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Laparoscopic live donor nephrectomy: the single surgeon technique
SURGEON AT WORK
Laparoscopic Live Donor Nephrectomy: The Single Surgeon Technique Patrick P Daily, MD, Kenneth D Chavin, MD, PhD, FACS placed on the table to the surgeon’s right at the level of the patient’s hips. Port placement and AESOP positioning are critical for the single surgeon technique. After establishing a pneumoperitoneum with a Veress needle in the left lower quadrant, an 8- to 12-mm port is placed at approximately McBurney’s point on the left side. The initial trocar is placed under direct vision using the Visiport visual trocar (United States Surgical Corp). The abdomen is then surveyed for any bowel injury and the additional ports are placed under direct laparoscopic vision. Next, an 8- to 12-mm port is placed at the umbilicus and a 5-mm port three fingerbreadths inferior to the xiphoid in the midline. The 30-degree camera is inserted in the umbilical port and attached to the robotic arm. As with most other donor nephrectomy techniques, dissection begins with mobilization of the colon. The lateral peritoneal reflection is divided along the avascular white line of Toldt from the splenic flexure to below the pelvic inlet. Care is taken not to divide the medial phrenocolic ligaments because they will provide counter traction for the endocatch bag, which will hook under the colon and retract it medially. The plane of dissection is between the colonic mesentery and the retroperitoneal structures. At this point, the left gonadal vein is identified and can be followed back to its origin at the left renal vein. The tissue anterior to the left vein is carefully divided along with Gerota’s fascia along the upper pole of the anterior surface of the kidney. Next, a Pfannenstiel incision is created and is carried down to the peritoneum.6 An Endocatch bag (United States Surgical Corp) is inserted and secured with a 3-0 vicryl purse string suture to maintain the pneumoperitoneum. The Endocatch bag is placed under the colon at the level of the splenic flexure and the colon is retracted medially. It is attached to the drapes with a Kelly in order to free up the surgeon’s hand. Early placement and proper positioning are key to the single surgeon technique. Gerota’s fascia is divided until the upper pole of the kidney is completely mobilized. Once the upper pole is dissected, the renal hilum can be exposed. The left gonadal vein is doubly
The worldwide shortage of cadaveric kidneys available for transplantation has led surgeons to seek out alternate sources for organs. After Clayman and associates first demonstrated the ability to perform laparoscopic native nephrectomy for benign renal disease in 1991,1 transplant surgeons began to assess this minimally invasive technique for live donor nephrectomies. The laparoscopic procedure has reduced donor fear concerning postoperative pain, length of recovery, and increased the number of individuals donating by as much as 25% at some institutions.2,3 Several different techniques have been used for donor nephrectomy, ranging from the method Ratner and associates4 initially described in 1995 to hand-assisted devices that reduce the learning curve in this technically demanding procedure.5 To date, all of these techniques require a second surgeon or assistant. We present our method of live laparoscopic donor nephrectomy, which is unique, in that it involves only a single surgeon. Procedure and positioning
After induction of general endotracheal anesthesia and administration of antibiotics, a Foley catheter is placed to decompress the bladder. An orogastric tube is inserted and nitrous oxide is avoided to reduce the interference of bowel within the operative field. The patient is then positioned using a beanbag in a modified lateral decubitis position. The kidney rest is elevated and the bed is partially flexed. An axillary roll is used to prevent brachial plexus injury and the left arm is placed on an elevated arm board. The patient’s right leg is flexed and pillows are used to support the left leg in a straight position. Next, wide silk tape is placed across the hips and shoulders and secured to the underside of the table to allow the patient to be airplaned in either direction. An AESOP 3000 robotic arm (Computer Motion, Inc) is No competing interests declared.
Received July 11, 2002; Revised January 24, 2003; Accepted April 30, 2003. From the Division of Transplant, Medical University of South Carolina, Charleston, SC. Correspondence address: Kenneth Chavin, MD, PhD, 96 Jonathan Lucas St, Suite 404 CSB, Charleston, SC 29425.
© 2003 by the American College of Surgeons Published by Elsevier Inc.
519
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(03)00480-0
520
Daily and Chavin
Laparoscopic Live Donor Nephrectomy
clipped and divided where it originates on the renal vein. Attention is now turned to the superior surface of the left renal vein. The adrenal vein is identified as it courses superiorly off of the renal vein, where it can be doubly clipped and divided. The kidney is then elevated laterally and anteriorly to better expose the renal artery. The tissue between the superior border of the left renal artery and the left adrenal gland is divided using both blunt and sharp dissection. At this point, we begin dissection of the ureter. Being careful not to disrupt the periureteral tissue, the ureter can be traced from the hilum caudally to its entry into the pelvis over the iliac vessels. We prefer not to divide the ureter until all posterior attachments to the kidney are divided. This prevents rotation of the kidney on its pedicle, resulting in vascular compromise. The ureter can now be doubly clipped distally and transected. Once the recipient team is ready and present in the room, a bolus of 3,000 units of heparin is administered. After 3 minutes, the renal artery is divided first using a GIA stapler with a vascular load. The stapler is reloaded and the renal vein is divided medial to the adrenal vein stump. The kidney, ureter, and perirenal fat are then placed into the Endocatch bag. After the purse string on the Endocatch bag is secured, the peritoneum can be opened and the organ recovered so it can be passed off and flushed on the back table. The peritoneum is closed with 3-0 vieryl suture and the Pfannenstiel incision is closed using a running #1 polydioxanone suture. A pneumoperitoneum is reestablished and the abdomen is inspected for any bleeding. Under direct laparoscopic vision, the left lower quadrant and umbilical port sites can be closed using the CarterThomason needle closure device and 2-0 vicryl sutures. Again under direct laparoscopic vision, the 5-mm port is removed and pneumoperitoneum released. Wounds are irrigated with antibiotic solution and the skin is closed using 4-0 monocryl sutures. Steri-strips (3M Company) and dressings are placed and the skin and fascia are infiltrated with 0.5% bupivicaine. Discussion
Our modification of the laparoscopic nephrectomy allows for a single surgeon to perform this operation safely
J Am Coll Surg
and efficiently. Early placement and securing of the Endocatch bag makes routine use of a second surgeon unnecessary. At the critical time of ligation of the vessels, a second surgeon should be available to facilitate removal of the kidney and to ensure safety to the patient if complications arise or there is misfire with a vascular GIA stapler. Mobilization of other organs is unnecessary in our approach, reducing complications and allowing for a faster recovery for the patient.7 We believe this modification of the laparoscopic donor nephrectomy is a further advance in a challenging but widely accepted technique. It might also be applied to laparoscopic nephrectomy for other pathology, again minimizing operating room personnel. Author Contributions
Study conception and design: Daily, Chavin Acquisition of data: Daily, Chavin Analysis and interpretation of data: Daily, Chavin Drafting of manuscript: Daily, Chavin Critical revision: Daily, Chavin Statistical expertise: Daily, Chavin Obtaining funding: Daily, Chavin Supervision: Daily, Chavin
REFERENCES 1. Clayman RV, Kavoussi LR, Soper JN, et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991;146:278–282. 2. Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy: The four year Johns Hopkins University experience. Nephrol Dial Transplant 1999;14:2090–2093. 3. Shafizadeh S, Mcevoy JR, Murray C, et al. Laparoscopic donor nephrectomy: impact on an established renal transplant program. Am Surg 2000;66:1132–1135. 4. Ratner LE, Cisek LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995;60:1047–1049. 5. Buell JF, Hanaway MJ, Potter SR, et al. Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy. Am J Transplant 2002; 2:983–988. 6. Ratner LE, Fabrizio M, Chavin K, et al. Technical considerations in the delivery of the kidney during laparoscopic live-donor nephrectomy. J Am Coll Surg 1999;189:427–430. 7. Shafizadeh SF, Daily PP, Baliga P, et al. Chylous ascites secondary to laparoscopic donor nephrectomy. Urology 2002;60:345.
Laparoscopic Live Donor Nephrectomy: The Single Surgeon Technique Patrick P Daily, MD, Kenneth D Chavin, MD, PhD, FACS placed on the table to the surgeon’s right at the level of the patient’s hips. Port placement and AESOP positioning are critical for the single surgeon technique. After establishing a pneumoperitoneum with a Veress needle in the left lower quadrant, an 8- to 12-mm port is placed at approximately McBurney’s point on the left side. The initial trocar is placed under direct vision using the Visiport visual trocar (United States Surgical Corp). The abdomen is then surveyed for any bowel injury and the additional ports are placed under direct laparoscopic vision. Next, an 8- to 12-mm port is placed at the umbilicus and a 5-mm port three fingerbreadths inferior to the xiphoid in the midline. The 30-degree camera is inserted in the umbilical port and attached to the robotic arm. As with most other donor nephrectomy techniques, dissection begins with mobilization of the colon. The lateral peritoneal reflection is divided along the avascular white line of Toldt from the splenic flexure to below the pelvic inlet. Care is taken not to divide the medial phrenocolic ligaments because they will provide counter traction for the endocatch bag, which will hook under the colon and retract it medially. The plane of dissection is between the colonic mesentery and the retroperitoneal structures. At this point, the left gonadal vein is identified and can be followed back to its origin at the left renal vein. The tissue anterior to the left vein is carefully divided along with Gerota’s fascia along the upper pole of the anterior surface of the kidney. Next, a Pfannenstiel incision is created and is carried down to the peritoneum.6 An Endocatch bag (United States Surgical Corp) is inserted and secured with a 3-0 vicryl purse string suture to maintain the pneumoperitoneum. The Endocatch bag is placed under the colon at the level of the splenic flexure and the colon is retracted medially. It is attached to the drapes with a Kelly in order to free up the surgeon’s hand. Early placement and proper positioning are key to the single surgeon technique. Gerota’s fascia is divided until the upper pole of the kidney is completely mobilized. Once the upper pole is dissected, the renal hilum can be exposed. The left gonadal vein is doubly
The worldwide shortage of cadaveric kidneys available for transplantation has led surgeons to seek out alternate sources for organs. After Clayman and associates first demonstrated the ability to perform laparoscopic native nephrectomy for benign renal disease in 1991,1 transplant surgeons began to assess this minimally invasive technique for live donor nephrectomies. The laparoscopic procedure has reduced donor fear concerning postoperative pain, length of recovery, and increased the number of individuals donating by as much as 25% at some institutions.2,3 Several different techniques have been used for donor nephrectomy, ranging from the method Ratner and associates4 initially described in 1995 to hand-assisted devices that reduce the learning curve in this technically demanding procedure.5 To date, all of these techniques require a second surgeon or assistant. We present our method of live laparoscopic donor nephrectomy, which is unique, in that it involves only a single surgeon. Procedure and positioning
After induction of general endotracheal anesthesia and administration of antibiotics, a Foley catheter is placed to decompress the bladder. An orogastric tube is inserted and nitrous oxide is avoided to reduce the interference of bowel within the operative field. The patient is then positioned using a beanbag in a modified lateral decubitis position. The kidney rest is elevated and the bed is partially flexed. An axillary roll is used to prevent brachial plexus injury and the left arm is placed on an elevated arm board. The patient’s right leg is flexed and pillows are used to support the left leg in a straight position. Next, wide silk tape is placed across the hips and shoulders and secured to the underside of the table to allow the patient to be airplaned in either direction. An AESOP 3000 robotic arm (Computer Motion, Inc) is No competing interests declared.
Received July 11, 2002; Revised January 24, 2003; Accepted April 30, 2003. From the Division of Transplant, Medical University of South Carolina, Charleston, SC. Correspondence address: Kenneth Chavin, MD, PhD, 96 Jonathan Lucas St, Suite 404 CSB, Charleston, SC 29425.
© 2003 by the American College of Surgeons Published by Elsevier Inc.
519
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(03)00480-0
520
Daily and Chavin
Laparoscopic Live Donor Nephrectomy
clipped and divided where it originates on the renal vein. Attention is now turned to the superior surface of the left renal vein. The adrenal vein is identified as it courses superiorly off of the renal vein, where it can be doubly clipped and divided. The kidney is then elevated laterally and anteriorly to better expose the renal artery. The tissue between the superior border of the left renal artery and the left adrenal gland is divided using both blunt and sharp dissection. At this point, we begin dissection of the ureter. Being careful not to disrupt the periureteral tissue, the ureter can be traced from the hilum caudally to its entry into the pelvis over the iliac vessels. We prefer not to divide the ureter until all posterior attachments to the kidney are divided. This prevents rotation of the kidney on its pedicle, resulting in vascular compromise. The ureter can now be doubly clipped distally and transected. Once the recipient team is ready and present in the room, a bolus of 3,000 units of heparin is administered. After 3 minutes, the renal artery is divided first using a GIA stapler with a vascular load. The stapler is reloaded and the renal vein is divided medial to the adrenal vein stump. The kidney, ureter, and perirenal fat are then placed into the Endocatch bag. After the purse string on the Endocatch bag is secured, the peritoneum can be opened and the organ recovered so it can be passed off and flushed on the back table. The peritoneum is closed with 3-0 vieryl suture and the Pfannenstiel incision is closed using a running #1 polydioxanone suture. A pneumoperitoneum is reestablished and the abdomen is inspected for any bleeding. Under direct laparoscopic vision, the left lower quadrant and umbilical port sites can be closed using the CarterThomason needle closure device and 2-0 vicryl sutures. Again under direct laparoscopic vision, the 5-mm port is removed and pneumoperitoneum released. Wounds are irrigated with antibiotic solution and the skin is closed using 4-0 monocryl sutures. Steri-strips (3M Company) and dressings are placed and the skin and fascia are infiltrated with 0.5% bupivicaine. Discussion
Our modification of the laparoscopic nephrectomy allows for a single surgeon to perform this operation safely
J Am Coll Surg
and efficiently. Early placement and securing of the Endocatch bag makes routine use of a second surgeon unnecessary. At the critical time of ligation of the vessels, a second surgeon should be available to facilitate removal of the kidney and to ensure safety to the patient if complications arise or there is misfire with a vascular GIA stapler. Mobilization of other organs is unnecessary in our approach, reducing complications and allowing for a faster recovery for the patient.7 We believe this modification of the laparoscopic donor nephrectomy is a further advance in a challenging but widely accepted technique. It might also be applied to laparoscopic nephrectomy for other pathology, again minimizing operating room personnel. Author Contributions
Study conception and design: Daily, Chavin Acquisition of data: Daily, Chavin Analysis and interpretation of data: Daily, Chavin Drafting of manuscript: Daily, Chavin Critical revision: Daily, Chavin Statistical expertise: Daily, Chavin Obtaining funding: Daily, Chavin Supervision: Daily, Chavin
REFERENCES 1. Clayman RV, Kavoussi LR, Soper JN, et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991;146:278–282. 2. Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy: The four year Johns Hopkins University experience. Nephrol Dial Transplant 1999;14:2090–2093. 3. Shafizadeh S, Mcevoy JR, Murray C, et al. Laparoscopic donor nephrectomy: impact on an established renal transplant program. Am Surg 2000;66:1132–1135. 4. Ratner LE, Cisek LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995;60:1047–1049. 5. Buell JF, Hanaway MJ, Potter SR, et al. Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy. Am J Transplant 2002; 2:983–988. 6. Ratner LE, Fabrizio M, Chavin K, et al. Technical considerations in the delivery of the kidney during laparoscopic live-donor nephrectomy. J Am Coll Surg 1999;189:427–430. 7. Shafizadeh SF, Daily PP, Baliga P, et al. Chylous ascites secondary to laparoscopic donor nephrectomy. Urology 2002;60:345.