Right-Sided Terminal Hand-Assisted Laparoscopic Donor Nephrectomy: The Halle Experience

Abstract

Introduction: Hand-assisted laparoscopic donor nephrectomy (HALDN) permits to combine the necessary extraction incision to manually assist the procedure. The left kidney has remained the preferred organ of choice, due to the greater vessel lengths. We describe in this video the right-side terminal HALDN with hand-assisted extension of the renal vessel, a technique that allowed the exposure of the right aortorenal junction providing maximal length of both vein and artery. In a prospective study, we compared 51 right- and 40 left-sided HALDN during a 7-year period with a 1-year follow-up. Materials and Methods: With the donor on the left flank, we performed a 5-port transperitoneal approach: 11-mm umbilical port for laparoscope, two 5-mm, and two 10-mm trocars as working ports. After superior retraction of the liver, the peritoneum was opened laterocolically and the colon mobilized. Afterward, follow the isolation of ureter, gonadal vessels, and renal hilum. Then, the ligation of the side branches of the renal vein and isolation of the vena cava and the aorta. Complete dissection of the kidney until it is only fixed by the hilar vessels. The renal vein is dissected down to its root from the cava and the renal artery. Then, the surgeon's left hand is placed intra-abdominally via a lower pararectal incision. After further vessel preparation by using the index and middle finger, the cava is pushed aside with identification and preparation of right artery down to its aortic origin. After IV heparin infusion, the ureter is cut between two clips and transected at the level of pelvis minor. The renal vein is accordingly held between two fingers (index and thumb) and closed by a triple-row Endo-TA stapler. The same procedure was followed for the artery. This simple maneuver results in recovery of the entire length of right artery, making a safe and simple anastomosis possible. Results: The median procedure time was 123 versus 135 minutes for left procedure. The mean warm ischemia time was 44 versus 41 seconds in left procedure. There were no conversions. Mean blood loss was 92 versus 101 mL in the left procedure. Mean Hospital discharge was 3.4 days. There was no vein thrombosis. Delayed graft function occurred in two recipients: one in the left and the other in the right group. No significant difference in creatinine was seen between the groups 1 year after the transplantation. One-year graft survival rate was 97.5% in the left versus 98.1% in the right group. Discussion/Conclusion: Even if laparoscopy has decreased the patient's morbidity, the evaluation process for the kidney extraction must follow the principle that the best kidney should always remain with the donor, independently from the surgical technique. The HALDN approach results in a significative improvement in length of right renal vessels. Moreover, dissection first of right renal vein allows a retrocaval isolation of the artery, obtaining a significative longer vessel. No competing financial interests exist. Runtime of video: 7 mins 06 secs