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A step-by-step approach to laparoscopic live donor nephrectomy

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A step-by-step approach to laparoscopic live donor nephrectomy
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   A Step-by-Step Approach to Laparoscopic Live Donor Nephrectomy   V. Bettschart, R. Schneider, C. Berutto, R. Groos, J.-P. Wauters, M. Edye, and F. Mosimann T HE shortage of cadaveric organs for kidney transplan-tation has caused an increase in the use of live donors.To date, the open transperitoneal or retroperitoneal ap-proaches are the most common methods of harvest. Theseoperations are very safe but they are not free of morbidityand pain, thus refraining many potential donors.In an effort to make nephrectomy more appealing, lapa-roscopic procedures have recently been promoted. 1,2 In thispaper, we describe the step-by-step approach that wefollowed to initiate laparoscopic live donor nephrectomy. PATIENTS AND METHODS The first step was a visit to the Mount Sinai Hospital in New York where Doctor Edye had already performed some 60 procurementsand perfected a technique allowing harvesting of the kidney oneach side. We were given free access to the video recording of hisprevious operations, which helped us very significantly in preparingour own protocol. The second step was a visit by Doctor Edye toLausanne where he taught us the first nephrectomy. The third step was a nephrectomy under the supervision of Doctor Edye fromNew York by video conference. The final step was, of course, tooperate independently.To date, we have done five nephrectomies, three on the right andtwo on the left side. Our donors have been three females and twomales, including one obese (BMI  33). One donor had two renalarteries.Contrary to several authors, we did not feel it necessary or saferto perform left nephrectomies only. The difficulty on the right sideis the short length of the vein. It has to be cut after the artery andthe preliminary control of the vena cava must be perfect. In ordernot to shorten the vein, we only kept the caval side row of staplesof a commercially available cartridge and discarded the others.Neither in our own or in Dr Edye’s experience has this modifiedstapling technique caused any bleeding. RESULTS The operations lasted 2.5 to 3.5 hours; there was no bloodloss. The kidneys were extracted in a plastic bag through a6-cm suprapubic incision. The median warm ischemia time was 3 minutes but in one case the extraction was difficult,due to imperfect positioning of the donor. This resulted ina 20-minute warm ischemia time that did not adverselyimpact graft function. In another graft, manipulation of theartery caused an intimal flap that was recognized only aftercompletion of the arterial anastomosis in the recipient: there-doing of this anastomosis had no deleterious effect ongraft function. In the donor with two arteries, the polar vessel was cut and had to be repaired before implantation:no focal ischemia was seen on a posttransplant isotopicnephrogram. All donors began oral fluids a few hours after theoperation and tolerated solids the following morning. Theyspontaneously left the hospital at day 5, on average. Twominor complications occurred in the donors: one flankhematoma in the obese man and a urinary tract infection inanother.The recipients were three females and two males, whohad been on hemodialysis for a mean of 14 months. One was still at the predialysis stage. All the grafts function well presently. Only the recipientof the obese donor experienced a clinically significant acutetubular necrosis; creatininemia decreased slowly but dialysis was not required. The other four recipients had a nearnormal creatininemia at discharge (Fig 1). No acute rejec-tion episode occurred. DISCUSSION It is our conviction that any hospital wishing to start alaparoscopic live donor nephrectomy program must firsthave an established routine in cadaveric kidney transplan-tation; the surgeons must also be familiar with the tradi-tional open approach, as conversion from laparoscopy maybe vital. In addition, they must have extensive experience in From the Department of Surgery, University Hospital (V.B.,R.S., C.B., R.G., J.-P.W., F.M.), Lausanne, Switzerland, and theDivision of Laparoscopic Surgery, Mount Sinai Hospital (M.E.),New York, New York. Address reprint requests to F. Mosimann, Department of Sur-gery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne,Switzerland. E-mail: Francois.Mosimann@chuv.hospvd.ch. Fig 1.  Recipients’ creatininemia.© 2000 by Elsevier Science Inc. 0041-1345/00/$–see front matter655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(99)00904-5 Transplantation Proceedings,  32, 117–118 (2000) 117  complex laparoscopic procedures, such as colectomy, sple-nectomy, and adrenalectomy. Finally, every precautionmust be taken not to expose the first donors to the ill effectsof a learning curve. 3 To comply with these principles, we elected to initiatelaparoscopic harvesting at our center in a stepwise manner.In this context, the video conference is a very usefulteaching tool that may allow newcomers on the field tominimize the effects of the learning curve phenomenon; we were indeed able to start our program with a very lowmorbidity. Our preliminary results also indicate that theprocedure is safely feasible on the left and right sides. Thisis, however, a difficult operation and any team wishing tointroduce it must be trained in open live donor nephrec-tomy and in advanced laparoscopy. Initial graft function inour recipients appears to be similar to that after open donornephrectomy, as in larger series. These observations remainof course to be confirmed by a longer followup. If they are,the willingness of the population to donate kidneys to sickrelatives will improve 4 and the greater pool of potentialorgan donors will make renal transplantation a more fre-quent operation. REFERENCES 1. Gill IS, Carbone JM, Clayman RV, et al: J Endourol 8:143,19942. Ratner LE, Ciseck LJ, Moor RG, et al: Transplantation60:1047, 19953. Flowers JL, Jacob S, Cho E, et al: Ann Surg 226:483, 19974. Ratner LE, Hiller J, Sroka M, et al: Transplant Proc 27:3402,1997 118 BETTSCHART, SCHNEIDER, BERUTTO ET AL
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