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Calcerrada Alises E, Antón Rodríguez C, Medina Pedrique M, Berrevoet F, Cuccurullo D, López Cano M, Stabilini C, Garcia-Urena MA. Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery. Langenbecks Arch Surg 2024; 409:166. [PMID: 38805110 DOI: 10.1007/s00423-024-03354-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery. METHODS We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed. RESULTS The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access. CONCLUSION The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.
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Affiliation(s)
- Enrique Calcerrada Alises
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario del Sureste, Madrid, Spain.
- Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Madrid, Spain.
| | - Cristina Antón Rodríguez
- Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Madrid, Spain
| | - Manuel Medina Pedrique
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario del Henares, Madrid, Spain
| | - Frederick Berrevoet
- Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Diego Cuccurullo
- Department of Surgery, Ospedale Monaldi-Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Manuel López Cano
- Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Research Institute General and Gastrointestinal Surgery Research Group, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Cesare Stabilini
- Department of Surgery (DiSC), University of Genoa, IRCCS Policlinico San Martino, Genoa, Italy
| | - Miguel Angel Garcia-Urena
- Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Madrid, Spain
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario del Henares, Madrid, Spain
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Rice TC, Kassam AF, Lewis HV, Hobeika M, Cuffy MC, Ratner LE, Diwan TS. Changing Education Paradigms: Training Transplant Fellows for High Stake Procedures. JOURNAL OF SURGICAL EDUCATION 2020; 77:830-836. [PMID: 32067900 DOI: 10.1016/j.jsurg.2020.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/23/2019] [Accepted: 01/19/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Living kidney donation is a unique operation, as healthy patients are placed at risks inherent with major surgery without physical benefit. The ethical implications associated with any morbidity make it a high-stakes procedure. Fellowships are faced with the dilemma of optimizing fellow training in this demanding procedure while providing safe outcomes to donors. The Laparoscopic Living Donor Nephrectomy (LDN) Workshop is a resource that can provide intense instruction to help bridge the training deficit. Our aim was to examine the course's effectiveness in improving fellows' skill and confidence related to implementing LDN into future practice. METHODS From 2017 to 2018, 36 abdominal transplant surgery fellows participated in a 2-day workshop consisting of live surgery observation, cadaver lab, and didactic sessions. Surveys were completed precourse, postcourse, and at 3-month postcourse follow-up. RESULTS Preworkshop, 61% of participants reported less than 50% confidence in independent performance of LDN. Following workshop completion, 95% reported improved confidence. At 3-month follow-up, there was a 30% (p < 0.05) increase in median confidence level. Immediately following the course, 67% reported improved ability to analyze kidneys prior to donation, 74% changed the way donor candidates were evaluated, and 67% reported enhanced ability to risk stratify donors. Eighty-five percent felt it strengthened operative techniques with 70% implementing new diagnostic treatments and surgical strategies. Seventy percent of participants felt it improved their communication with colleagues and 67% had enhanced communication with patients. These trends were maintained at 3-month follow-up. CONCLUSION These results indicated that the LDN Workshop improves confidence and increases fellows' skillset in a high-stakes procedure. The LDN Workshop is a useful adjunct to fellowship training to optimize successful, efficient, and safe performance of a demanding procedure in a uniquely healthy donor population.
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Affiliation(s)
- Teresa C Rice
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Hannah V Lewis
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Mark Hobeika
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Madison C Cuffy
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University, New York, New York
| | - Tayyab S Diwan
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio.
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Shahbazov R, Maluf D, Azari F, Hakim D, Martin O, Dicocco P, Alejo JL, Saracino G, Hakim N. Laparoscopic Versus Finger-Assisted Open Donor Nephrectomy Technique: A Possible Safe Alternative. EXP CLIN TRANSPLANT 2019; 18:585-590. [PMID: 31526334 DOI: 10.6002/ect.2019.0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite the present use ofthe laparoscopic technique for living-donor kidney nephrectomy, a search for alternative techniques continues.The aim of this study was to compare finger-assisted open donor nephrectomy versus laparoscopic donor nephrectomy. MATERIALS AND METHODS This study included retrospective data of 95 consecutive donors in a transplant center who were under going donor nephrectomy RESULTS: Donor demographics and clinical characteristics were generally similar between treatment groups. There were fewer female donors in the finger-assisted open donor nephrectomy treatment group (70.5% vs 29.5%; P = .003), but median body mass index was similar between groups (28 vs 26 kg/m²; P = .032). Patients who received laparoscopic donor nephrectomy had longer operative duration (3.5 vs 1.2 h; P < .001), longer combined length of incision (6 vs 5 cm; P = .001), andshorter median hospital length of stay (3 vs 4 days; P < .001). A left nephrectomy was preferred in both groups. Minor postoperative complications occurred less often in the finger-assisted open donor nephrectomy group (14.7% vs 31.6%; P = .0094). Donors who received laparoscopic nephrectomy had lower glomerular filtration rate at 1 year after donation (60 vs 89 mL/min/1.73 m²; P < .001) than donors who received finger-assisted nephrectomy. However, recipients of donors of both procedures had similar glomerular filtration rate at 1 year after transplant (65 vs 69 mL/min/1.73 m²; P = .5). CONCLUSIONS Our study demonstrated that finger-assisted open donor nephrectomy is a successful and safe alternative versus laparoscopic donor nephrectomy, providing favorable results for patients in terms of complications and outcomes.
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Affiliation(s)
- Rauf Shahbazov
- >From the Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, New York, USA
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Nunes-Carneiro D, Marques-Pinto A, Braga I, Cabral JF, Almeida M, Cavadas V, de Almeida R, Castro-Henriques A, Fraga A, Silva-Ramos M. Mini-incision Living Donor Nephrectomy and Trans-peritoneal Laparoscopic Nephrectomy: Will There Be a Place for New Evidence? Transplant Proc 2019; 51:1555-1558. [PMID: 31155191 DOI: 10.1016/j.transproceed.2019.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To compare mini-incision donor nephrectomy (MDN) with laparoscopic donor nephrectomy (LDN) performed by the same surgical team, regarding short- and long-term outcomes. METHODS Three hundred and five patients, who underwent donor nephrectomy in our institution, through an MDN (n = 141) between January 1998-November 2011 and LDN (n = 164) since June 2010-December 2017, were compared. RESULTS The mean operative time for MDN (120 ± 29 minutes) was not significantly different when compared to LDN (113 ± 34 minutes), but when comparing the first 50 LDN and the 50 most recent, we found a reduction in the duration of the procedure. Laparoscopic donors had a shorter warm ischemia time (229 seconds vs 310 seconds, P = .01), particularly the 50 most recent, hospital stay (4.3 days vs 5.9 days, P < .001), and postoperative complications (P = .03). The incidence of graft acute tubular necrosis (ATN) was superior in the MDN (89% vs 25%, P < .001), although there was no significant difference regarding first-year serum creatinine (SCr) and glomerular filtration rate (GFR) (SCr 1.38 mg/dL vs SCr 1.33 mg/dL and GFR 63.7 mL/min vs 63.1 mL/min) comparing the 2 groups. Long-term graft survival did not significantly differ between groups. There was also no relationship between postoperative ATN events and long-term graft function. CONCLUSIONS With the growing experience of the high-volume centers and with specialized teams, LDN could be considered the most suitable technique for living donor nephrectomy with better results in short-term results (warm ischemia time, hospital stay, and postoperative complications), without difference in long-term outcomes.
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Affiliation(s)
- Diogo Nunes-Carneiro
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal.
| | - André Marques-Pinto
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Isaac Braga
- Urology Department, Instituto Português de Oncologia do Porto, Portugal
| | - João Ferreira Cabral
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Manuela Almeida
- Nephrology and Kidney Transplantation Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Vítor Cavadas
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - R de Almeida
- Angiology and Vascular Surgery Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - António Castro-Henriques
- Nephrology and Kidney Transplantation Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Avelino Fraga
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Miguel Silva-Ramos
- Urology Department, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
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Gautier S, Monakhov A, Miloserdov I, Arzumanov S, Tsirulnikova O, Semash K, Dzhanbekov T. Simultaneous laparoscopic left lateral sectionectomy and nephrectomy in the same living donor: The first case report. Am J Transplant 2019; 19:1847-1851. [PMID: 30768839 DOI: 10.1111/ajt.15318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 02/08/2019] [Indexed: 01/25/2023]
Abstract
With the presence of organ shortage, living donors remain important sources of grafts, especially for pediatric recipients. Laparoscopic nephrectomy has become the gold standard for living donors. Additionally, laparoscopic partial liver procurement in living donors has proven its safety and feasibility in the latest studies. We have combined both approaches to perform a simultaneous liver-kidney transplantation in a pediatric patient from the same living donor. Our experience of laparoscopic left lateral sectionectomy and laparoscopic nephrectomy in living donors was the basis for adapting to this procedure. A 29-year-old mother was an ABO-incompatible (ABOi) donor for the left lateral section (LLS) of the liver and left kidney for her 2-year-old son. The postoperative period was uneventful. Two sessions of plasmapheresis and rituximab induction were necessary to prepare for ABOi transplantation. The donor and recipient were discharged on postoperative days 5 and 28, respectively. Simultaneous laparoscopic left lateral sectionectomy and nephrectomy in the same living donor is feasible for transplantation from the parent to the child with advanced laparoscopic expertise.
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Affiliation(s)
- Sergey Gautier
- Department of Surgery, National Medical Research Center of Transplantology and Artificial Organs named after academician V.I. Shumakov, Moscow, Russia.,Department of Transplantology and Artificial Organs, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Artem Monakhov
- Department of Surgery, National Medical Research Center of Transplantology and Artificial Organs named after academician V.I. Shumakov, Moscow, Russia.,Department of Transplantology and Artificial Organs, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Igor Miloserdov
- Department of Surgery, National Medical Research Center of Transplantology and Artificial Organs named after academician V.I. Shumakov, Moscow, Russia.,Department of Transplantology and Artificial Organs, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Sergey Arzumanov
- Department of Kidney Transplantation and Vascular Surgery in Urology, N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology, Moscow, Russia
| | - Olga Tsirulnikova
- Department of Transplantology and Artificial Organs, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Konstantin Semash
- Department of Surgery, National Medical Research Center of Transplantology and Artificial Organs named after academician V.I. Shumakov, Moscow, Russia
| | - Timur Dzhanbekov
- Department of Surgery, National Medical Research Center of Transplantology and Artificial Organs named after academician V.I. Shumakov, Moscow, Russia
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Margreiter C, Gummerer M, Gallotta V, Scheidl S, Öfner D, Kienzl-Wagner K, Maier HT, Oberhuber R, Margreiter R, Schneeberger S. Open Management of the Renal Vein Is a Safe Modification in Right-Sided Laparoscopic Living Donor Nephrectomy to Maximize Graft Vein Length. Transplant Proc 2018; 50:3199-3203. [PMID: 30577185 DOI: 10.1016/j.transproceed.2018.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The primary objective in living donor kidney transplantation is donor safety. In laparoscopic living donor nephrectomy, most centers prefer the left kidney for donation given the shorter renal vein, higher rate of thromboses, and more difficult surgical procedure for right kidney retrieval. The goal of this study was to demonstrate the feasibility of a hybrid technique using a Satinsky clamp in right-sided living donor nephrectomy to obtain maximal renal vein and to compare the outcome with standard left-sided laparoscopic donor nephrectomies. MATERIAL AND METHODS Between 2005 and 2013, 77 patients underwent a left (group L) and 54 a right (group R) living donor nephrectomy. In group R, after laparoscopic dissection and mobilization of the right kidney, two 12-mm trocar incisions in the right upper quadrant were connected in a 5-7 cm subcostal incision. The caval vein was partially clamped under direct vision prior to dissection of the renal vein. The venotomy was then closed with a running 4-0 Prolene suture. The two groups were compared with regard to surgical complications, graft function, and graft survival. RESULTS Using this technique, no significant difference with regard to complications or graft function was observed. Serum creatinine at discharge in donor group L was 1.23 (±0.43) mg/dL and in donor group R 1.21 (±0.37) mg/dL (P = .71). Graft survival at one year was 100% in both groups. CONCLUSION Open management of the renal vein is a safe alternative in laparoscopic right-sided donor nephrectomy and ensures maximal length of the vein.
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Affiliation(s)
- C Margreiter
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.
| | - M Gummerer
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria; Department of Vascular Surgery, Medical University of Innsbruck, Austria
| | - V Gallotta
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria; Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - S Scheidl
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - D Öfner
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - K Kienzl-Wagner
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - H T Maier
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - R Oberhuber
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - R Margreiter
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - S Schneeberger
- Department of Visceral, Transplant, and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Qiu Y, Wang X, Song T, Rao Z, Liu J, Huang Z, Lin T. Comparison of Both Sides for Retroperitoneal Laparoscopic Donor Nephrectomy: Experience From a Single Center in China. Transplant Proc 2018; 49:1244-1248. [PMID: 28735988 DOI: 10.1016/j.transproceed.2017.02.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/14/2016] [Accepted: 02/07/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic donor nephrectomy (LDN) has gradually become the main approach to obtain live donor kidneys. However, the shorter right renal vein limits its wider application. The aim of this study was to compare the outcomes of left- and right-side retroperitoneal LDN. METHODS We reviewed the perioperative data of 527 consecutive donors receiving retroperitoneal pure LDN with a new method at our center between April 2009 and April 2014. The patients were divided into group A (the first 100 patients) and group B (the remaining 427 patients). A total of 423 cases of left donor surgery and 104 cases of right donor surgery were compared. The comparison of the laterality of LDN was also performed between group A and group B. RESULTS This is currently the largest case series of LDN in our country. Although right-side LDN patients had longer operation time and a slightly higher incidence of intraoperative complications compared with left-side LDN patients, the operation time was shorter in both the groups compared with previous reports. In group B, patients undergoing right-side LDN had longer operation time and more frequent complications. Once the learning curve of 100 cases was completed, the incidence of complications and operation time were greatly reduced in both sides for LDN. There was no significant difference in the serum creatinine levels in recipients at 6 months of follow-up. CONCLUSIONS Despite a slightly higher incidence of complications and longer operation time, right-side LDN can achieve equally safe and effective transplantation outcomes. This expands the source of potential donor kidneys.
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Affiliation(s)
- Y Qiu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X Wang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - T Song
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Z Rao
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - J Liu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Z Huang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - T Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Ravaioli M, Capocasale E, Furian L, De Pace V, Iaria M, Spagnoletti G, Salerno MP, Giacomoni A, De Carlis L, Di Bella C, Rostand NM, Boschiero L, Pasquale G, Bosio A, Collini A, Carmellini M, Airoldi A, Bondonno G, Ditonno P, Impedovo SV, Beretta C, Giussani A, Socci C, Parolini DC, Abelli M, Ticozzelli E, Baccarani U, Adani GL, Caputo F, Buscemi B, Frongia M, Solinas A, Gruttadauria S, Spada M, Pinna AD, Romagnoli J. Are there any relations among transplant centre volume, surgical technique and anatomy for donor graft selection? Ten-year multicentric Italian experience on mini-invasive living donor nephrectomy. Nephrol Dial Transplant 2017; 32:2126-2131. [DOI: 10.1093/ndt/gfx285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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9
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Serrano OK, Bangdiwala AS, Vock DM, Berglund D, Dunn TB, Finger EB, Pruett TL, Matas AJ, Kandaswamy R. Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis. Am J Transplant 2017; 17:1868-1878. [PMID: 28029219 DOI: 10.1111/ajt.14187] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/20/2016] [Indexed: 01/25/2023]
Abstract
The United Network for Organ Sharing recommends that fellowship-trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS-approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases.
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Affiliation(s)
- O K Serrano
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A S Bangdiwala
- Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - D M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - D Berglund
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
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Davila HH, Storey RE, Rose MC. Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique. J Robot Surg 2016; 10:285-8. [PMID: 27272759 DOI: 10.1007/s11701-016-0608-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/24/2016] [Indexed: 11/25/2022]
Abstract
Herein, we describe several steps to improve surgeon autonomy during a Left Robotic-Assisted Laparoscopic Radical Nephrectomy (RALRN), using the Da Vinci Si system. Our kidney cancer program is based on 2 community hospitals. We use the Da Vinci Si system. Access is obtained with the following trocars: Two 8 mm robotic, one 8 mm robotic, bariatric length (arm 3), 15 mm for the assistant and 12 mm for the camera. We use curved monopolar scissors in robotic arm 1, Bipolar Maryland in arm 2, Prograsp Forceps in arm 3, and we alternate throughout the surgery with EndoWrist clip appliers and the vessel sealer. Here, we described three steps and the use of 3 robotic instruments to improve surgeon autonomy. Step 1: the lower pole of the kidney was dissected and this was retracted upwards and laterally. This maneuver was performed using the 3rd robotic arm with the Prograsp Forceps. Step 2: the monopolar scissors was replaced (robotic arm 1) with the robotic EndoWrist clip applier, 10 mm Hem-o-Lok. The renal artery and vein were controlled and transected by the main surgeon. Step 3: the superior, posterolateral dissection and all bleeders were carefully coagulated by the surgeon with the EndoWrist one vessel sealer. We have now performed 15 RALRN following these steps. Our results were: blood loss 300 cc, console time 140 min, operating room time 200 min, anesthesia time 180 min, hospital stay 2.5 days, 1 incisional hernia, pathology: (13) RCC clear cell, (1) chromophobe and (1) papillary type 1. Tumor Stage: (5) T1b, (8) T2a, (2) T2b. We provide a concise, step-by-step technique for radical nephrectomy (RN) using the Da Vinci Si robotic system that may provide more autonomy to the surgeon, while maintaining surgical outcome equivalent to standard laparoscopic RN.
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Affiliation(s)
- Hugo H Davila
- Florida Healthcare Specialist, Urology and Minimally Invasive Surgery, 3730 7th Terrance, Vero Beach, FL, 32960, USA.
- Florida Cancer Specialist at Vero Beach, Vero Beach, FL, USA.
- Scully-Welsh Cancer Center, Indian River Urology Associates, Florida State University College of Medicine, 787 37th Street, Suite E-200, Vero Beach, FL, 32960, USA.
| | - Raul E Storey
- Florida Healthcare Specialist, Urology and Minimally Invasive Surgery, 3730 7th Terrance, Vero Beach, FL, 32960, USA
- Florida Cancer Specialist at Vero Beach, Vero Beach, FL, USA
- Scully-Welsh Cancer Center, Indian River Urology Associates, Florida State University College of Medicine, 787 37th Street, Suite E-200, Vero Beach, FL, 32960, USA
| | - Marc C Rose
- Scully-Welsh Cancer Center, Indian River Urology Associates, Florida State University College of Medicine, 787 37th Street, Suite E-200, Vero Beach, FL, 32960, USA
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11
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Khalil A, Mujtaba MA, Taber TE, Yaqub MS, Goggins W, Powelson J, Sundaram C, Sharfuddin AA. Trends and outcomes in right vs. left living donor nephrectomy: an analysis of the OPTN/UNOS database of donor and recipient outcomes - should we be doing more right-sided nephrectomies? Clin Transplant 2015; 30:145-53. [DOI: 10.1111/ctr.12668] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Ali Khalil
- Division of Nephrology; Department of Medicine; Indiana University; Indianapolis IN USA
| | - Muhammad A. Mujtaba
- Division of Nephrology; Department of Medicine; Indiana University; Indianapolis IN USA
| | - Tim E. Taber
- Division of Nephrology; Department of Medicine; Indiana University; Indianapolis IN USA
| | - Muhammad S. Yaqub
- Division of Nephrology; Department of Medicine; Indiana University; Indianapolis IN USA
| | - William Goggins
- Division of Transplant Surgery; Department of Surgery; Indiana University; Indianapolis IN USA
| | - John Powelson
- Division of Transplant Surgery; Department of Surgery; Indiana University; Indianapolis IN USA
| | | | - Asif A. Sharfuddin
- Division of Nephrology; Department of Medicine; Indiana University; Indianapolis IN USA
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