Hand-assisted Laparoscopic Live Donor Nephrectomy Research Articles

Retroperitoneal Laparoscopic Live-Donor Nephrectomy: Introduction of Simple Hand-Assisted Technique (Without Hand Port)

Objective Compared with the transperitoneal approach, retroperitoneal laparoscopic live-donor nephrectomy offers a substantial advantage. However, retroperitoneal access is more difficult because of the limited working space. The objective of this study was to report our experience with hand-assisted retroperitoneal laparoscopic live-donor nephrectomy without a hand port. Materials and Methods Intraoperative and immediate postoperative surgical outcomes were reviewed for 23 modified retroperitoneal laparoscopic live-donor nephrectomies performed from May 2009 to January 2010. All kidneys were from living related donors. No prisoners or organs from prisoners were used in this study. Results Retroperitoneal laparoscopic live-donor nephrectomy was successfully completed in all patients, without conversion to open surgery. Mean (range) operative was 114 (98–130) minutes; warm ischemia time was 1.6 (1.3–2.1) minutes; estimated blood loss was 20 (10–50) mL; and postoperative hospital stay was 6.9 (5–10) days. No serious complications such as massive bleeding or bowel injury occurred. In 1 patient, a hematoma of renal fossa developed, which was successfully treated at repeat operation. All kidneys demonstrated good primary function except 1 that exhibited delayed graft function. Conclusions Retroperitoneal laparoscopic live-donor nephrectomy combines the benefits of both hand assistance and the retroperitoneal approach, to minimize the risk of short- and long-term complications associated with the transabdominal approach. The technique could be a cost-effective procedure suitable for use in developing countries.

Overcoming the learning curve in hand-assisted laparoscopic live donor nephrectomy - a study in the animal model.

The demand for kidneys in South Africa is staggering. Only 38% of the kidney transplants done in 2008 were from related living donors. Laparoscopic living donor nephrectomy has been shown to have the advantages of decreased postoperative pain, better cosmesis and a quicker return to work when compared with the open technique. With limited surgical expertise, a realistic model was needed to overcome the learning curve. Methods. A total of 21 nephrectomies were performed on 12 pigs. The transperitoneal hand-assisted laparoscopic technique was used. Results. The median operative time was 75 minutes and the median warm ischaemic time 88 seconds. Three cases were aborted owing to major vascular injuries. Discussion. The advent of laparoscopic techniques has been associated with an increase in morbidity and complications in donor and recipient during the initial learning curve. We found that with our porcine model, 21 nephrectomies were adequate in overcoming the learning curve. After 15 nephrectomies no complications were noted.

Transperitoneal Deviceless Hand-Assisted Laparoscopic Living Donor Nephrectomy: An Alternative Technique for Kidney Recovery

Deviceless hand-assisted laparoscopic living donor nephrectomy is an alternative surgical technique that relies on the classic laparoscopic approach, supported by insertion of the surgeon's hand during kidney recovery without the need to use any device because of the sealing effect of the particular wall incision. From 2006 to 2008, deviceless hand-assisted laparoscopic living donor nephrectomy was performed in 25 patients (M/F = 7/18; mean age = 53 years; range = 30-68). One right nephrectomy was performed. We made a lateral paramedian incision. No sealing device is required in our technique because the pneumoperitoneum is maintained by the sealing effect of two complexes: the peritoneum/deep rectus abdominis muscle fascia and muscle itself/lateral edge of the double fascial incision. These structures clench around the surgeon's wrist, preventing leakage of CO₂. After dissection, the kidney is removed through the hand port without an endobag. Mean surgical time was 105 minutes (range = 60-150), estimated blood loss was 50 to 200 mL, and mean warm ischemia time was 3.5 minutes (range = 2-11). Mean hospital stay was 4 days (range = 3-6). One uncontrollable hemorrhage due to a renal vein lesion required conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.8 to 2.6 mg/dL. The ability to better control bleeding by manual compression, as well as the advantages related to decreased donor morbidity, shorter hospital stay, cost saving, and excellent graft function, make this deviceless technique a good option for kidney recovery.

Impact of Hand-Assisted Laparoscopic Living Donor Nephrectomy on Donor's Quality of Life, Emotional, and Social State

Background Laparoscopic donor nephrectomy has become the preferred method for live kidney donation in many centers. Herein we have reported on donor-related quality of life (QoL) and social state after laparoscopic hand-assisted nephrectomy (HALDN) for living kidney donation. Patients and Methods Between December, 2003 and May, 2008, we performed 48 HALDN. To evaluate QoL, we mailed to the donors a structured questionnaire based on a combination of the WHOQOL-BREF questionnaire and the 36-item health survey (SF-36) with slight modifications. The QoL scores were compared with data from a matched group of the German healthy population. We evaluated clinical results in donors and recipients by reviewing the records, and calculated 1-year graft survival according to the Kaplan-Meier method. Results In all domains, the QoL scores were higher than those among the normal population. The higher QoL was independent of time since donation. When asked to rate their health at the time of the questionnaire, 91% rated it as good, very good, or excellent, 6% as fair, and 3% as poor. When asked to rate the pain around their scar, 91% rated it as mild or absent: Of the patients, 94% were likely to say that they would donate again, if it were possible. For 6% of the patients the overall experience was stressful. Conclusion HALDN is safe. QoL changes after kidney donation are low and comparable to those of the healthy population.

Hand‐assisted versus total laparoscopic live donor nephrectomy: comparison and technique evolution at a single center in Taiwan

To compare the outcome of hand-assisted laparoscopic live donor nephrectomy (HLDN) and total laparoscopic live donor nephrectomy (TLDN) in a single center. The demographics, complications, and outcomes were compared between successfully performed 51 HLDN and 42 TLDN. The patients' demographics including body mass index were all similar. Four conversions were excluded for the outcome analysis. The operation time of HLDN group (188 ± 62 min) was shorter, although not significantly, than that of TLDN group's (207 ± 30 min) (p = 0.065). However, the operation time of the first 24 cases (237 ± 66 min) was significantly longer than that of the later 69 performed (180 ± 35 min). The warm ischemia time was shorter in HLDN (2.5 ± 1.3 min) compared to that of TLDN (4.1 ± 1.7 min) (p < 0.01), but the serum creatinine values (mg/dL) of recipients were equivalent (HLDN/TLDN = 1.18 ± 0.3:1.14 ± 0.3, p = 0.587). There was no difference in the length of hospital stay (6.7 vs. 6.4 d, p = 0.475). There was no graft loss, but one ureter stricture (HLDN group) and one urinary leakage (TLDN group) were recorded. Both HLDN and TLDN are effective and safe as reflected in graft functions and limited complications. There was a learning curve in establishing the technique of laparoscopic donor nephrectomy.

Hand-Assisted Laparoscopic Living-Donor Nephrectomy Versus Open Surgery: Evaluation of Surgical Trauma and Late Graft Function in 82 Patients

Objective We evaluated and quantified surgical trauma and late graft function in cases of hand-assisted laparoscopic living-donor nephrectomy (HALLDN) versus open living-donor nephrectom (OLDN). Methods This study is a retrospective nonrandomized single-center analysis. Between 1995 and January 2008, 82 patients with end-stage renal disease received kidney transplantations from living donors. Open living-donor nephrectomy was performed in 37 donors, and 45 underwent laparoscopic hand-assisted nephrectomy. Demographic data and perioperative and postoperative data, such as markers of acute phase (C-reactive protein; serum amyloid A) and biochemical markers of glomerular filtration (serum creatinine, serum cystatin C), were compared at serial time points. Results The mean operative times for HALLDN and OLDN were 165 min and 195 min, respectively. The average warm ischemia time was 45 seconds for laparoscopy and 87 seconds for open surgery. The evaluation of acute phase markers demonstrated a minimally invasiven nature of laparoscopy, with same late graft function compared with open surgery. Conclusion When the surgery was performed by experienced surgeons, hand-assisted living- donor nephrectomy showed shorter operative and warm ischemia times than open surgery, offering at least the same functional results and decreasing surgical complications compared with a completely laparoscopic technique.

Transperitoneal Laparoscopic Living Donor Nephrectomy: 2 Years' Experience

Due to the shortage of organ donations and the rising number of patients with terminal renal insufficiency, living donor kidney donation has become increasingly important during recent years. Hand-assisted laparoscopic living donor nephrectomy (LLDN) is an alternative to the conventional open approach and may decrease the surgical trauma to the donor. The aim of this study was to report our experience with this technique. We reviewed demographic data, operative duration, hospital stay, and postoperative complications among 100 LLDNs performed from August 2006 to July 2008. We also performed a retrospective analysis of chemical and biochemical data of recipients. Thirty female and 70 male subjects of mean age of 35.88 +/- 12.21 years were operated on during this period. The mean operative time for donor nephrectomy was 138.30 +/- 31.92 minutes (range 60-205) and for recipients, 87.66 +/- 11.79 minutes (range = 75-120), with a mean warm ischemia time of 5.19 +/- 1.76 minutes (range = 2-8). The donors' mean hospital stay was 28.34 +/- 8.31 hours (range = 24-72). Five donor operations were converted to open nephrectomy because of uncontrolled bleeding or abnormal anatomy. There was no need for blood transfusions or reoperations in the donors. Mean hospital stay for the recipients was 9.44 +/- 3.61 days (range = 5-22). Creatinine and blood urea nitrogen decreased from preoperative values of 10.46 +/- 3.73 and 66.10 +/- 25.16 to 1.39 +/- 0.38 and 29.64 +/- 8.83 mg/dL at discharge. The renal graft was rejected in two cases due to immunologic causes without any response to therapy. There was no vascular thrombosis in the transplanted kidneys. LLDN is a viable alternative to the standard open nephrectomy. It may have a positive impact on the donor pool by minimizing disincentives to living donation. The results of our program were acceptable; this approach may be the procedure of choice in the future in our center.

Comparison of Renal Artery Occlusion Techniques in Hand-Assisted Laparoscopic Living Donor Nephrectomy

This study assessed differences in outcomes between left renal artery clipping and stapling techniques in hand-assisted laparoscopic living donor nephrectomy (HALDN). From 2003 to 2007, 55 HALDN procedures were performed by one laparoscopy-trained urologist. During the first 30 months, 27 consecutive HALDN patients underwent renal artery occlusion with two nonabsorbable polymer locking clips (group 1). The subsequent 18 months saw 28 consecutive HALDN patients receive three-row vascular stapling to occlude the renal artery (group 2). The preoperative patient factors were age, sex, body mass index, serum creatinine (Cr), and presence of supernumerary left renal artery. Intraoperative factors included estimated blood loss (EBL), operative time (OT), and warm ischemia time (WIT). Postoperative data were 24-hour Cr and hemoglobin concentration, transfusion requirement, hospitalization time, and complications. Data are presented as mean +/- standard deviation and analyzed using parametric tests (alpha = 0.05). No significant difference was found between groups with respect to preoperative factors, OT, and EBL; however, WIT was shorter in group 2 (3.6 +/- 0.2 vs 2.6 +/- 0.3, P = 0.048). Within-group comparisons revealed longer WIT for patients with supernumerary renal artery compared with those with a single artery (group 1, P = 0.044; group 2, P = 0.042). Moreover, no major between-group variations were seen in postoperative donor outcomes. Left renal artery ligation during HALDN using a three-row vascular stapler is safe and yields donor outcomes comparable to dual polymer clips. In addition, left renal artery stapling may decrease WIT compared with dual clipping.

TN02 HAND‐ASSISTED LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: THE PRINCE OF WALES HOSPITAL EXPERIENCE

Purpose and Methodology: Hand-assisted laparoscopic live donor nephrectomy (HALDN) has the benefits of quick operating time, short warm ischaemic time and fewer ureteric complications with possibly more safety for the donor [1, 2]. We aim to report the results of our HALDN cases performed at Prince of Wales Hospital, Sydney Australia. Results: Nine left-sided HALDN were completed successfully - two had dual arterial supply with all others having a single artery. We report an average warm ischaemic time (defined as the time from renal artery clamping until the end of perfusion) of 6.8 minutes (5–8 minutes) and operating time of 4.5 hours (3:43–5:30 hours). The mean length of stay was 4.4 days (3–6 days). No donors required blood transfusions or suffered any complications. Average urine production in the first day following the operation was 1.34 ml/kg/hr. No recipients needed dialysis or experienced ureteric complications and/or delayed graft function. There were two elective conversions to an open procedure – one due to a third renal artery that was not identified on preoperative imaging, the other due to insufficient vessel length. Conclusion: HALDN is the preferred technique because it is designed to minimise risk to the donor by facilitating direct control of bleeding, without the need for additional incisions or forfeiting graft function.

Hand-assisted laparoscopic live donor nephrectomy – right-sided approach: experience attained in 38 cases

Removal of a donor kidney by laparoscopic nephrectomy is a safe method that is widely being used mainly in left donor nephrectomy. However, in right donor nephrectomy wherever the right renal vein is too short, the open surgery has been more frequently described in the literature. Purpose: To describe our experience in 38 renal transplants using two different techniques in right donor nephrectomy. Method: From February 2002 to May 2009, 38 hand-assisted laparoscopic right donor nephrectomies were performed. Twenty-five of these laparoscopic nephrectomies were performed by the method with the assistant using his hand to assist the surgery, and 13 nephrectomies were performed by the laparoscopic method assisted by the first surgeon. Results: Right donor nephrectomies assisted either by the hand of the assistant or the surgeon had similar results. All recipients had diuresis in the immediate post-operative period and the one week after the transplantation serum creatinine level was found to be 1.90mg/dl (± 1.55). Conclusion: Although the hand techniques are similar, we concluded that the laparoscopic nephrectomy assisted by the surgeon is more adequate for the right kidney extraction. It can be performed either by a resident doctor or a surgeon from the transplantation team whether experienced or not in nephrectomy for transplantation.

Strategic Hand Assistance for Effective and Safe Retroperitoneoscopic Live Donor Nephrectomy

Hand-assisted laparoscopic live donor nephrectomy has been widely applied, because it enables safe dissection of the renal vessels, reducing warm ischemia time (WIT) during rapid extraction of the kidney. In the method described in the current series, the hand-port device was placed after the kidney was mostly mobilized using a pure retroperitoneoscopic procedure. After placement of the hand port, the ureter was completely dissected by an open procedure. Finally, the renal vessels were dissected and transected under the hand-assisted retroperitoneoscopic procedure, and the kidney removed through the hand port. We performed 66 retroperitoneoscopic live donor nephrectomies, including 14 right-sided and 52 left-sided procedures, with this original method of hand assistance. The mean operative time, WIT, blood loss, and renal vein length were 246 ± 43 minutes, 209 ± 124 seconds, 202 ± 180 mL, and 17.4 ± 6.4 mm, respectively. Comparison of the operative data between the initial 30 cases and the recent 36 cases using the established method showed significant differences in blood loss and WIT that approached statistical significance. No delayed graft function was observed in the current series. The technical and functional outcomes were acceptable. The site and timing of hand assistance minimize the disadvantage of a small working space during the retroperitoneoscopic procedure, making surgery easier and safer.

Comparison of Laparoscopic Versus Hand-Assisted Live Donor Nephrectomy

The aim of the present study was to compare hand-assisted laparoscopic live donor nephrectomy with the classic laparoscopic method, using meta-analytical techniques. A literature search was performed for studies comparing hand-assisted laparoscopic nephrectomy with classic laparoscopic nephrectomy for live kidney donation between 1999 and 2005. The following end points were evaluated: operative time, warm ischemia time, intraoperative adverse events, donor and recipient postoperative complications, and length of hospital stay. Nine comparative studies matched the selection criteria, reporting on 376 patients, of whom 202 (53.7%) had hand-assisted laparoscopic nephrectomy and 174 (46.3%) had the classic laparoscopic technique. Conversion to open surgery was 2.97% in the hand-assisted group and 4.60% in the laparoscopic group (P=0.35). Total operative and warm ischemia times were significantly shorter for hand-assisted laparoscopy by 30.03 minutes (P=0.02) and 1.14 minutes (P<0.001), respectively. The intraoperative blood loss was less for the hand-assisted laparoscopy group by 34.16 mL (P=0.008), although intraoperative (3.46% vs. 7.47%; P=0.24) and postoperative (5.94% vs. 10.34%; P=0.30) donor complications and recipient complications (including delayed graft function and primary nonfunction, 8.41% vs. 7.42%; P=0.32) were similar between the hand-assisted and laparoscopic groups. Hand-assisted laparoscopic nephrectomy appeared to have the same donor and recipient complication rate with standard laparoscopy but offered substantial advantages in terms of shortened operative and warm ischemia time as well as decreased intraoperative bleeding.

Telementoring Facilitates Independent Hand-Assisted Laparoscopic Living Donor Nephrectomy

Laparoscopic living donor nephrectomy is a major advance but a challenging procedure to learn even after laparoscopic training. It requires significant previous training in both laparoscopic and transplant surgery. Telementoring has been shown to reduce the laparoscopic learning curve in other fields. Of six cases of hand-assisted laparoscopic (HAL) living donor nephrectomy at our institution, an on-site mentor supervised the initial two. We present the subsequent four cases as the first documented examples of telementored HAL live donor nephrectomy. Telelink was established with a Comstation (Zydacron, UK) incorporating a Z360 telementoring codec and four ISDN lines (512 kb/s) with time delay of 500 ms for both audio and video. The remote surgeon in Minnesota (USA) could change independently between the laparoscopic and external views. The operating surgeons were able to look at the mentor and converse with him throughout. There were no adverse events in recipients and graft function was excellent. With regards to the telementored group the mean operative time was 240 minutes, the mean warm ischemic time 189 seconds, the mean estimated blood loss 171 mL, and the mean length of hospital stay 3 days. Telementoring for laparoscopic donor nephrectomy is feasible, effective, and likely to aid independent practice by providing continued supervision and reducing the learning period.

Hand‐assisted laparoscopic and open living donor nephrectomy in Korea

We compared the results of hand-assisted laparoscopic living donor nephrectomy (LLDN) and conventional open living donor nephrectomy (OLDN). The clinical data on 49 hand-assisted LLDN and 21 OLDN on the left side performed at two institutions in Korea from January 2001 to February 2003 were reviewed. Demographic data of donors and recipients were similar in the two groups. There was one conversion to an open procedure due to bleeding in the LLDN group. The median operation times (180 min in LLDN versus 170 min in OLDN) and warm ischemic times (2.5 min in LLDN versus 2.0 min in OLDN) in the two groups were similar. The estimated mean blood loss, duration of hospital stay and complication rate was also similar in the two groups. The LLDN group reported less pain (visual analog scale) postoperatively (4.1 versus 5.3), but this was not significant (P=0.058). The time to oral intake in the LLDN group was significantly longer by an average of 1 day (P=0.001). Return to work was sooner in the LLDN group (4.0 weeks versus 6.0 weeks; P=0.026). The recipient graft function was equivalent between the two groups. Hand-assisted LLDN appears to be a safe and effective alternative to OLDN. Our findings suggest that this technique may give the ability provide grafts of similar quality to OLDN, while extending to the donors the advantages of a traditional LLDN procedure.

Hand-assisted laparoscopic live donor nephrectomy: Report of 100 cases

Introduction Laparoscopic live donor nephrectomy is not yet widespread in Japan. After our first hand-assisted laparoscopic live donor nephrectomy (HALapNx) in 2001, we report our 100 cases and examine the possibility of making this technique widely available in Japan. Methods HALapNx was performed in 100 cases (44 males and 56 females) from February 2001 through July 2003. The operative procedure for HALapNx was briefly described here. First, 2 12-mm ports were placed in the midaxillary line at the superior and inferior level of the umbilicus. Next, a 5-cm incision was made in the midline periumbilicus and the hand port system was fitted through the abdominal incision. After 10 mm Hg pneumoperitoneum, HALapNx begins with mobilization of the left colon. Results HALapNx was completed successfully in all cases and no patients required conversion to laparotomy. The estimated blood loss was 33.5 ± 40.3 g and no patient required blood transfusion. The mean operative time was 168.8 ± 47.6 minutes, and there was no major complication in a donor. Conclusions HALapNx is technically feasible and may offer several advantages over open donor nephrectomy in terms of less blood loss, less postoperative pain, and minimal cosmetic disfigurement. In Japan, laparoscopic donor nephrectomy is not yet widespread, possibly due to the need for surgical laparoscopic skills. We believe that the best way to make laparoscopic donor naphrectomy widely available is through hand-assisted laparoscopic surgery.

Laparoscopic donor nephrectomy: New combination of hand-assisted and standard approaches

Background Although laparoscopic live donor nephrectomy (LLDN) was conceived to decrease morbidity and reduce donor disincentives, it requires considerable experience. We present a new combination of hand-assisted and standard laparoscopic approaches to live donor nephrectomy. Methods Between March 2002 and February 2003, ten LLDNs were performed with the new procedures. Using the new methodology the surgeon can withdraw his hand and insert a trocar through the hand-assisted device whenever he desires. Although the hand-assisted procedure was performed in most patients, we attempted to dissect the renal hilum without hand assistance in the final patient, successfully procuring the kidney. Results Mean operation time was 245 minutes and warm ischemic time was 179 seconds. No vascular, renal parenchymal, or ureteral injuries occurred. The patient with multiple left renal arteries had a longer warm ischemic time and delayed graft function. Mean predonation creatinine was 0.97 mg/dL, it increased to 1.44 and 1.15 mg/dL at 7 days and 3 months postdonation, respectively. One patient had chylous ascites and another had a transient left brachial plexus paralysis. Conclusions Both pure laparoscopic and hand-assisted LLDN have advantages and disadvantages. In our modification, the free conversion from hand-assisted to a purely laparoscopic approach allows the surgeon to practice two procedures simultaneously. With this combination, 90% of the LLDN were accomplished, with pure laparoscopy in the last case.

A systematic review of hand-assisted laparoscopic live donor nephrectomy.

We provide a systematic review of hand-assisted laparoscopic live donor nephrectomy (HALDN), a relatively new procedure. Medline search of HALDN between 1995 and 2002 was conducted. Published studies were scored by two independent assessors using a modified form of 11 generic questions. All questions required one of three responses: 0--criterion not reported, 1--criterion reported but inadequate, 2--criterion reported and adequate. The studies were placed according to their scores in category A (score 20-22), category B (17-19) and category C (16 or less). Higher scores indicate better quality of studies. Where possible, statistical analysis of comparative data was performed. Most reports of HALDN are expert series, some comparative and a few prospective. There was good correlation between the assessors (r = 0.91), and of the seven published series on HALDN, two fell into category B and five into category C. At present, there is only one published randomised-controlled trial of HALDN vs. open donor nephrectomy; this is the only such trial in laparoscopic urology. HALDN allows kidneys to be harvested with short operating and warm ischaemia times and fewer ureteric complications. HALDN is a relatively new and effective technique, designed to make kidney donation more attractive and minimally invasive without affecting recipient outcomes. More prospective data of this technique is needed, and wide variation in reported outcome parameters need to be standardised to allow meaningful comparison.

Hand-assisted Laparoscopic Living Donor Nephrectomy

Introduction: Laparoscopic living donor nephrectomy (LDN) for renal transplantation is increasingly being performed to improve donor outcomes, by reducing perioperative morbidity without adversely impacting on allograft function in the recipient. We report our initial experience with hand-assisted LDN. Materials and Methods: From March 2002 to January 2003, 10 hand-assisted LDNs were performed in 2 institutions. Potential donors were evaluated for suitability, which included a renal angiogram. Only donors with uncomplicated vascular arrangements of the left kidney were offered this technique. During surgery, dissection of the donor kidney was performed laparoscopically, aided by the surgeon’s non-dominant hand inserted into the abdominal cavity through a hand-assist device via a 7-cm abdominal incision. The graft was subsequently delivered through the incision. Results: The mean operating time was 163.5 ± 32 minutes and the mean warm ischaemic time was 2.16 ± 0.72 minutes. There were no conversions to the open nephrectomy technique or requirement for perioperative transfusions. Postoperatively, patients returned to normal diet by 1.8 ± 0.8 days and needed opiate analgesia up to a maximum of 48 hours. On average, the patients started ambulation at 2.1 ± 0.9 days and were discharged 4 ± 1.5 days after surgery. There were no significant complications other than 3 superficial wound infections. All grafts had immediate graft function. Serum creatinine levels of all recipients fell within 24 hours and reached baseline at a mean of 5.7 ± 4.6 days. Conclusions: Hand-assisted LDN is safe, feasible and can be performed with minimal morbidity. It also allows for excellent allograft function.

Right laparoscopic live donor nephrectomy: a single institution experience.

Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach. We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function. The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation. Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.

Hand-Assisted Laparoscopic Living-Donor Nephrectomy as an Alternative to Traditional Laparoscopic Living-Donor Nephrectomy

The benefits of laparoscopic living-donor nephrectomy (LDN) are well described, while similar data on hand-assisted laparoscopic living-donor nephrectomy (HALDN) are lacking. We compare hand-assisted laparoscopic living-donor nephrectomy with open donor nephrectomy. One hundred consecutive hand-assisted laparoscopic living-donor nephrectomy (10/98-8/01) donor/recipient pairs were compared to 50 open donor nephrectomy pairs (8/97-1/00). Mean donor weights were similar (179.6 +/- 40.8 vs. 167.4 +/- 30.3 lb; p = NS), while donor age was greater among hand-assisted laparoscopic living-donor nephrectomy (38.2 +/- 9.5 vs. 31.2 +/- 7.8 year; p < 0.01). Right nephrectomies was fewer in hand-assisted laparoscopic living-donor nephrectomy [17/100 (17%) vs. 22/50 (44%); p < 0.05]. Operative time for hand-assisted laparoscopic living-donor nephrectomy (3.9 +/- 0.7 vs. 2.9 +/- 0.5 h; p < 0.01) was longer; however, return to diet (6.9 +/- 2.8 vs. 25.6 +/- 6.1 h; p < 0.01), narcotics requirement (17.9 +/- 6.3 vs. 56.3 +/- 6.4h; p < 0.01) and length of stay (51.7 +/- 22.2 vs. 129.6 +/- 65.7 h; p < 0.01) were less than open donor nephrectomy. Costs were similar ($11072 vs. 10840). Graft function and 1-week Cr of 1.4 +/- 0.9 vs. 1.6 +/- 1.1 g/dL (p = NS) were similar. With the introduction of HALDN, our laparoscopic living-donor nephrectomy program has increased by 20%. Thus, similar to traditional laparoscopic donor nephrectomy, hand-assisted laparoscopic living-donor nephrectomy provides advantages over open donor nephrectomy without increasing costs.