Hand-assisted Laparoscopic Donor Nephrectomy Research Articles

Initial experience with hand-assisted laparoscopic donor nephrectomy: a single-centre experience over 5 years

Objective: The objective of this study was to evaluate outcome after hand-assisted live donor nephrectomy with a retroperitoneal approach during a 5 year period.Materials and methods: All donor nephrectomies at Odense University Hospital, Denmark, from January 2008 to December 2012 were identified retrospectively, and the medical records were examined.Results: In total, 108 patients were enrolled: 68 females, with a median age of 50 years (range 24–68 years), and 40 males, with a median age of 51 years (32–70 years). The median body mass index (BMI) was 25 kg/m² (19–33 kg/m²) in females and 27 kg/m² (21–38 kg/m²) in males. The median intraoperative bleeding was 175 ml. The median warm ischaemia time was 3.2 min (1.5–6.7 min). The median operative time was 230 min (161–360 min). The median hospital stay was 4 days (2–10 days). Thirty donors (28%) had 34 early complications. Six donors (6%) needed reoperation. Late complications were seen in seven (7%). Sixteen donors (15%) were obese (BMI ≥30 kg/m²), which was associated with significant complications (p < .0001). There was a significantly higher complication rate in donors who were smokers and ingested alcohol above the Danish recommended limits (p < .0001). Fifteen donors (13%) developed hypertension postoperatively within the first year. There was no mortality. A total of 104 (96%) of the recipients had a functional transplant after 1 year.Conclusion: Hand-assisted donor nephrectomy is a safe procedure. Potential candidates should be advised to stop smoking and to avoid alcohol before surgery, especially those with a BMI of 30 kg/m² or higher.

The Authors' Reply.

We are grateful to Prof. Wadström for commenting on our recent manuscript on the long-term outcomes with 3 different laparoscopic donor nephrectomy (LDN) techniques at the University of Minnesota. It is evident that the group at Karolinska University Hospital has advanced our knowledge of the retroperitoneoscopic LDN (RP-LDN). As Prof. Wadström indicates, our incidence of postoperative ileus and incisional hernia was 3% to 4% and 1% to 4%, respectively. By contrast, in one of the largest series in the literature with RP-LDN, Wadström et al1 did not observe a single case of postoperative ileus and a 0.4% hernia rate in 413 patients. Of interest, this was a multi-institutional study that included 4 different centers and significant differences were noted in the learning curve of the technique between centers. Conceptually, there are theoretical advantages of RP-LDN, namely, direct hilar access, avoidance of intraabdominal organ mobilization, and ease of access in a hostile abdomen. We acknowledge that RP-LDN has the potential to reduce postoperative ileus and intraabdominal adhesions as a result of the avoidance of intraperitoneal (IP) entry. However, despite these advantages, RP-LDN has not been adopted widely. Two recent review articles comparing techniques in LDN concluded that RP-LDN appears to be associated with fewer postoperative complications.2,3 Both articles acknowledge the poor quality and considerable heterogeneity of the included studies. For instance, in their meta-analysis He et al3 reviewed 55 articles on the IP LDN and compared them with only 6 articles on the RP-LDN. Thus, the Karolinska University Hospital experience has not been consistently reproduced by other groups. In our limited and anecdotal experience, we found RP-LDN to be a useful adjunct; however, one that was not easily replicated in the setting of a transplant surgery training program. In our article, we emphasized our diverse experience with LDN as a component of an abdominal transplant surgery fellowship where fellows play an integral role in the kidney program. We speculate that part of our initial reservations with RP-LDN were due to the ease with which fellows could adopt the IP LDN technique. Also, considering that in the current general surgery training paradigm, surgery residents are exposed to extensive IP laparoscopy and are therefore familiar with the logistics of the technique, it is not surprising why RP-LDN was not embraced. These observations are corroborated by a recent study from China, where Ma et al4 explored the learning curve of RP-LDN. They report a 23% complication rate in their first 40 cases. By contrast, we recently presented our experience with teaching transplant surgery fellows the hand-assisted LDN and found that fellows learn the procedure by approximately 36 cases with an estimated complication rate of 3.2%.5 In summary, we acknowledge that RP-LDN is a useful technique in the LDN armamentarium. In certain clinical situations, namely, those in which IP access raises the risks of the procedure, RP-LDN may prove especially valuable. However, we caution that widespread experience with this procedure is limited, and the theoretical advantages have not been reproducibly documented.

Hand-Assisted Laparoscopic Donor Nephrectomy in Complete Situs Inversus

Complete situs inversus is a rare congenital anomaly characterized by transposition of organs. We report a case of renal transplantation using a kidney from a living complete situs inversus donor. The recipient was a 59-year-old female with end-stage renal disease because of type 2 diabetes mellitus. The donor was the 56-year-old sister of the recipient with complete situs inversus. CT angiogram of the abdomen and pelvis showed complete situs inversus and an otherwise normal appearance of the bilateral kidneys with patent bilateral single renal arteries and longer renal vein in the right kidney. The patient was taken to the operating room for a hand-assisted laparoscopic right donor nephrectomy. The patient tolerated the procedure well and was discharged home in good condition on postoperative day 1. The recipient experienced no episodes of acute rejection or infection, with serum creatinine levels of 0.8–1.2 mg/dL. Laparoscopic donor nephrectomy in a patient with complete situs inversus remains a technically feasible operation and the presence of situs inversus should not preclude consideration for living kidney donation.

Neutrophil-Gelatinase Associated Lipocalin (N-GAL) to Assess Perioperative Acute Kidney Injury in Hand-Assisted Laparoscopic Donor Nephrectomy: A Pilot Study

Abstract Perioperative insults, including hypotension, hypovolaemia and pneumoperitoneum may occur during laparoscopic live donor nephrectomy. These may have deleterious effects to both donor and recipient. The extent and significance of these insults is poorly understood and difficult to quantify. The aim of this study was to evaluate acute kidney injury (AKI) in the donor using the novel biomarker neutrophil-gelatinase associated lipocalin (N-GAL). We report the results of a pilot study of 20 patients undergoing hand-assisted live donor nephrectomy. eGFR and serum NGAL measurements (Triage CardioRenal Panel, Alere) were obtained preoperatively, immediately post-operatively, day 1 and 6 weeks post-operatively. Mean pre-operative eGFR was 105.6+/-10.1ml/min/1.73m2. Mean eGFR 6 weeks postoperatively demonstrated a 29.4+/-8.8% reduction from baseline. Serum N-GAL increased by 34.1+/-16.7% following an overnight fast pre-operatively (day 0) (ΔNGAL 45.1+/-36.0ng/ml), by a further 14.9+/-7.2% following surgery (immediate post-op). The largest ΔNGAL was observed during the pre-operative fasting period. ΔNGAL [day -1 to day 0] and [day -1 to post-op] were found to correlate inversely with eGFR at 6 weeks (p&lt;0.05, r2=0.47 and p&lt;0.001, r2=0.52 respectively). We conclude that clinically significant AKI does occur in the donor following live donor nephrectomy. Optimisation of perioperative fluid management is likely to have a protective role.

Hand-assisted Laparoscopic Donor Nephrectomy and Cytokine Changes

BackgroundLaparoscopic living-donor nephrectomy (LDN) exerts systemic effects causing transaminitis and increased urinary neutrophil gelatinase-associated lipocalm (NGAL) excretion. Hand-assisted laparoscopic donor nephrectomy, which tends to be shorter with less pneumoperitoneum, may be hypothesized to produce less systemic stimulation than total laparoscopic LDN. MethodsSerial urine and serum samples were collected from 15 patients undergoing HALDN. Samples were analyzed for NGAL and kidney injury molecule 1 (KIM-1) levels preoperatively and 24 hours post-surgery. Data relating to alanine aminotransferase, creatinine, and estimated glomerular filtration rate was also analyzed in 48 live donors preoperatively and at 24 hours and 48 hours post-surgery and compared to published data on LDN. ResultsExpected changes to creatinine and estimated glomerular filtration rates were observed in the donors. Compared to the preoperative levels, alanine aminotransferase levels showed a significant decrease at 24 hours (P = .004) and were not significantly different from baseline levels at 48 hours (P = .08). Serum KIM-1 and NGAL levels remained unchanged (P = .89 and P = .14, respectively) at 24 hours after donation. Similarly, urinary levels of KIM-1 and NGAL were not statistically significantly different after donation. Mean operating time for this cohort was 1 hour, 36 minutes. ConclusionsIn contrast to other published data, our cohort did not exhibit changes to liver function tests or biomarker changes after donor nephrectomy. This could be because of the lower operative time (96 minutes vs. 216 minutes) or because of the intermittent release of the pneumoperitoneum in the hand-assisted method which may exert less of a systemic inflammatory response.

Living Kidney Donors With Adrenal Incidentalomas: Are They Appropriate Donors?

To determine the incidence of adrenal incidentalomas (AIs) in a single-center series of living renal donors, to describe an evaluation algorithm for AIs in this patient population, and to compare the complication rates of hand-assisted laparoscopic donor nephrectomy (HALDN) with those of combined HALDN and adrenalectomy. We performed a single-center, retrospective study of consecutive living kidney donors who underwent laparoscopic nephrectomy for transplantation, with or without simultaneous ipsilateral adrenalectomy, between January 2008 and September 2014. During the study period, AIs were detected in 18 of 1033 potential living renal donors who underwent computerized tomographic angiography. Application of additional donor selection criteria and of an adrenal mass assessment algorithm resulted in 849 HALDN, of which 13 were combined with simultaneous adrenalectomy. The hospital length of stay (2.4 vs 2.6 days), perioperative (0.025 vs 0.077), early (0.073 vs 0.077), and late (0.014 vs 0.077) postoperative complication rates, and conversion to open donor nephrectomy (0.008 vs 0.00) were not significantly different. Mean operative time was significantly longer in the adrenalectomy group. None of the adrenal masses were malignant. Here, we presented our algorithm to manage the living kidney donors with AIs. Although donor population with AIs was relatively small in number, simultaneous adrenalectomy and ipsilateral nephrectomy seemed to be technically safe and conferred no identifiable increased risk of malignancy for the kidney transplant donor, when the incidentaloma is nonfunctional and less than or equal to 4 cm as assessed by preoperative imaging.

Neutrophil-gelatinase associated lipocalin (N-GAL) to assess perioperative acute kidney injury in hand-assisted laparoscopic donor nephrectomy: A pilot study

IntroductionThe aim of this study was to evaluate donor acute kidney injury (AKI) using a novel biomarker (NGAL). MethodologyA pilot study of 20 patients undergoing hand-assisted live donor nephrectomy was undertaken. eGFR and serum NGAL measurements were obtained pre-operatively, immediately post-operatively, day 1 and 6 weeks post-operatively. ResultsMean age: 40.6±11.1 years. Mean pre-operative eGFR: 105.6±10.1ml/min/1.73m2. Mean day 1 post-op eGFR: 65.7±10.4ml/min/1.73m2 (37.7±9.2% reduction from baseline). Mean eGFR 6 weeks post-operatively was 74.1±8.6ml/min/1.73m2 (29.4±8.8% reduction from baseline). Serum NGAL increased by 34.1±16.7% following an overnight fast pre-operatively (day 0) (ΔNGAL 45.1±36.0ng/ml), by a further 14.9±7.2% following surgery (post-op) and a further 3.1±1.2% by post-operative day 1. The largest ΔNGAL was observed during the pre-operative fasting period. ΔNGAL [day −1 to day 0] and [day −1 to post-op] were found to correlate inversely with eGFR at 6 weeks (p<0.05, r2=0.47 and p<0.001, r2=0.52, respectively). ConclusionSignificant AKI occurs with live donor nephrectomy. This is difficult to quantify using standard biochemistry due to the overwhelming effect of nephrectomy on eGFR. AKI is associated with poorer donor eGFR at 6 weeks. Pre-operative hypovolaemia plays a role in AKI. Optimisation of perioperative fluid management is likely to have a protective role.

Kidney Laterality and the Safety of Hand-assisted Live Donor Nephrectomy: Review of 1000 Consecutive Cases at a Single Center

To determine the feasibility of performing right-sided, hand-assisted, laparoscopic donor nephrectomy (HALDN) and compare with the results of left-sided surgeries in both donors and recipients. Between September 2006 and September 2013, 1000 consecutive patients underwent HALDN at our institution. Patient characteristics and the intraoperative or postoperative parameters of the donors and recipients were retrospectively evaluated. Preoperative data, including relative renal function, vascular anatomy, and parenchymal abnormalities, were evaluated to determine the reasons for harvesting the right kidney. Intraoperative and postoperative data, including pneumoperitoneum time, warm ischemia time, complications, chronic kidney disease stage, and graft function, were compared between donors and recipients who underwent right- and left-sided procurement. Mean follow-up period was 21 months in donor and 42 months in recipient. Right-sided HALDN was performed on 421 patients (42.1%). The most common reasons for selecting the right kidney was reduced right kidney function (53.4%) followed by multiple left renal arteries (34.2%). None of 1000 patients required conversion to open surgery or developed major complications. Serum creatinine concentrations and chronic kidney disease stage at the last follow-up examinations were similar in donors. There were no significant differences in graft function and ureter-related complications between right- and left-sided kidneys at the last follow-up examination. Right-side HALDN is a safe procedure. The donor side can be freely selected using HALDN to benefit both donors and recipients.

Reply

We appreciate the editorial comments1 and congratulations on our work. Our hand-assisted laparoscopic donor nephrectomy (HALDN) series demonstrates the safety of using the right kidney for living donor transplantation. Free selection of the donor side without technical obstacles can be easily achieved by HALDN. In a sense, the right-side donor nephrectomy is technically easier and less traumatic on the vascular structure than the left-side surgery considering the normal vascular anatomy.2 An unmentioned point in our article is the risk of varicocele in left-side donor nephrectomy because of the increased left testicular vein resistance.

Transition From Hand-Assisted to Pure Laparoscopic Donor Nephrectomy

Background and Objectives:We compared perioperative donor outcomes and early graft function of hand-assisted laparoscopic donor nephrectomy (HALDN) and pure laparoscopic donor nephrectomy (PLDN) performed by a single surgeon, to define the feasibility of technical transition from HALDN to PLDN.Methods:From October 1, 2012, through June 30, 2014, 60 donor nephrectomies were performed by a single surgeon who lacked experience with laparoscopic renal surgery: the first 30 by HALDN and the last 30 by PLDN. Operative and convalescence parameters were compared, as were intra- and postoperative complications within 90 days according to the Satava and Clavien-Dindo classifications, respectively. Binary logistic regression analysis was used to estimate the association of baseline characteristics with complications.Results:Baseline characteristics were similar in the 2 groups, except for American Society of Anesthesiologists score II (10.0% vs 43.3%; P = .007). All procedures were completed as planned. All operative and convalescence parameters of donors and graft outcomes were similar in the 2 groups, as were overall rates of intraoperative (43.3% vs 36.7%, P = .598) and postoperative (86.7% vs 70.0%; P = .209) complications. No factor was significantly predictive of intraoperative complications, whereas sex (female vs male, odds ratio, 0.183; P = .029) and learning curve (odds ratio, 0.602; P = .036) were significant determinants of postoperative complication.Conclusion:The technical transition from HALDN to PLDN does not involve a steep learning curve for surgeons less experienced with laparoscopic renal surgery and maintains similar perioperative donor and graft outcomes.

Stress predicts the trajectory of wound healing in living kidney donors as measured by high-resolution ultrasound.

Psychological stress has been shown to be an influential factor on the rate of wound healing; however these findings have been demonstrated predominantly on artificially created wounds. Due to the absence of major co-morbidities, living kidney donors are a unique group in which to study this relationship. This study investigated the effect of preoperative stress and personality on surgical wound healing through the use of high-resolution ultrasound. Living kidney donors due to undergo a hand-assisted laparoscopic donor nephrectomy were asked to complete the Perceived Stress Scale, the Life Orientation Test-Revised and the Ten Item Personality Inventory prior to surgery. High-resolution ultrasound scans of surgical wounds were performed on the first three post-operative days and once following discharge (mean=15.3 days; s.d. 2.8). Two measurements from each image were obtained: wound width (size of wound) and median intensity (a marker of tissue fluid). Latent Growth Curve Models (LGCMs) were used to evaluate wound healing. 52 living kidney donors participated. Higher pre-operative life stress, lower optimism and lower conscientiousness were associated with delayed wound healing in living kidney donors for both outcomes. Increased emotional stability was associated with faster wound healing as demonstrated by a change in median intensity. Possible confounding factors, such as age, BMI, smoking status, local anaesthetic use and wound drain placement were not influential. This study, which measured wound healing in a novel patient sample using a novel technique, has demonstrated a negative association between stress and wound healing and the positive influence of optimism, conscientiousness and emotional stability.

Risk factors for perioperative complications in hand-assisted laparoscopic donor nephrectomy.

Living donor kidney transplant is the preferred treatment for end-stage renal disease; however, the shortage of kidney donors remains a big problem. One of the major reasons for the shortage of living donors is the risk of potentially serious surgical complications of a procedure in which the donor has no personal medical benefit. Therefore it is important to understand the risk factors for perioperative complications associated with donor nephrectomy. Hand-assisted laparoscopic donor nephrectomy is the preferred approach for kidney procurement in many medical centers. This review gives an overview of the risk factors in donor nephrectomy and more specifically in hand-assisted laparoscopic donor nephrectomy.

Ex Vivo Ureteroscopy with Laser Infundibulotomy in Living Donor Kidney Transplantation

Introduction: The management of incidentally discovered renal stones in living donor candidates is evolving. Recently, the safety and efficacy of ex vivo ureteroscopy for stone removal in donor kidneys have been described.1–3 Here, we present our experience with ex vivo ureteroscopy and laser infundibulotomy for the treatment of a stone contained within a calyceal diverticulum. Calyceal diverticulae are known to harbor bacteria and pose an infection risk for the immunosuppressed recipient,4 leading us to decide that treatment was prudent before transplantation. Materials and Methods: A 38-year-old woman with a previous stone episode presented for the evaluation as a living kidney donor. Preoperative computed tomography angiogram revealed two incidental stones in the left kidney, measuring 6 and 2 mm, with a density of 530 Hounsfield units. Litholink 24-hour urine collection was significant for hypernatremia and hypercalciuria. Following left hand-assisted laparoscopic donor nephrectomy, the kidney was placed on ice and flushed in a standard manner. A flexible ureteroscope was used to visually inspect the collecting system. The 6-mm stone was noted to be within a calyceal diverticulum. Using a 200-μm holmium:YAG laser, infundibulotomy followed by lithotripsy was performed. Stone fragments were removed using a zero-tip nitinol basket. Results: Stone treatment time was 26 minutes. The kidney was visually stone free at the completion of the procedure and was successfully transplanted into a pediatric recipient. Total cold ischemia time was 209 minutes. A modified Lich-Gregoir ureteral anastomosis was performed using a double-J ureteral stent, which was removed 2 weeks postoperatively. Recipient creatinine was 1.2 with no postoperative complications at 2 months of follow-up. Conclusions: Stones contained within a calyceal diverticulum should not serve as an absolute contraindication to kidney donation. Ex vivo stone removal is technically straightforward and has the added benefit of minimizing the risks of bleeding, infection, and anesthetic complications to the donor. Although recipient renal function may have been negatively affected by a 26-minute increase in cold ischemia time, this was likely minimal as successful transplants are routinely performed with cold ischemia times in excess of 10 hours.5 Additionally, this risk is partially outweighed by the benefit of reducing potential complications in the donor by consolidating operative intervention to a single setting. Possible complications of this technique include prolonged operative (and therefore cold ischemia) time, inability to locate the calyceal diverticulum, and postoperative bleeding. Potential candidates for this approach should have a sufficiently small stone burden that can be cleared in a timely manner. Had we not been able to localize the diverticulum, transplantation would have proceeded as planned with consideration of stone removal at a later time. Significant post-transplantation bleeding that did not respond to conservative measures, while unlikely, would be managed on a case-by-case basis. Donors require close urologic follow-up and monitoring of their 24-hour urine parameters to decrease the risk of future stone events. Further research should be performed to evaluate the safety and long-term effects of this technique. Source of work or study: Intraoperative video recorded at the University of Pittsburgh Medical Center. No competing financial interests exist. Running time: 4 mins 25 secs

Hand-Assisted Laparoscopic Versus Open Donor Nephrectomy: A Retrospective Comparison of Perioperative and Functional Results in a Tertiary Care Center in Mexico

BackgroundLaparoscopic nephrectomy for living donors is the current procedure of choice. Hand-assisted laparoscopic donor nephrectomy (HALDN) is the variation of this technique currently used in our institution. Though the advantages and disadvantages have been described for this procedure, the graft function compared with open surgery has been shown to be equal. We compared the outcomes of patients undergoing the former standard open donor nephrectomy (ODN) versus the current HALDN technique. MethodsIn this retrospective, comparative, and analytic study we reviewed our institutional database of renal transplantation procedures from January 2005 to April 2011 for perioperative variables and 1-year follow-up data. Donor renal function was evaluated with serum creatinine concentrations and estimated glomerular filtration rates with the Chronic Kidney Disease–Epidemiology formula. Complications were reported with the Clavien-Dindo classification. ResultsThe 190 consecutive donors included 99 ODN and 91 HALDN, who did not show baseline differences. ODN had a shorter mean operative time (217 ± 57.5 vs 270 ± 60.1 minutes) and shorter warm ischemia time (2.12 ± 1.4 vs 4.62 ± 2.7 minutes). HALDN had less operative blood loss (274.4 ± 198.1 vs 202.99 ± 157.1 mL) and shorter in-hospital stay (5.58 ± 2.2 vs 4.23 ± 1.8 days). There were no significant differences in 30-day surgical complications or transfusion requirements. No graft loss was reported. No difference in renal function was observed between the groups at days 1–2 or months 1, 6, or 12 after nephrectomy. ConclusionsLaparoscopic surgery has replaced conventional open surgery for living renal donors. HALDN is a safe and successful procedure compared with ODN. It is now the procedure of choice in our institution.

Effect of Gentamicin-Containing Collagen Sponges on Surgical Site Infection after Hand-Assisted Laparoscopic Donor Nephrectomy

Postoperative surgical site infection (SSI) can be considered a frequent complication of hand-assisted laparoscopic donor nephrectomy (HALDN). Since 2007, our center used routinely a gentamicin-containing collagen sponge (GCCS) when closing the wound. The effect of GCCS on SSI is not elucidated clearly. In this retrospective cohort study, we assessed the effects of GCCS on SSI after HALDN. Between December 2004 and November 2007, we treated 100 patients without GCCS, and from November 2007 to July 2010, there were 100 patients with GCCS placed after HALDN. A SSI was defined as an incisional infection that required an intervention such as opening of the site or antibiotic treatment within 90 days after surgery. Implantation of a GCCS resulted in a statistically significant reduction in the SSI rate, from 6% to 0 (p=0.01). All infections occurred in the Pfannenstiel incision site. There was no significant difference between the groups in the creatinine concentration after three months. The use of gentamicin-containing collagen sponges reduces the risk of SSI significantly after HALDN without compromising kidney function.

V50 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 p...

Another Option for Laparoscopic Living Donor Nephrectomy: A Single Center Experience Comparing Two-Port Versus Hand-Assisted Technique

To compare the clinical outcomes of two-port laparoscopic donor nephrectomy (TPLDN) vs hand-assisted laparoscopic donor nephrectomy (HALDN). Between November 2010 and March 2012, 100 kidney donors scheduled for left nephrectomy were alternatively assigned to HALDN or TPLDN in a 1:1 fashion. All procedures were performed by the same laparoscopic surgeon. Demographic data and intraoperative and early postoperative data were collected prospectively and analyzed. There was no difference in the operating time (133±12 vs 142±17 min, P=0.07), blood loss (55±46 vs 58±52 mL, P=0.84), complication rate (10% vs 12%, P=0.74), and length of hospital stay (3.8±0.8 vs 4.1±2.8 days, P=0.5) between the HALDN and TPLDN groups. The warm ischemia time was longer in the TPLDN group (2.2±0.7 vs 3.5±0.9 min, P<0.001). No statistically significant differences were found in the analgesic requirement and the visual analog pain scores. There was a trend toward quicker return to 100% recovery in the TPLDN group (60±46 vs 39±15 days, P=0.05). The TPLDN group had a significantly smaller surgical incision (8.2±0.6 vs 5.5±0.4 cm, P<0.001) and higher scar satisfaction score (7.8±1.5 vs 8.6±1.3, P=0.02) than the HALDN group. No differences were found in the recipient serum creatinine values or in the incidence of delayed graft function. In comparing TPLDN and HALDN, there was no significant difference in a majority of the operative and postoperative parameters. TPLDN might be associated with smaller surgical incision, improved cosmetic satisfaction, and equivalent recipient graft function.

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

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

The Safety and Efficacy of Laparoscopic Donor Nephrectomy for Renal Transplantation: An Updated Meta-analysis

BackgroundCurrently, the laparoscopic technique is widely used for living donor nephrectomy. Does it provides adequate safety and benefits for the living donor? We performed a meta-analysis to evaluate the safety and efficacy of laparoscopic donor nephrectomy (LDN) as well as an analysis of postoperative quality of life compared with the open donor nephrectomy (ODN). MethodsEligible studies were identified from electronic databases: Cochrane CENTRAL, PubMed, and EMBASE as of October 2011. Relevant parameters explored by-using Review Manager V5.0 included operative time, warm ischemia time, intraoperative blood loss, hospital stay and time to return to work. ResultsCompared with ODN, LDN showed a shorter hospital stay (days; mean difference [MD]: −1.27, P < .00001) and time to return to work (days; MD: −16.35, P < .00001), less intraoperative blood loss (ml; MD: −101.23, P = .0001) without an increase among donor intraoperative and postoperative complications or compromise of recipient graft function. Hand-assisted laparoscopic donor nephrectomy (HLDN) showed a shorter warm ischemia time (minutes) than the standard laparoscopic donor nephrectomy (MD: −1.02, P < .00001). We also observed that hospital stay (days) significantly favored SLDN compared with HLDN (MD: 0.33, P < .005), but operative times, intraoperative estimated blood loss, and donor postoperative complications were not significantly different between them. Donor postoperative quality of life revealed only physical functioning and bodily pain scores to significantly favor LDN. ConclusionsLDN is a safe surgical procedure for a living donor.

Transperitoneal Hand-Assisted Laparoscopic Donor Nephrectomy of the Right Kidney: Is There An Issue with the Renal Vessels?

Objective: Short right renal vessels might complicate kidney transplantation causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy is presented. Patients and methods: Eighty-two living kidney donors underwent hand-assisted laparoscopic donor nephrectomy (HALDN) between 2003 and 2008. Right-sided HALDN was performed in 73 living kidney donors. The operative technique of right-sided HALDN was modified in order to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were collected prospectively. Results: All procedures were completed laparoscopically with no conversion. Mean operative time was 127 min (vs. 138 min in left HALDN, p=0.08). The mean warm ischemia time was 41 sec (vs. 39 sec in left HALDN, p=0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p=0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p=0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation. Conclusions: Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.