Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

Hand-assisted laparoscopic donor nephrectomy: a single centre experience

Introduction

The advantages of a minimally invasive nephrectomy are a faster recovery and better quality of life for the donors. Until recently, the majority of donor nephrectomies in Poland were done by open surgery.

Aim

To present a single centre experience in hand-assisted laparoscopic donor nephrectomy (HALDN).

Material and methods

The first videoscopic left donor nephrectomy in Poland was performed in our department in 2003 using a hand-assisted retroperitoneal approach. From 2011, we changed the method to a transperitoneal approach and started to harvest also right kidneys. Since then, it has become the method of choice for donor nephrectomy and has been performed in 59 cases. Preoperatively, kidneys were assessed by scintigraphy and by angio-computed tomography. We harvested 32 left and 27 right kidneys. There were double renal arteries in 2 cases and triple renal arteries in 1 case. The warm ischaemia time (WIT) was 80–420 s (average 176.13 s); operative time was 85–210 min (average 140 min).

Results

All procedures were uncomplicated, and all donors were discharged after 2–8 days with normal creatinine levels. The average follow-up period lasted 23 months (1–51 months). Out of all of the cases, 1 case had two minor complications, while all others were uneventful. None of the donors were lost to follow-up. All of the kidneys were transplanted. There were 2 cases of delayed graft function (DGF) and 2 cases of ureter necrosis. One of those kidneys was lost in the third postoperative week.

Conclusions

Our limited experience shows that HALDN is a safe method and should be used routinely instead of open surgery.

Minimally Invasive Surgery for Live Kidney Donors: Techniques and Challenges

Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced postoperative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.

HandPort Laparoscopic Surgery-Review and Current Status

HandPort laparoscopic surgery is a hybrid operation that allows the surgeon to introduce his nondominant hand into abdominal cavity through the port while maintaining pneumoperitoneum. It also helps to gain experience and expertise to learn advanced laparoscopic procedures. The common surgeries where HandPort is useful are laparoscopic splenectomy, colectomies, and donor nephrectomies. HandPort facilitates dissection and extraction of specimens. Hand in abdomen restores tactile sensation which is lacking in laparoscopic procedures. It reduces operative time, increases technical expertise of surgeon, and decreases blood loss. This article reviews the current status of HandPort laparoscopic surgery, the various HandPort devices, and their use.

Retroperitoneoscopic Hand-Assisted Live-Donor Nephrectomy According to the Basic Principle of Transplantation in Donor Kidney Selection

PURPOSE

We assessed the feasibility of retroperitoneoscopic hand-assisted live-donor nephrectomy according to the basic principle of transplantation in kidney selection, namely, leaving the better-functioning kidney in the donor.

PATIENTS AND METHODS

Thirty consecutive live-donor nephrectomies, including 10 right-sided and 20 left-sided procedures, were evaluated. The surgery was started endoscopically using three ports, followed by hand assistance for dissecting the renal pedicles through the extended inner-port incision. A vascular Endostapler and polymer clips were used to transect the renal vessels.

RESULTS

Two right-sided cases required open conversion because of multiple renal vessels and uncontrollable bleeding. The median operative time, warm ischemia time (WIT), blood loss, and renal vein length were 244 minutes (upper and lower quartile 215 and 274 minutes), 186 seconds (134, 239 seconds), 175 mL (45, 305 mL), and 22 mm (19, 26 mm), respectively. The operative time and WIT were longer, and the renal vein was shorter, in the right-sided than in the left-sided procedures (P < 0.05), but no difference was found in the other perioperative data for the two sides. No delayed graft function was observed, and the kidney function 1 month postoperatively was acceptable in all donors and all recipients.

CONCLUSION

Our technical devices, such as the site and timing of hand assistance and control of the renal vessels, seem feasible. Although we could not draw a conclusion about the safety of the right-sided procedure, this alternative procedure should be applicable for laparoscopic donor nephrectomy uninfluenced by the side of the donor kidney provided the surgical team has sufficient expertise.

Effect of robotic assistance on the "learning curve" for laparoscopic hand-assisted donor nephrectomy

BACKGROUND

The number of living-related donor kidney transplantations have increased since the advent of minimally invasive surgery. Robotic technology has emerged as a promising alternative to laparoscopic techniques. The authors reviewed their institution experience with robotic hand-assisted donor nephrectomies (RHADNs).

METHODS

Between August 2000 and April 2006, 273 robotically assisted left donor nephrectomies were performed using a hand-assisted technique. Prospectively collected information for 214 patients regarding complications, hospital stay, blood loss, warm ischemia time, operative time, and outcomes is presented.

RESULTS

The cohort of donors included 110 men and 104 women with a mean age of 36 years (range, 18-61 years). These donors included 86 African Americans, 46 Caucasians, 74 Hispanics, and 8 of other races. Left renal artery anomalies were found in 61 patients (29%). Four patients underwent conversion to open surgery. The hospital stay was 2.3 days (range, 1-8 days), the blood loss 82 ml (range, 10-1,500 ml), and the mean warm ischemia time 98 s (range, 50-200 s). The operative time was 201 min (range, 100-320 min) for the first 74 cases, 129 min (range, 65-240 min) for the second 70 cases, and 103 min for the last 70 cases (p < 0.001), for an overall average of 150 min. Complications decreased significantly after the first 74 cases. The 1-year patient survival rate was 100%, and the 1-year graft survival rate was 98%. The average recipient creatinine at 6 months was 1.4 mg/dl.

CONCLUSIONS

Specific changes in operative technique over time have improved patient safety and diminished complications with RHADN. Currently, RHADN can be performed expeditiously with a minimal rate of complications and conversion to open procedure by a surgical team with appropriate training and experience.

Objective assessment comparing hand-assisted and conventional laparoscopic surgery

BACKGROUND

Although several reports have subjectively highlighted the benefits of hand-assisted as compared with conventional laparoscopic surgery, there has been little objective analysis comparing these two techniques.

METHODS

For this study, 12 trained laparoscopic surgeons completed standardized knot-tying and dissection tasks in a laparoscopic trainer using both hand-assisted (HandPort) and traditional laparoscopic techniques. Motion analysis with the Imperial College Surgical Assessment Device was used to assess performance, measuring the number of movements made, the path length of hand travel, and the time taken. Mann-Whitney U tests were used to compare hand-assisted (HA) and conventional laparoscopic (L) performance. A p value less than 0.05 was deemed significant. Means and standard deviations are shown in the results.

RESULTS

In knot tying, for both the dominant and nondominant hands, hand-assisted rather than conventional laparoscopic techniques resulted in reduced movements (dominant: HA [114 +/- 50] vs L [321 +/- 118, p < 0.001], nondominant: HA [89 +/- 36] vs L [296 +/- 96, p < 0.001]); path length (dominant: HA [1,083 +/- 680 mm] vs L [3,637 +/- 1,852 mm, p < 0.001], nondominant: HA [549 +/- 339 mm] vs L [2,556 +/- 1,042 mm, p < 0.001]); and time taken (HA [162 +/- 50 s] vs L [460 +/- 179 s, p < 0.001]). However, there was no statistical difference for any measured variable with respect to the dissection task.

CONCLUSION

Hand-assisted surgery significantly improves the knot-tying ability among trained laparoscopic surgeons. However, there appears to be no improvement in performance for this specific dissection task.

Handassistierte transperitoneale laparoskopische Donornephrektomie

From December 2004 to May 2005 we performed hand assisted laparoscopic donor nephrectomy in 13 female and seven male patients. The median age was 37 years. As immunosuppressant drug, we consistently used tacrolimus, mycophenolate mofetil, methylprednisolone and a monoclonal antibody. The median surgical time was 138 min (range 113-180), and the median warm ischemic time was 87 s (range 63-150). These results are comparable to the surgical and warm ischemic times for open donor nephrectomy. The hospitalization period of the donors was between 5 and 7 days. Renal function and acute-phase parameters showed a transient increase during and after the operation. Most of the patients reached the baseline levels at day 3 and 4, respectively. Together with the clinical data, these findings verify the minimal invasiveness of laparoscopic donor nephrectomy. In the future, this surgical method will probably be the procedure of choice.

Hand port use for extraction during laparoscopic donor nephrectomy

OBJECTIVES

To report our technique of laparoscopic donor nephrectomy using the hand port for specimen extraction. In 1999, our institution began a kidney transplant program. Donor nephrectomies have since been exclusively performed laparoscopically. Early in our experience, we used a specimen extraction bag to assist in graft removal, but encountered some complications. We subsequently changed our technique to include a hand port for specimen extraction.

METHODS

A database of our experience was kept prospectively. The records of both donors and recipients were reviewed. We describe our technique of laparoscopic donor nephrectomy, including our new method of specimen extraction using a hand port.

RESULTS

A total of 230 consecutive procedures were reviewed. We had excellent donor outcomes, including a mean operative time of 107.9 minutes and an estimated blood loss of 112.4 mL. In addition, the complication (12.6%) and open conversion (1.3%) rates were low. The time needed for specimen extraction decreased from 3.16 minutes to 1.16 minutes (P <0.05) after implementation of the hand port.

CONCLUSIONS

The hand port modification decreased the extraction time and allowed for a safer method of extraction. We believe that the hand port facilitates a procedure that contains a small margin of error.

200 Consecutive Hand Assisted Laparoscopic Donor Nephrectomies: Evolution of Operative Technique and Outcomes

PURPOSE

Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described.

MATERIALS AND METHODS

We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies.

RESULTS

With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%.

CONCLUSIONS

This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.

Nefrectomía radical laparoscópica

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

Immunologic effects of hand-assisted surgery on peritoneal macrophages: Comparison to open and standard laparoscopic approaches

BACKGROUND

Exaggerated activation of peritoneal immunity after major abdominal surgery activates peritoneal macrophages (PMs), which may lead to a relative local immunosuppression. Although laparoscopy (L) is known to elicit a smaller attenuation of peritoneal host defenses, compared with open (O) surgery, effects of the hand-assisted (HA) approach have not been investigated to date.

METHODS

Eighteen pigs underwent a transabdominal nephrectomy via O, HA, or L approach. PMs were harvested at 4, 12, and 24 hours through an intraperitoneal drain and stimulated in vitro with lipopolysaccharide. The production of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) by the purified macrophage cultures was measured with the use of a standard enzyme-linked immunosorbent assay technique. Statistical comparison was performed by using analysis of variance and Student t test.

RESULTS

In vitro lipopolysaccharide-induced IL-6 and TNF-alpha production by PMs increased over the 24-hour period in all 3 groups. Stimulated PMs harvested at 12 and 24 hours postoperatively secreted higher levels of IL-6 in the O group, compared with both the HA group (P = .02, P = .01) and L group (P = .04, P = .001). PMs harvested at 4, 12 and 24 hours postoperatively also produced more TNF-alpha in O group, compared with both the HA group (P = .03, P = .03, and P = .01) and L group (P = .01, P = .05 and P = .03). There was no significant difference between H and L groups in production of either cytokine.

CONCLUSIONS

Abdominal surgery attenuates peritoneal host defenses regardless of the surgical approach employed. However, for the first time, we demonstrated that the HA approach, similar to laparoscopy, is superior to open surgery in the degree of PM activation. Overall, in addition to clinical benefits of minimal access, HA surgery may confer an immunologic advantage over laparotomy.

Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy: Experience from the First 75 Consecutive Cases

BACKGROUND

The two major life-threatening complications associated with laparoscopic live donor nephrectomy are sudden severe bleeding and intestinal injury. A combined technique-hand-assisted and retroperitoneoscopic (HARS)-reduces the risk of these life-threatening complications. In this study, we report on our experience from the first 75 consecutive HARS operations.

METHODS

The data has been collected prospectively according to intention to treat and includes all consecutive donors operated with the HARS technique. Warm ischemia time, operating time, and blood loss were recorded. Complications, convalescence, and allograft outcome were followed postoperatively with a mean follow-up of 701 (range 60-1438) days.

RESULTS

The mean operating time was 138 (range 85-260) minutes and the mean warm ischemia time 175 (85-510) seconds. The operative time was significantly longer in male donors. The mean bleeding was 176 (50-700) ml. There were no conversions to open surgery. Major complications comprised one pulmonary embolus and one donor required 2 units of blood transfusion. One donor was reoperated due to suspicion of trocar hernia. Nine patients experienced minor complications (fever, n=4; urinary tract infection, n=2; chylous ascites, n=1; orchialgia, n=1; subcostal pain, n=1). All except two kidneys had immediate onset of function. Neither of these could, however, be attributed to the donor operation. One recipient experienced urinary leakage and one a stenosis. Recipient and graft survival were 99% and 96%, respectively.

CONCLUSIONS

We conclude that HARS facilitates the procedure by enabling short operating times and at the same time significantly reducing the risks associated with endoscopic live donor nephrectomy.

Hand-Assisted Laparoscopic Donor Nephrectomy: A Low Rate of Complications

Background

Laparoscopic donor nephrectomy is associated with a higher incidence of ureteral complications. Hand-assisted dissection minimizes the use of instruments for intraoperative retraction and handling of periureteric tissue, and may reduce posttransplant complications.

Objective

To assess the outcome of hand-assisted laparoscopic donor nephrectomy, in particular ureteral complications.

Methods

Records of 143 kidney transplant recipients who received allografts removed using the hand-assisted laparoscopic technique were retrospectively studied.

Results

Total operating time was 2.0±0.55 (range 1.08–4) hours. Warm ischemia time was 1.45±0.60 (range 0.58–3.00) minutes. Length of artery, vein, and ureter was 2.4±0.5 cm, 3.0±0.5 cm, and 10.3±2.1 cm, respectively. Estimated blood loss averaged 86.3±55.6 mL. Intraoperative suction was not needed in 65% of patients. Two donors developed incisional hernias and 1 had a postoperative ileus. Four of 143 (2.8%) recipients developed ureteral complications: reoperations for ureteral necrosis (1), stenting for ureteral stenosis (2), and urethral catheterization for ureterovesical leak (1). Graft loss in the first year after transplantation occurred because of renal vein thrombosis, thrombosis of revised arterial anastomosis, arterial thrombosis due to myocardial infarction, vasculitis, focal segmental glomerulosclerosis, and chronic rejection. Delayed graft function developed in 3 recipients. The acute rejection rate was 14.6%. Mean serum creatinine levels at 1 and 3 years were 134±61 μmol/L (1.52±0.69 mg/dL) and 121±35 μmol/L (1.37±0.40 mg/dL), respectively.

Conclusions

Hand-assisted laparoscopic donor nephrectomy is associated with a low incidence of ureteral complications; may reduce the technical difficulty of the operation and minimize retraction with instruments, resulting in fewer complications for donors and recipients; and minimizes donor blood loss.

Hand-assisted laparoscopic and open living donor nephrectomy in Korea

BACKGROUND

We compared the results of hand-assisted laparoscopic living donor nephrectomy (LLDN) and conventional open living donor nephrectomy (OLDN).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Terminal hand-assist for laparoscopic donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices.

METHOD

The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible.

RESULTS

Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 +/- 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days.

CONCLUSIONS

Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.

Visual impairment after laparoscopic donor nephrectomy

Loss of vision after surgery is rare and has never been reported after a laparoscopic procedure. We describe a case of visual deficits secondary to posterior ischemic optic neuropathy after a laparoscopic donor nephrectomy. The potential etiologies of postoperative visual loss are reviewed, and recommendations for avoiding this complication are discussed.

Use of the LigaSure Vessel Sealing Device in Laparoscopic Living-Donor Nephrectomy

BACKGROUND

Laparoscopic living-donor nephrectomy has gained acceptance within the transplant community. The technique requires advanced laparoscopic techniques, and great care must be taken to ensure safety of the operation for the donor and transplantability of the donor kidney. Minimizing the risk of bleeding and trauma to the kidney are important features of a successful living-donor nephrectomy. Improved laparoscopic instrumentation has afforded greater safety and efficacy through technical advances.

METHODS

The LigaSure device was used in 124 consecutive living-donor nephrectomies beginning in 1999. A transplant database was reviewed for operative statistics including intraoperative blood loss and operating time.

RESULTS

The LigaSure device was used to dissect and seal all venous and arterial branches. Estimated blood loss was 90 +/- 53 mL. A suction device was required in only 40 (32%) of the cases. No patient experienced postoperative bleeding. There were two donor complications: one incisional hernia and one ileus. All kidneys functioned immediately upon reperfusion.

CONCLUSIONS

The LigaSure device is an extremely effective tool for obtaining hemostasis by sealing both venous and arterial branches of the major renal vessels. This is also effective in sealing lymphatic tissues and thereby facilitating dissection. Avoiding the use of metallic clips simplified final division of the renal artery and vein. As with any laparoscopic instrument, the anatomic geometry of the operative field may limit use based upon port placement.

An audit over 2 years’ practice of open and laparoscopic live-donor nephrectomy at renal transplant centres in the UK and Ireland

OBJECTIVE

To collate information on the practice of live-donor nephrectomy and compare this with the published British Transplantation Society (BTS) guidelines for best practice, using two questionnaires sent to all renal transplant centres in the UK and Ireland to cover practice for the years 2000 and 2002.

METHODS

A postal questionnaire was sent to all surgical kidney transplant consultants in the UK and Ireland, including questions on the practice of live-donor nephrectomy in the year 2000 (the questionnaire was sent in 2001) and 2002 (questionnaire sent in 2003).

RESULTS

All 28 centres responded fully for both years; 27 centres used live kidney donation in 2000, decreasing to 24 in 2002. Consultants reported 356 operations in 2000, representing 19% of all kidney transplants, and 403 in 2002, representing 23% of all kidney transplants. Three centres offered laparoscopic donor nephrectomy in 2000, and five did so in 2002. Most centres organize donor and recipient operations synchronously, and most have a consultant anaesthetist present for the donor procedure. There were variations in the use of analgesia and thromboprophylaxis, and in donor follow-up.

CONCLUSIONS

There is widespread application of live-donor nephrectomy in the UK but BTS guidelines are not closely followed. Minimal access donor nephrectomy is offered at a few centres but many have plans to introduce this into their practice.

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 colectomy vs open colectomy: a prospective randomized study

BACKGROUND

We compared the perioperative parameters and outcomes achieved with hand-assisted laparoscopic colectomy (HALC) vs open colectomy (OC) for the management of benign and malignant colorectal disease, including cancer patients treated with curative intent.

METHODS

Sixty eligible patients were randomized to either HALC (n = 30) or OC (n = 30) treatment groups. We used Pearson's chi-square and two-sample t-tests to compare the differences in demographics and perioperative parameters.

RESULTS

There were no significant differences in age, gender distribution, disease pattern, operative procedure, comorbidity, or history of abdominal surgery. The HALC patients had significantly shorter hospital stays and incision lengths, faster recovery of gastrointestinal function, less analgesic use and blood loss, and lower pain scores on postoperative days 1, 3, and 14. There were no significant differences in operative time, complications, or time to return to normal activity.

CONCLUSION

Hand-assisted laparoscopic colectomy (HALC) is safe and produces better therapeutic results in terms of perioperative parameters than OC.

Hand-assisted laparoscopic live donor nephrectomy

Background

Hand-assisted laparoscopic donor nephrectomy (HLDN) may have advantages over laparoscopic donor nephrectomy, such as shorter learning curve, operation and warm ischaemia times. The aim of this study was to evaluate the feasibility and safety of HLDN.

Methods

Between January 2000 and October 2002, 50 consecutive HLDN procedures were performed through a low transverse abdominal incision, 23 right sided and 27 left sided.

Results

The median age of the donors was 44 years. No HLDN required conversion to an open procedure. The median operating time for HLDN was 153 min. The median warm ischaemia time was 3 (range 1·0–4·5) min and the median blood loss was 50 (range 20–500) ml in both left- and right-sided procedures. Eight patients suffered ten minor complications during their admission. The duration of hospital stay was 5 days for donors. Three recipients developed graft failure owing to acute rejection, renal vein thrombosis and ischaemic necrosis.

Conclusion

Both left- and right-sided HLDN procedures were feasible and safe through a low transverse abdominal incision.

Right donor nephrectomy: A comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches

BACKGROUND

We compare the anatomic and functional outcomes of right live-donor nephrectomy (LDN) using either a hand-assisted approach (HALDN) or a pure retroperitoneoscopic approach (RLDN) in two institutions.

PATIENTS AND METHODS

Data were recorded prospectively in 59 patients undergoing right LDN using either hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation.

RESULTS

Demographics were similar with respect to age (41.1+/-11.5 vs. 44.5+/-8.5 years) and human leukocyte antigen mismatches (2.7+/-1.8 vs. 2.6+/-1.6). Operative times were longer for HALDN (3.4+/-0.7 vs. 3.0+/-0.7 hours, P <0.04), whereas warm ischemia time was shorter (3:55+/-1:47 vs. 4:55+/-0:55 minutes, P <0.001). Length of renal vein and artery were equivalent (2.4/3.4 vs. 2.3/3.2 cm, P =0.5). Complication rates were similar (10% vs. 7%, P =0.5), including conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1) in the HALDN group, and a small parenchymal injury (n=1) and a capsular tear (n=1) in the RLDN group. Donor length of stay and convalescence were similar in both groups (43.5+/-14.1 vs. 45.7+/-25.3 hours, P =0.1; convalescence 23.5+/-5.3 vs. 20.2+/-4.1 days, P =0.5). One-week, 1-month, and 1-year serum creatinine levels were equivalent with both approaches. No grafts were lost in either group.

CONCLUSIONS

This study confirms that the HALDN and RLDN techniques can provide kidney grafts with equivalent-length vessels and excellent function.

Hand-Assisted Surgery Improves Outcomes for Laparoscopic Nephrectomy

Laparoscopy has become the preferred method for nephrectomy in many medical centers. We compared our experience with hand-assisted laparoscopic nephrectomy (HALN) and standard laparoscopic nephrectomy (LN). Data were prospectively collected on 119 consecutive patients undergoing laparoscopic nephrectomy between August 2000 and November 2002. Outcomes were compared for LN versus HALN using Wilcoxon rank sum test for quantitative outcomes and Fisher exact test and x2 for qualitative outcomes. Thirty-nine patients underwent LN: 16 live donor, 16 radical, and 7 simple nephrectomies. Eighty patients were treated with HALN: 47 live donor, 32 radical, and 1 simple nephrectomy. There were no differences in mean age (49.2 years LN vs. 47.7 years HALN, P = 0.60) or weight (192.2 lb LN, 179.2 lb HALN, P = 0.12). Mean tumor size (4.77 cm LN vs. 7.12 cm HALN, P = 0.07) and length of extraction incision (8.37 cm LN vs. 7.87 cm HALN, P = 0.08) were similar. Total hospital charges ($19,352 vs. $18,505, P = 0.29) and length of stay (3.68 days vs. 3.72 days, P = 0.15) were equivalent for LN and HALN. Average operative time for HALN was significantly shorter (202 minutes vs. 258 minutes, P = 0.0001), and blood loss was less for HALN (71.7 cc vs. 113.1 cc, P = 0.007). Wound complications rates were similar (6.5% HALN vs. 13% LN, P = 0.34), but overall morbidity rates were higher after LN (28.2% vs. 6.3%, P = 0.001). Compared with pure laparoscopic nephrectomy, the hand-assisted approach reduces operative time and blood loss without increasing total hospital charges or length of stay. In our patients, HALN was also associated with fewer postoperative complications than standard laparoscopic nephrectomy. Hand-assisted laparoscopy may allow for the performance of increasingly complex procedures while maintaining the benefits of minimally invasive surgery.

Laparoscopic live donor nephrectomy

Removing disincentives to donation

Laparoscopic donor nephrectomy

Background

Living kidney donation represents an important source of organs for patients with end-stage renal failure. Over the past decade, laparoscopic donor nephrectomy has replaced the conventional open procedure in many transplant centres. Using evidence-based methods, this study examines the current status of laparoscopic donor nephrectomy.

Method

A Medline literature search (PubMed database, 1999–2002) and manual cross-referencing were performed to identify all articles relating to laparoscopic donor nephrectomy. Safety and efficacy criteria were analysed systematically for each study. Studies included were categorized using an evidence-based level grading system.

Results

Of 687 publications, 20 studies with level I–II evidence and 12 with level III evidence were analysed. Only one level I study could be identified. Level I and level II evidence suggests superiority of the laparoscopic approach in regard to postoperative analgesic consumption, hospital stay and return to work. Other safety and efficacy criteria, including donor and recipient outcomes, were similar between the two techniques.

Conclusion

Laparoscopic donor nephrectomy has gained community acceptance by physicians and patients over the past decade. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the ‘gold standard’ for donor nephrectomy in the near future.

Comparison of Outcomes in Noncomplicated and in Higher-Risk Donors after Standard versus Hand-Assisted Laparoscopic Nephrectomy

Hand-assisted techniques facilitated dissemination of the laparoscopic approach in live kidney donors and addressed concerns regarding potential procedural complications. We report our experience with both standard and hand-assisted laparoscopic nephrectomy in routine, complicated, and higher-risk donors. From July 1999 to September 2002, 47 donors underwent standard laparoscopic donor nephrectomy (SLDN; n = 29) or hand-assisted laparoscopic donor nephrectomy (HALDN; n = 18). Donors were “complicated” if they were >60 years of age, obese, refused blood-product transfusion, had multiple renal arteries or veins, or had right nephrectomies. “Higher-risk” donors had two or more risk factors. Results for SLDN and HALDN were compared for the overall groups and for the “complicated” and “higher-risk” groups. No donor required blood transfusion or reoperation. Warm-ischemia times were shorter in left nephrectomies (191 ± 72 seconds vs. 337 ± 95 seconds, P = 0.005), and blood loss was greater in patients with a body mass index ≥30 kg/m2 (296 ± 232 mL vs. 170 ± 139 mL, P = 0.03). Higher-risk donors had an increased operative blood loss and longer hospital stay than low-risk donors. Mean donor creatinine at discharge was 1.19 ± 0.2 mg/dL. Comparison of SLDN versus HALDN revealed shorter operating times for the latter, which approached statistical significance. Warm-ischemia time, operative blood loss, length of hospitalization, and donor and recipient discharge creatinines were similar for both groups. Laparoscopic donor nephrectomy can be applied to selected higher-risk donors with outcomes comparable to uncomplicated donors. Hand-assisted techniques facilitate the procedure during the learning curve, with advantages similar to standard laparoscopic techniques.

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.