Pedicular Vascular Control in Laparoscopic Living Donor Nephrectomy: The Use of Clips Instead of Stapler in 341 Donors

Evaluating the differences in the early laparoscopic donor nephrectomy learning curves of a Swiss high volume transplant program and a South African low volume transplant program after knowledge transfer

Background

To describe the retroperitoneoscopic donor nephrectomy learning curve differences between a high volume (training) hospital in Basel, Switzerland, and a low volume (trainee) hospital in Cape Town, South Africa, after knowledge transfer. The South African hospital is resource constraint in hospital and training equipment. Techniques for performing the surgery were near identical.

Methods

Both units maintained prospective databases. Comparisons were made of the first 74 cases in each database: Basel’s series were from 19 January 2001 until 28 June 2004, while the Cape Town Hospital were from 8 April 2008 until 15 July 2008. Four surgeons operated in the Basel group, while only one surgeon operated in the Cape Town group. Variables compared include operating time (first skin incision until kidney was extracted), warm ischaemic time (renal arterial occlusion until cold bench reperfusion), blood loss, graft function, and hospital stay. We also analysed the first and last 25 cases of each series. Subgroup analysis of a single Basel surgeon was conducted.

Results

Donor age (means: Basel vs. Cape Town 54 vs. 33 p < 0.0001) and gender (males vs. females Cape Town 57% male and Basel 31% male) differed widely. The Basel group did more left-sided operations (72% vs. 58%). Operative times, blood loss and donor creatinine did not differ. Warm ischaemic time was significantly shorter in the Basel group (Cape Town mean 204 s Basel mean 130 s P = 0.0023). There was double the number of early graft failures in the South African group (six vs. three)—not related to donor surgery. Both groups showed a decline in operating times, plateauing at 30–34 cases.

Conclusions

There are statistically significant differences in some aspects of the learning curves of the Swiss (training) and South African (trainee) hospitals. These differences are clinically not pronounced, and the knowledge transfer was worth the effort.

A necessary step toward kidney donor safety: the transition from locking polymer clips to transfixion techniques in laparoscopic donor nephrectomy

Donor safety is of paramount importance in addressing end-stage renal failure through living kidney transplantation. The United States Food and Drug Administration (FDA) issued a Class II recall on the use of Hem-o-lok (Teleflex, Limerick, Pennsylvania, United States) polymer clips on the renal artery in laparoscopic donor nephrectomy (LDN) in June 2006 following 3 reported cases of donor deaths secondary to slipped ligature. The National University Hospital of Singapore made the transition regarding hilar control in minimally invasive donor nephrectomy, from using polymer and titanium clips to transfixion techniques (pure or hand-assisted laparoscopic) via laparoscopic staples or intracorporeal suturing, respectively. This study assessed safety during the transition in arterial transfixion techniques in minimally invasive donor nephrectomy for both donors and recipients. Forty-five consecutive kidney donors underwent donor nephrectomy over a 2-year period starting from June 2010. A total of 37 donors who underwent LDN (pure laparoscopic or hand-assisted laparoscopic) were included in the analysis. Of the 37 patients, 23 kidney donors had renal arterial control using Hem-o-lok while 14 patients from November 2011 onward underwent transfixion of the renal artery. The 2 groups of donor who underwent renal arterial control by either clips ligature or transfixion technique were comparable. The outcomes for the recipients in each group were similar with no statistical difference between postoperative creatinine level, incidence of delayed graft function, or graft survival at 1 year. We conclude that the transition in renal arterial control technique to transfixion techniques in LDN in line with FDA recommendation is feasible and affords equivalent donor and recipient outcomes.

Comparative analysis of pedicular vascular control techniques during laparoscopic nephrectomy: en bloc stapling or separate ligation?

OBJECTIVE

To compare the safety and efficacy of en bloc stapling and separate ligation techniques for renal vascular control during laparoscopic nephrectomy.

PATIENTS AND METHODS

Clinical data were collected from 60 patients who underwent laparoscopic nephrectomies using en bloc stapling (n = 27, group 1) or the separate ligation method (n = 33, group 2). Comparative analysis was carried out between the two groups, examining operative times, blood loss, intra- and postoperative complications and hospital stay.

RESULTS

Compared with the separate ligation method, the en bloc hilar control technique was associated with a shorter total operating time (98 vs. 121 min, p = 0.029). However, both groups were similar in terms of estimated blood loss, hemoglobin drop, changes in creatinine level and postoperative hospital stay. The total complication rates in group 1 and 2 were 3.7 and 15.1%, respectively, with a statistically significant difference. There were no complications related to the use of the endo-GIA stapler and no patients required conversion to open surgery in group 1. In group 2, 2 patients required conversion to open surgery, including 1 due to renal vein bleeding secondary to inaccurate vascular control and the other due to bleeding from the vena cava during dissection. In addition, 1 patient had a superficial bowel injury that was repaired laparoscopically and another had a superficial liver tear that was managed without conversion or transfusion.

CONCLUSION

En bloc ligation of the renal hilum is an easy and reliable technique that allows safe and fast control of the renal pedicle.

Evolution of laparoscopic live donor nephrectomy: a single-center experience with 1510 cases over 14 years

OBJECTIVE

This study evaluated the outcomes of laparoscopic donor nephrectomy (LDN) and proposed modifications for kidney donation surgery. From February 1997 to February 2011, 1510 LDNs were performed.

PATIENTS AND METHODS

Surgical modifications included a modified open access technique for entry into the abdominal cavity, using vascular clips for safe and cost-effective control of the renal pedicle, control of the lumbar veins, and adrenal vein using bipolar cautery instead of clips, and leaving the gonadal vein intact with the ureter. Kidneys were extracted by hand through a Pfannenstiel incision. Heparin was not used after the first 300 cases to prevent potential hemorrhagic complications.

RESULTS

Although three major vascular injuries occurred using the closed access method that were managed successfully, no access-related complications occurred using the modified open access technique. Clip failure did not happen in any cases. Patient and graft survival at 1 year post-transplantation were 96.5% and 95.5%, respectively, and at 5 years post-transplantation were 95.3% and 89.5%, respectively.

CONCLUSION

The proposed surgical modifications are based on 14 years of experience and 1510 cases, and make LDN simple, safe, and cost-effective. The excellent recipient and graft outcomes with minimal morbidity obtained further confirm that LDN can be considered as the gold standard for kidney donation surgery.

Left-Sided Inferior Vena Cava Found Incidentally During Laparoscopic Donor Nephrectomy: Report of Three Cases

Laparoscopic donor nephrectomy can be a challenging procedure in patients with abdominal great-vessel anomalies. We report our experience with three cases of laparoscopic donor nephrectomy with a rare incidentally found left-sided inferior vena cava.