Renal transplantation remains
the only treatment for end stage renal disease which can give patients
an independent lifestyle free from dialysis. With the introduction
of effective immunosuppression, graft survival has dramatically
improved. Using registry data from the United Network for Organ
sharing (UNOS), it is clearly evident that living donor kidney transplantation
is superior to cadaver renal transplantation. The graft/patient
survival rates for recipients of cadaveric donor kidneys are 88.1%
- 95% at one year and 68.7% - 87.5% at three years. Comparatively,
the living donor graft/patient survival rates are 93% - 98% and
83.7% - 94.3% at one and three years respectively.
In addition to greater graft/patient
survival, live donor kidney transplantation offers many other advantages.
The waiting time for recipients of a live donor kidney is dramatically
shorter than that of a cadaver renal transplant. Although the waiting
period can vary within regions, recipients of live donor kidneys
usually wait 2-3 months in Baltimore, Maryland (Lloyd Ratner, M.D,
personal communication, July, 1998). This compares to the 3 to 5
year wait for a cadaver donor kidney significantly increasing the
amount of time on dialysis. Since the live donor transplantation
surgery is elective both the recipient and donor's medical status
can be optimized. Living donors provide a greater chance for a zero
HLA mismatch, less cold ishemic time, and reduced immunosuppression
Unfortunately, living donor transplantation
accounts for only 29.3% of the total renal transplants in 1997.
This is related in part to the disincentives associated with donation.
Such factors as prolonged hospitalization, postoperative pain, extensive
postoperative recovery associated with lost wages, and even cosmetic
results of major abdominal surgery share in deterring live donor
With the advent of minimally
invasive surgical techniques more invasive procedures have been
replaced using less morbid techniques such as laparoscopy. The first
major laparoscopic renal procedure was performed in 1990. Clayman
and associates performed a laparoscopic nephrectomy for a renal
mass. Since that time laparoscopy has been used to perform not only
simple nephrectornies but also radical nephrectomies, renal biopsies,
pyeloplasties, partial nephrectomies, and nephroureterectomies.
In 1994, Gill et al. successfully
performed a laparoscopic donor nephrectomy in a porcine model. Subsequently,
Ratner and associates were the first to clinically develop a technique
for a laparoscopic live donor nephrectomy in February, 1995. Herein,
we describe the technique of laparoscopic live donor nephrectomy
and briefly report our results. Laparoscopic live donor nephrectomy
has resulted in decreased hospital stay, less postoperative analgesic
requirements, earlier return to the activities of daily living,
and earlier return to employment with no affect on allograft function
Preoperative evaluation ensures
that the donor is left with normal renal function after unilateral
nephrectomy. All potential donors undergo extensive medical and
psychological evaluation in accordance with guidelines published
by the American Society of Transplant Physicians. The transplant
team carefully evaluates the donor's motivation and emotional stability.
In addition, donors have a battery of radiographic and laboratory
studies including three-dimensional computed tomography and ABO
histocompatibility testing. The evaluation of both donor and recipient
can vary somewhat among transplantation centers. A relative contraindication
to laparoscopic donor nephrectomy is in a patients with a history
of multiple intrabdominal operations.
Laparoscopic donor nephrectomy
requires accurate preoperative radiographic imaging. When compared
to its open counterpart, laparoscopic live donor nephrectomy requires
a higher degree of resolution of venous anatomy on pre-operative
radiologic evaluation. Preoperative radiographic images assist in
planning the operative approach.
We have recently employed dual
phase spiral computed tomography(CT) with three dimensional angiography
for preoperative evaluation of the living donor patients. In a recent
study by Smith et al., CT angiography adequately depicted renal
vascular anatomy when compared to standard angiography . In addition,
venous anatomy which is critical during laparoscopic dissection
is optimally identified.
In preparation for surgery, patients do not receive any specific
preoperative bowel regimen. Following the induction of general endotracheal
anesthesia and the administration of broad-spectrum intravenous
antibiotic prophylaxis, a foley catheter is placed in the bladder.
An oral-gastric tube remains in place until the completion of the
procedure. The patient is placed in the modified flank position
with the torso in a 45 degree lateral decubitus position and secured
to the table. The hips are rolled slightly posterior to allow exposure
to the lower abdominal midline. The arms are flexed and placed at
chest level with appropriate axillary and lower extremity padding.
A pneumoperitoneum is established using a Veress needle and three
transperitoneal laparoscopic ports are placed as illustrated. The
peritoneal cavity is insufflated to 15 mm Hg.
The first 10/12 millimeter (mm)
port is placed lateral to the rectus muscle half-way between the
umbilicus and iliac crest using an optical trocar(Visiport RPF optical
trocar, US Surgical Corp(USSC)., Norwalk, CT) and the zero degree
lens. The second 10/12 min port is placed at the umbilicus, and
a 5 mm port is placed in the midline between the umbilicus and xiphoid
both under direct vision. All trocars are secured in place with
a 2-0 vicryl suture to prevent inadvertent withdraw during the procedure.
The umbilical port is used primarily as the camera port throughout
the dissection. A 30 degree lens is used for visualization during
the procedure. We employ the AESOP 1000 (Computer Motion Inc., Goleta,
CA) to hold and direct the laparoscope during the procedure. This
device has been shown to increase surgical efficiency and decrease
During the procedure, it is important
keep the patient volume expanded. Pneumoperitoneum has been shown
to decrease renal blood flow, however, vigorous hydration and reduced
intrabdominal pressure maintains urine output. Therefore, we keep
the patient volume expanded during the procedure and insufflate
with the lowest pressure to safely proceed with the dissection.
Patients are routinely given in excess of 5 to 7 liters of crystalloid
intravenously in addition to 12.5 mg of mannitol and 40mg of lasix.
Left sided donor
Using the Debakey forceps in
the 5mm port and the laparoscopic scissors in the lateral port,
the ipsilateral colon is reflected medially beginning at the splenic
flexure to the level of the siginoid colon by incising the lateral
peritoneal reflection .
Electrocautery is used as necessary,
however, extreme caution must be used to avoid thermal injury to
the colon. The phrenocolic ligaments at the level of the splenic
flexure must be completely divided to allow the colon to be completely,
reflected medially. At this point a 2 mm trochar may be placed in
the flank to assist in retracting the colon medially. The lienorenal
and splenocolic ligaments at the inferior border of the spleen are
divided allowing the spleen to be retracted superiorly as needed.
The colorenal ligaments are divided and Gerota's fascia exposed.
The next step is freeing the upper pole of the kidney within Gerota's
This is one of the most technically
challenging parts of the procedure and care must be taken to avoid
injury to the kidney, spleen, and renal hilum. Lobulations can easily
be mistaken for the border of the upper pole. Once the superior
extent is identified, dissection is then facilitated with gentle
elevation of the upper pole with a blunt retractor such as the 5
mm irrigation/suction device in the 5mm port site(figure3) . When
performing this maneuver it is important to place the retractor
under direct vision and advance the tip of the retractor to the
sidewall to prevent inadvertent injury to surrounding organs. Blunt
and sharp dissection are needed to free the upper pole attachments.
Once the upper pole is completely free, the hilar vessels are exposed.
Gerota's fascia is incised on the medial aspect of the kidney,and
the renal vein should be readily apparent. The renal vein is freed
from its adventitial attachments, and the gonadal, adrenal, and
any associated lumbar veins are identified, clipped, and divided
The right angle clip applier can
facilitate placement of clips on the gonadal and adrenal vein. Two
clips should are placed in opposite directions to assure complete
occlusion. It should be noted that the adrenal vessel can be a source
of troublesome bleeding if the dissection is to aggressive along
the renal vein. The lumbar vessels can be identified by gently lifting
the renal vein. The renal artery which usually lies posterior to
the vein is now identified and freed. Sharp dissection of the abundant
lymphatic tissue is required to adequately expose the artery. Clips
are helpful during the dissection to prevent lymphatic leakage.
Maximal vascular should be achieved by completely dissecting the
renal artery to its proximal origin at the aorta. In order to prevent
vasospasm, the renal artery can be bathed with a topical solution
of papaverine. At this point, the patient is given 12.5 grams of
mannitol and 40 mg of lasix intravenously.
The lateral, posterior, and inferior attachments
to the kidney are left intact. This three point fixation limits
the mobility of the kidney and prevents torsion of the kidney on
its vascular pedicle. Attention is now focused on the ureteral dissection
inferiorly. Just below the renal hilum, the gonadal vein is again
identified and a plane is created medially toward the sidewall.
This dissection proceeds inferiorly where the ureter crosses the
iliac vessels. A GIA stapler is used to transect the gonadal vessels
at the level of the pelvis. Once the ureter is dissected to the
level of the left iliac artery and vein, it is divided using the
10 mm clip applier.
The remaining inferior attachments
are divided followed by the lateral attachments to the kidney. With
gentle elevation of the lower pole the remaining posterior renal
and ureteral attachments are divided with sharp and blunt dissection.
Before dividing the vascular pedicle,
a 5 cm periumbilical incision is made in the midline through the
umbilicus using the umbilical port as the superior margin . Care
is taken to keep the peritoneum intact in order to preserve the
pneumoperitoneum. Prior to division of the vascular pedicle, the
patient is given 3000 units of heparin sulfate. The camera is moved
to the left lower quadrant port, and the endovascular GIA stapler(Autosuture,
USSC, Norwalk, CT) is used to sequentially divide the renal artery
Once the pedicle is divided, the
umbilical port is removed, and a 15mm Endocatch bag(USSC, Norwalk,
CT) is placed through the umbilical port site. The kidney is placed
in the bag under direct vision by grasping the perirenal adipose
tissue. Once secured, the peritoneum is opened and the kidney delivered.
It is imperative not to force the kidney through the incision. In
fact, the incision should be lengthened in order to atraurnatically
accompany the kidney. In some individuals, a pfannenstiel incision
can be employed . When using this incision, the fascia is incised
leaving the peritoneum intact. A purse string suture is placed in
the peritoneum, and the trocar reinserted through which the Endocatch
(USSC) is deployed. The pfannenstiel incision is particularly useful
in small individuals allowing for greater space to manipulate the
bag. Once removed, the kidney is transferred to the recipient surgical
After injection of protamine sulfate(30
mg), the fascia is closed with interrupted number 1 Polydioxanone(PDS)suture,
and a pneurnoperitoneum is reestablished. The renal bed is inspected
for active bleeding as well as the trocar sites. The carbon dioxide
is evacuated from the abdomen, and the lateral 12 min trocar site
is closed under laparoscopic vision using a Carter Thomason closure
device(Inlet Medical inc., Eden Prairie, MN) and 2-0 vicryl. The
skin is closed with 4-0 vicryl(polyglactin) and Steristrips are
Right sided approach
Left-sided donor nephrectomies
are technically easier to perform. However, right-sided nephrectomies
are occasionally required because of the relative renal function
or vascular configuration. This side proves to be more technically
difficult because the liver must be retracted cephalad to allow
dissection of the upper pole. Also, the application of the endo-GIA
stapler on the right renal vein results in a loss of 1.0 -1.5 cm
of length. We have experienced allograft renal vein thrombosis presumably
due to a short, thin right renal vein. With right sided donor nephrectomies,
the following modifications are suggested. The midline port between
the xiphoid and umbilicus is placed more superiorly. This trocar
can be a 10/12mm port since an incision will be made through the
site to deliver the kidney. The dissection of the right upper pole
is difficult and requires elevation of the liver. Once again, the
liver can be elevated using a blunt instrument placed directly under
the liver to the right sidewall. This prevents injury to the liver
and surrounding structures. A complete dissection of the lateral
peritoneal reflection at the level of the liver facilitates this
maneuver. Exposure of the short right renal vein at the level of
the vena cava is only accomplished after the duodenum in reflected
medially (Kocher maneuver).
When removing the kidney, a 6 -8
cm right upper quadrant transverse incision is created as opposed
to the midline or pfannenstiel incision for left-sided procedures.
This incision is only created when the entire kidney has been mobilized
and the ureter divided. After placement of a self-retaining retractor,
the renal hilum is identified. The renal artery is divided between
0 silk ties or clips, and the renal vein is divided after placement
of a Satinsky clamp across the inferior vena cava. This allows maximal
length on the renal vein. The kidney is delivered to the surgical
team. The Vena Cava can be closed with 4-0 prolene or the VCS clip
applier(USSC). The surgical wound is closed using 1 PDS for the
fascia and either a subcuticular suture or staples for the skin.
The peritoneal cavity is reinsufflated and the renal bed is inspected.
The port sites are closed with the modified Carter-Thomason instrument.
At the completion of the procedure,
the oral-gastric tube is removed. Patients are usually transferred
to a standard urology or general surgical floor unless otherwise
indicated. They may begin a clear liquid diet on the first postoperative
day, and the diet is advanced as tolerated. In addition, the foley
catheter is removed on post-operative day one, and a metabolic panel
and complete cell count is obtained. Patients are discharged when
tolerating a regular diet and are ambulating without assistance.
The first 110 laparoscopic donor nephrectomies performed at our
institution were compared with the open approach. Length of hospital
stay, perioperative analgesic requirements, complication, and readmission
rates were significantly lower in the laparoscopic group. (16-18
) Mean operative time was 232 minutes and estimated blood loss was
200 cc. . Patients returned to work approximately 2 weeks earlier
after laparoscopic donor nephrectomy. Furthermore, live donor renal
transplants increased by over 100% since the introduction of the
laparoscopic operation. Live donor transplants now account for 55%
of all renal transplants performed at Johns Hopkins Hospital.
Complications related to the procedure
were seen in 11 (10%) patients. These included one retroperitoneal
bleed (0.9%), one incisional hernia (0.9%), one pneumonia (0.9%),
six patients with transient thigh numbness (5.5%), and one rectus
sheath hematoma (0.9%) secondary to an injury to the inferior epigastric
artery requiring ligation, and one bowel injury (0.9%).
Theoretical concerns that the pneumoperitoneum required for laparoscopy
leads to decreased renal blood flow and transient renal ischemia
with acute tubular necrosis and altered function have been unfounded.
Overall recipient and graft survival rates were similar for the
laparoscopic and open groups. Immediate graft function was noted
in all patients. Using the Cockroft-Gault method for determining
creatinine clearance, there was no clinically significant difference
in the creatinine clearance in the laparoscopic and open groups
at 30 months Likewise, there was no significant difference in ureteral
or vascular complications. To date, there have been 10 (9.1 %) graft
losses in the post-operative period.
live Donor Nephrectomy: The Recipient|
Two suffered vascular thrombosis.
Each of these kidneys were from the right side with duplicated renal
veins. As a result of these problems, we prefer to use the left
kidney when using the laparoscopic approach. The right kidney should
be harvested with caution.
Laparoscopic live donor nephrectomy
offers many advantages compared to the traditional open approach.
The procedure does not effect recipient outcome and can be performed
safely by the experienced laparoscopic surgeon. It has resulted
in less postoperative analgesic requirements, decreased hospital
stay, and earlier return to activities of daily living and employment.
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