeevan KV, and Sudhindran S: Terminal hand-assist for laparoscopic donor nephrectomy. Transplant Proc 36: 1905–1906, 2004. 4. Kuo PC, Sitzmann JV, and Johnson LB: An alternative extraction site for laparoscopic donor nephrectomy. J Am Coll Surg 188: 72–73, 1999. 5. Shalhav AL, Siqueira TM Jr, Gardner TA, et al: Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy. J Urol 168: 941–944, 2002. 6. Tooher RL, Rao MM, Scott DF, et al: A systematic review of laparoscopic live-donor nephrectomy. Transplantation 78: 404 – 414, 2004. 7. Gershbein AB, and Fuchs GJ: Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques. J Endourol 16: 509 –513, 2002. 8. Kercher K, Dahl D, Harland R, et al: Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia. Urology 58: 152–156, 2001. 9. Wolf JS Jr, Merion RM, Leichtman AB, et al: Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation 72: 284 – 290, 2001. 10. Buzdon MM, Cho E, Jacobs SC, et al: Warm ischemia time does not correlate with recipient graft function in laparoscopic donor nephrectomy. Surg Endosc 17: 746 –749, 2003.
UROLOGY 67 (4), 2006
HAND PORT USE FOR EXTRACTION DURING LAPAROSCOPIC DONOR NEPHRECTOMY COSTAS D. LALLAS, ERIK P. CASTLE,
AND
PAUL E. ANDREWS
ABSTRACT Objectives. To report our technique of laparoscopic donor nephrectomy using the hand port for specimen extraction. In 1999, our institution began a kidney transplant program. Donor nephrectomies have since been exclusively performed laparoscopically. Early in our experience, we used a specimen extraction bag to assist in graft removal, but encountered some complications. We subsequently changed our technique to include a hand port for specimen extraction. Methods. A database of our experience was kept prospectively. The records of both donors and recipients were reviewed. We describe our technique of laparoscopic donor nephrectomy, including our new method of specimen extraction using a hand port. Results. A total of 230 consecutive procedures were reviewed. We had excellent donor outcomes, including a mean operative time of 107.9 minutes and an estimated blood loss of 112.4 mL. In addition, the complication (12.6%) and open conversion (1.3%) rates were low. The time needed for specimen extraction decreased from 3.16 minutes to 1.16 minutes (P ⬍0.05) after implementation of the hand port. Conclusions. The hand port modification decreased the extraction time and allowed for a safer method of extraction. We believe that the hand port facilitates a procedure that contains a small margin of error. UROLOGY 67: 706–708, 2006. © 2006 Elsevier Inc.
L
aparoscopic donor nephrectomy (LDN) is the emerging standard for procurement of live donor kidneys. The reasons for this phenomenon are less postoperative pain, a shorter hospital stay, a shorter convalescence, and better cosmesis. Moreover, the appeal of these clear benefits to the donor has been credited with increasing the willingness of individuals to undergo live kidney donation.1 We began our renal transplant program in 1999 and have since performed all our donor nephrectomies laparoscopically. Early in our series, specimen extraction was noted to be a particularly stressful portion of the procedure, and we encountered one episode of a small cortical fracture in a graft while trying to capture it in a laparoscopic entrapment bag. We accordingly converted from a laparoscopic entrapment bag to a hand port for specimen extraction and believe this modification has had an extremely positive impact on our experience. Although our dissection continues to be From the Department of Urology, Mayo Clinic, Scottsdale, Arizona Reprint requests: Paul E. Andrews, M.D., Department of Urology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85257. E-mail: [email protected] Submitted: June 7, 2005, accepted (with revisions): October 19, 2005 © 2006 ELSEVIER INC. 706
ALL RIGHTS RESERVED
performed purely laparoscopically, we have found that the hand port facilitates a procedure with a notoriously small margin of error. We reviewed our experience and report it here. MATERIAL AND METHODS The records of all patients who underwent LDN at our institution from June 1999 to April 2005 were reviewed after obtaining approval from our institutional review board. All cases were performed exclusively by, or under the tutelage of, one surgeon (P.E.A.). We used a transperitoneal approach for both left and rightsided LDN. The hand port was placed through either a lower midline or Pfannenstiel incision at the beginning of each case (Fig. 1). The pneumoperitoneum was established through the hand port at 15 mm Hg. LDN dissection was performed purely laparoscopically. Once the ureter and renal hilum were secured, the surgeon placed his arm (right arm for left-sided and left arm for right-sided procedures) through the hand port to extract the specimen swiftly and hand it off to the transplant team, who had prepared the recipient in an adjacent room.
RESULTS During the period of interest, we performed 230 LDNs. Consistent with prior reports, we had significantly more women donors than men.2 More than 13% (31 total) of the kidneys that we used 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.10.065
FIGURE 2. Mean extraction time before and after use of hand port (P ⬍0.05).
TABLE II. Recipient serum creatinine measurements during first year after transplant Serum Creatinine (mg/dL) 1 wk 6 mo 1 yr
Recipients 1–68
Recipients 69–230
2.2 ⫾ 2.0 1.4 ⫾ 0.6 1.3 ⫾ 0.4
2.1 ⫾ 1.6 1.4 ⫾ 0.4 1.5 ⫾ 0.4
No P values were statistically significant.
FIGURE 1. Diagram of Pfannenstiel incision for (A) placement of hand port and (B) standard setup for left LDN.
TABLE I. Donor (n ⴝ 230) and perioperative details Characteristic Mean age (yr) Sex (n) Male Female Side (n) Right Left Multiple renal arteries Average OR time (min) EBL (mL) Open conversions (n) Complications (n) LOS (days)
Donors 1–68 39.8 ⫾ 11.7
Donors 69–230 40.9 ⫾ 11.2
29 39
53 109
6 62 5 (7.4) 143.9 ⫾ 38.7 110.8 ⫾ 38.1 3 10 (14.7) 2.4 ⫾ 1.1
25 137 18 (11.1) 98.6 ⫾ 25.9 85.3 ⫾ 72.9 0 19 (11.7) 2.2 ⫾ 0.66
KEY: OR ⫽ operating room; EBL ⫽ estimated blood loss; LOS ⫽ length of stay. Data in parentheses are percentages.
were right sided and about 10% of the total donor grafts had multiple renal arteries. In addition, we also calculated our overall open conversion and complication rates (1.3% and 12.6%, respectively). UROLOGY 67 (4), 2006
It should be noted that none of our open conversions and 1 of 29 of our complications were related to specimen extraction (a small cortical fracture with no permanent damage to the transplanted kidney). The mean total operative time was a little less than 2 hours. These data are presented in Table I and have been divided between our first 68 and last 162 cases, without and with the hand port, respectively. We noted a decreased operative time, estimated blood loss, open conversion rate, and complication rate with increased experience, despite undertaking more challenging cases (ie, more rightsided LDNs and kidneys with multiple vessels). Starting with our 69th case, we converted to a hand port for specimen extraction. We immediately noted a difference in our mean extraction time, which was essentially halved (Fig. 2). We evaluated this decrease in warm ischemic time and its relation to both short and long-term graft survival but found no difference between the two methods of extraction (Table II). However, although the one cortical fracture on extraction was related to capturing the donor kidney in a laparoscopic entrapment bag, we have encountered no such difficulty with the hand port. COMMENT Although laparoscopy has reinvigorated living renal transplantation, the procedure itself can be 707
taxing. As a result, we consider any procedural modification that can broaden the diminutive margin of error of LDN as beneficial. Several groups who considered more traditional methods suboptimal have revised the extraction portion of the case.3–5 In addition, other institutions have noted the benefits of hand-assisted laparoscopy with regard to specimen extraction.6 – 8 Admittedly, we are not the first group to propose terminal manual extraction after a pure laparoscopic dissection.3,5 These two groups also turned to manual extraction after encountering complications with the laparoscopic entrapment bag. We believe that placing the hand port at the beginning of the case facilitates establishment of the pneumoperitoneum and port placement, in addition to its benefits in extraction. Additionally, we maintain a purely laparoscopic dissection because of our efficiency with this technique; this is how we have performed all our laparoscopic renal surgery for the past 6 years. Moreover, the cost difference between the hand port and the laparoscopic entrapment bag has been negligible at $84 more for the hand port according to the respective manufacturers’ quoted prices to our institution (Applied Medical, Rancho Santa Margarita, Calif and U.S. Surgical, Norwalk, Conn). Thus, this modification significantly increased the margin of error of LDN at an insignificant cost. The efficiency that the hand port imparts to extraction is due largely to the surgeon’s ability to break any residual fascial attachments between the donor kidney and the surrounding retroperitoneal structures. These attachments can be problematic when using an entrapment bag but are nothing but a nuisance with a hand port. It should be noted that the entire extraction is performed under direct vision; thus, these residual attachments are examined before manipulating them to prevent any untoward outcomes. Hand-assisted LDN has a shorter warm ischemic time than pure LDN, and this is largely a result of the method of extraction.6,7,9 This advantage, however, conveys questionable clinical significance, and it has been suggested that the shorter warm ischemic times associated with hand-assisted LDN, and even open donor nephrectomy, do not offer a measurable advantage in recipient graft function when considering the serum creatinine trends during 1 year.10 Correspondingly, we could not dem-
708
onstrate a significant difference when comparing the recipients from our first 68 donors and those for our last 162. Nonetheless, we believe that the extraction is a more controlled process when using the hand port, and we have been more satisfied because we have not caused any further damage to a graft since enacting this change. CONCLUSIONS We report our experience with hand port extraction after pure LDN. Although we found no demonstrable change in recipient renal function, the warm ischemic time was essentially halved after this procedural modification. In addition, we encountered no additional complications in relation to extraction after converting to the hand port. In all, we believe that using the hand port eases some of the burden of this anxiety-ridden procedure. REFERENCES 1. Ratner LE, Montgomery RA, and Kavoussi LR: Laparoscopic live donor nephrectomy: a review of the first 5 years. Urol Clin North Am 28: 709 –719, 2001. 2. Troppmann C, Ormond DB, and Perez RV: Laparoscopic (vs open) live donor nephrectomy: a UNOS database analysis of early graft function and survival. Am J Transplant 3: 1295–1301, 2003. 3. Bhat HS, Sanjeevan KV, and Sudhindran S: Terminal hand-assist for laparoscopic donor nephrectomy. Transplant Proc 36: 1905–1906, 2004. 4. Kuo PC, Sitzmann JV, and Johnson LB: An alternative extraction site for laparoscopic donor nephrectomy. J Am Coll Surg 188: 72–73, 1999. 5. Shalhav AL, Siqueira TM Jr, Gardner TA, et al: Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy. J Urol 168: 941–944, 2002. 6. Tooher RL, Rao MM, Scott DF, et al: A systematic review of laparoscopic live-donor nephrectomy. Transplantation 78: 404 – 414, 2004. 7. Gershbein AB, and Fuchs GJ: Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques. J Endourol 16: 509 –513, 2002. 8. Kercher K, Dahl D, Harland R, et al: Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia. Urology 58: 152–156, 2001. 9. Wolf JS Jr, Merion RM, Leichtman AB, et al: Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation 72: 284 – 290, 2001. 10. Buzdon MM, Cho E, Jacobs SC, et al: Warm ischemia time does not correlate with recipient graft function in laparoscopic donor nephrectomy. Surg Endosc 17: 746 –749, 2003.
UROLOGY 67 (4), 2006