Evolution of Technique in Laparoscopic Donor Nephrectomy: A Single Center Experience

Introduction

Renal transplantation is the most successful therapy for improving survival and quality of life for end-stage renal disease (ESRD). ¹ Living donor kidney transplantation (LDKTx) has been used as an alternative to reduce the stay on the waiting list of patients with ESRD and has expanded the donor pool dramatically over the last decade. Since donor nephrectomy is a surgical procedure performed in otherwise healthy patients, in which manipulation of vessels can cause life-threatening bleeding,^2,3 over the years efforts have been made to minimize complication rates and, moreover, make surgery faster and safer, reduce hospital length of stay (LOS) and pain, allow a quicker return to normal activity, and improve cosmesis of patients. ⁴ Open donor nephrectomy (ODN) was the standard procedure before 1995, with large studies reporting an estimated perioperative mortality of 0.03%, and 0.2% and 8% major and minor complication rates, respectively.^5,6 After the first-described laparoscopic donor nephrectomy (LDN) by Ratner et al., in 1995, ⁷ and the hand-assisted laparoscopic donor nephrectomy (HALDN) variant described by Wolf et al., in 1998, ⁸ there has been a decrease in donor morbidity, as well as a faster donor recovery, and similar patient and graft survival compared with ODN in several major transplant centers. ⁹ For these reasons LDN has become the standard procedure for LDKTx. ¹⁰ To further improve safety and efficacy, some changes have been made to this procedure in response to the surgeons' learning curve, complications encountered, and technological advancements.^10–12 This study aims to describe the evolution of surgical technique with LDN at our institute.

Materials and Methods

We retrospectively analyzed our experience with LDN performed from January, 2003 to November, 2016, focusing on describing the modifications of the surgical technique and devices made in those years. Demographics, operative factors, and postoperative complications of donors were reviewed.

At the beginning of our experience with LDKTx, in 1999, donor nephrectomies were performed with the open technique. In 2003, after 40 cases of ODN, we introduced LDN, which became our standard procedure.

As of November 2016, we have performed 144 LDN, all with the transperitoneal approach. During donor evaluation, kidney vascular anatomy is studied with a high resolution spiral computed tomography, providing a three-dimensional reconstruction of the vascular anatomy.

We perform LDN with patients in a flexed lateral decubitus. Pneumoperitoneum induction at 12-cm H₂O carbon dioxide pressure is obtained with open technique or, in cases of left kidney procurement, with the Veress needle in the left upper quadrant, 3 cm below the left subcostal border in the midclavicular line (Palmer's point). At this point, a 30° 10-mm laparoscope is inserted through a 12-mm trocar in periumbilical position and, after abdomen inspection, two more 12-mm trocars are inserted under direct vision in the left or right hypochondrium and in the left or right iliac fossa, for a left or right nephrectomy.

In some cases, a fourth 5-mm trocar is inserted in the left or right flank to retract the colon during vessel transection, as per surgeon's choice. Using electrocautery, clips, and bipolar forceps, and after visualization and dissection of the ureter, the kidney is completely mobilized and freed from adipose tissue, and dissection of the renal vessels is performed.

During the first period of our experience (2003–2008), donor nephrectomies were performed with the HALDN technique. When graft vessels were freed and ready for resection, the first assistant introduced a hand through a lap disk placed in the iliac fossa, raised the kidney, stretching the graft vessels, which were closed with Hem-o-lok^® clips, and transected with cold scissors. From 2009, with the increase of surgeons' experience, pure LDN became the standard procedure. From that point we started delivering the graft through a 5 to 8 cm Pfannenstiel incision, with an Endo Catch™ inserted through the incision, before vessel division. Since then, after experiencing 1 case of massive intraoperative bleeding due to Hem-o-lok dislodgement from the renal artery, we started using the laparoscopic-articulating Multifire Endo GIA™ (gastrointestinal anastomosis) stapler (Covidien, Medtronic, Minneapolis, MN) with 45-mm vascular loads to divide the renal artery, followed by the vein. Over the last 3 years, we have used a Multifire Endo TA™ (thoracoabdominal) laparoscopic stapler (Covidien) with 30-mm vascular loads, followed by section with cold scissors beyond stapler line, to obtain the advantage of gaining a millimeter from the absence of staple lines on the specimen side.

Results

From the beginning of our experience with LDKTx we have performed 185 cases. From 2003 to 2016, 144 LDN were performed. Forty consecutive cases were performed with the hand-assisted technique. From 2009, 94 were pure LDN, and 10 were hand assisted. Patient demographics and intraoperative data are listed in Table 1. The data collected included donor gender, age, body mass index (BMI), intraoperative blood loss, length of procedure, and length of postoperative hospital stay. Intraoperative and postoperative complications following modified Clavien classification of complications for patients undergoing living donation ¹³ are reported in Table 2. Left kidneys have been preferred, allowing us to obtain longer vessels. In cases of complex vascular anatomy (more than two arteries or veins) we chose the contralateral kidney.

Our policy has been to keep donor's BMI under 30. All patients with BMI over 30 have been started on a diet plan to lose weight. We experienced 3 cases of intraoperative bleeding, 2 of which were bleeding from renal artery for dislodgement of Hem-o-lok clips during pure LDN requiring surgical conversion to open technique and 1 requiring blood transfusion. Two patients experienced seroma of the Pfannenstiel incision that required percutaneous drainage. In 1 case, a patient experienced a hematoma of the Pfannenstiel incision, requiring readmission and surgical revision. One patient experienced postoperative ileus, while good postoperative pain control was achieved after protocol preoperative placement of epidural catheter for intraoperative and postoperative analgesia. No cases of primary nonfunction of laparoscopically procured kidneys occurred. All donors with a median follow-up of 6.2 ± 3.6 years are well.

Discussion

From its introduction in 1995, LDN has revolutionized LDKTx, becoming by far the method of choice in Western countries, and significantly increasing the pool of donors in those countries. ¹³ The decreased pain and disability associated with kidney donation accomplished thanks to a minimally-invasive surgical approach has improved its acceptance among potential donors and, most likely, has contributed to the marked increase of LDKTx in the last decade.^9,14,15

Over the years, the need to make this procedure safer went hand in hand with the new criteria for selecting donors, with multiple risk factors such as age, obesity, or kidney vascular anatomy complexity (mainly multiple arteries or veins). ¹⁶

In contrast, the need to subject healthy patients to this intervention does not completely rule out the risk of complications, which unfortunately, as shown in the literature, can be extremely serious.

This has resulted in the constant commitment of our LDN team to optimizing procedures and protocols. Our commitment led us to introduce some changes in the technique and the use of the devices each time we felt this could improve the outcome of the intervention. Namely, switching from ODN to LDN enabled us to significantly reduce complications related to wound infections, including incisional hernias, and minimized patients' postoperative pain, allowing for a more rapid recovery. When we started using the LDN technique we felt that the first assistant introducing his/her hand during the final part of the procedure would allow us to better control the vessels, also allowing us to fully exploit their length. Subsequently, with our increased experience we realized that pure LDN allowed us to obtain the same results, although with no real disadvantage in terms of operative time or vascular control, as some groups have documented, ¹⁷ but also offered a cosmetic advantage with the Pfannenstiel incision in a procedure mostly performed in young women. The changes in our use of the devices were mandatory due to the significant complications with use of the nontransfixion devices, which, as described in the literature,^2,3,18,19 were eventually contraindicated in LDN. In both our cases of complications, there were no significant differences in LOS and outcome for the donors, but from that time we preferred a transfixion technique using laparoscopic staplers.

Conclusions

Our experience with LDN confirms the safety and efficacy of LDN for LDKTx. Continual modifications of surgical technique, integrating new developing technologies and responding to surgeons' learning curves, are contributing to the safety profile of this procedure.