UROLOGY ANZJSurg.com
Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy Shengqiang Yu, Changping Men, Lingling Liu, Guanglei Li, Dongfu Liu, Zhenli Gao and Ke Wang Urology Department, Yantai Yuhuangding Hospital, Medical College of Qingdao University, Yantai, China
Key words hand assisted, inguinal incision, live donor nephrectomy, renal transplant, retroperitoneal laparoscopy. Correspondence Dr Ke Wang, Urology Department, Yantai Yuhuangding Hospital, Medical College of Qingdao University, Yantai 264000, China. Email: [email protected] S. Yu MD; C. Men MD; L. Liu MD; G. Li MD; D. Liu MD; Z. Gao MD; K. Wang MD. Shengqiang Yu and Changping Men contributed equally to this work. Accepted for publication 21 January 2014. doi: 10.1111/ans.12561
Abstract Background: Retroperitoneoscopic live donor nephrectomy has been performed in many countries. The purpose of this study was to evaluate the inguinal incision as a route for hand-assisted manipulation and allograft retrieval. Methods: From April 2011 to June 2012, a prospective clinical study of 21 cases of retroperitoneal live donor nephrectomy was performed at our hospital. All donors were grouped in a test group (n = 11, inguinal incision) or a control group (n = 10, lumbar incision). The operative time, warm ischaemia time, blood loss, hospital stay, cosmetic satisfaction, incision complications, and recipient’s serum creatinines were compared between groups. Results: All 21 cases of retroperitoneal live donor nephrectomy were accomplished successfully without serious complications. There was no difference in blood loss and operative time between groups. The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group. The abdominal asymmetry (4/10) and wound dehiscence occurred only in the control group. The recipient’s serum creatinine was lower in the test group at 1 day (P < 0.01) and 3 days (P < 0.05) after transplantation. Conclusion: The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneoscopic live donor nephrectomy, and has a potential to be generally applied in the future.
Introduction The laparoscopic technique has been widely used for living donor nephrectomy (LDN).1 Compared with open donor nephrectomy, LDN has advantages of less trauma, less intra-operative blood loss, less post-operative complications, and shorter hospital stay, without differences in renal allograft function.2,3 With the rapid development of laparoscopic technique, retroperitoneal LDN gained increasing popularity with lower risk for early and late intraperitoneal donor complications.4 The retroperitoneal LDN provides direct access to the renal artery and vein, without disturbing intra-abdominal organs.4,5 The graft retrieval incision is also important in encouraging kidney donation and ensuring better cosmesis, especially for young ladies who intend to donate a kidney. Our previous study6,7 has shown that inguinal incision is a safe and ideal graft retrieval route in both transperitoneal and retroperitoneal LDN. In this study, we further improved the retroperitoneal LDN techniques with a novel hand-assisted approach in handling the renal vessels. © 2014 Royal Australasian College of Surgeons
From April 2011 to June 2012, we performed 21 cases of retroperitoneal LDN with inguinal incision (11 cases) or lumbar incision (10 cases), and compared the clinical outcomes between groups.
Methods Donors and recipients From April 2011 to June 2012, 21 consecutive renal transplantations were performed from living donors in our hospital. All living donor nephrectomies were performed by a retroperitoneoscopic approach. Donors underwent standard pre-donation medical assessment. Obese donors with body mass index >30, older donors (age >60 years), donors with a history of abdominal surgery on the ipsilateral side and donors with bilateral multiple arteries were excluded. All patients were informed of the study and gave their consent. The 21 pairs of donor–recipient were divided to a test group (n = 11) and a control group (n = 10). An inguinal incision (as a hand-assisted route ANZ J Surg 84 (2014) 649–652
650
Yu et al.
Table 1 Demographic parameters of donors and recipients
(a)
Parameters
Test group
Control group
P-value
Number of patients Donor’s age (years) Donor’s sex (male/female) Donor’s BMI (kg/m2) Recipient’s age (years) Recipient’s sex (male/female) Recipient’s BMI (kg/m2)
11 41.1 ± 8.3 7/4 25.0 ± 3.2 34.2 ± 10.5 7/4
10 39.6 ± 9.4 6/4 24.8 ± 3.4 34.6 ± 11.2 5/5
— 0.704 — 0.871 0.931 —
23.2 ± 1.9
22.8 ± 1.9
0.642
BMI, body mass index.
(b)
Fig. 1. Patient position and incisions for live donor nephrectomies. Port A for a 12-mm trocar, port B for a 5-mm trocar and port C for a 12-mm trocar.
Fig. 2. The renal vessels were clipped with the assistance of hand. (a) The renal artery was pulled gently by fingers, then was clipped with two Hem-o-lok clips at the proximal end just close to the abdominal aorta. The finger, renal artery and abdominal aorta were pointed out by arrows. (b) The renal vein was handled similarly to the artery. The finger, renal vein and abdominal aorta were pointed out by arrows.
and allograft retrieval pathway) was used in the test group, and a lumbar incision was used in the control group. Donor parameters are listed in Table 1. The protocol was approved by our local institutional ethics committee and conforms to the ethical guidelines of the 1975 Declaration of Helsinki.
Live donor nephrectomies procedure All donors were placed in a lateral decubitus position. The heparin or mannitol was not administered during the surgery. As previously reported,7 port A (12-mm trocar) was placed at the posterior axillary line under the 12th rib; port B (5-mm trocar) was placed at the anterior axillary line under the 12th rib; port C (10-mm trocar) was placed at the mid-axillary line above the iliac crest (Fig. 1). The kidney, ureter and renal vessels were dissected and mobilized, and the ureter was transected at the level of the iliac vessels.7 For the test group, the renal vessels were dissected with hand assistance from the inguinal incision. A 5–7-cm skin incision was made 2 cm above the inguinal ligament (Fig. 1). The skin, subcutaneous tissue, oblique externus abdominis muscle, endo-abdominal fascia and obliquus internus abdominis were incised. The surgical assistant’s hand was introduced through this incision directly. The
Fig. 3. The kidney was taken out by hand from inguinal incision. The inguinal incision and kidney were pointed out by arrows.
retroperitoneal cavity was sealed again by the assistant’s wrist or upper arm to maintain CO2 pressure. The allograft was retracted by hand with the surveillance of laparoscopy. The renal artery was gently ligated with two Hem-o-lok clips at the proximal end just © 2014 Royal Australasian College of Surgeons
Inguinal incision in nephrectomy
651
Table 2 Characteristics and surgical outcomes of the test and control groups Parameters Donor kidney laterality (right/left) Operative time (min) Blood loss (mL) Warm ischaemia time (s) Donor hospital stay (days) One-year graft survival rate (%) Abdomen asymmetry Wound faulty union Incision satisfaction 3 months after surgery (1/2/3)†
Test group (n = 11)
Control group (n = 10)
P-value
9/2 76.5 ± 7.1 45.9 ± 10.9 62.9 ± 4.3 4.5 ± 0.7 100 0/11 0/11 1/3/7
8/2 74.2 ± 7.7 47.5 ± 12.1 87.2 ± 6.1 6.5 ± 0.8 100 4/11 1/11 6/3/1
— 0.494 0.754 0.000 0.000 — — — 0.018
†Incision satisfaction was rated as (1) not satisfied, (2) satisfied and (3) highly satisfied.
close to the abdominal aorta and divided with scissors (Fig. 2a). The renal vein was handled similarly (Fig. 2b). This allowed maximal length of allograft vessels. The kidney was retrieved rapidly by the hand from the inguinal incision (Fig. 3). For the control group, a lumbar incision was created from port A to B; the external and internal oblique muscles were cut, and the endo-abdominal fascia and obliquus internus abdominis was left intact. After the renal artery and vein were ligated and divided, then the endo-abdominal fascia and obliquus internus abdominis was incised, and the kidney was retrieved by the operator’s hand or endobag from the lumbar incision.7
Fig. 4. The inguinal incision scar of test group at 3 months after surgery.
Clinical data
Statistical analysis Statistical analyses were performed with SPSS software (SPSS 22.0.0 trial version, IBM, New York, NY, USA). Categorical data were compared with chi-square test; measurement data were compared with the Student’s t-test. P < 0.05 was considered statistically significant.
Results All 21 cases of retroperitoneal LDN were performed successfully, without donor death, serious complications or conversion to open surgery. There was no difference in blood loss, operative time and 1-year graft survival rate between groups (Table 2). The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group (Table 2). The inguinal incision scar at 3 months after surgery is shown in Figure 4. There were no incisional herniae or wound infections in all donors. The abdominal asymmetry (4/10) and wound © 2014 Royal Australasian College of Surgeons
700
Serum creatinine (µmol/L)
All the donors and recipients were followed up for at least 12 months. For the donors, the operative time, operative blood loss, warm ischaemia time and hospital stay were recorded and compared. Incisional complications included abdominal asymmetry, incisional hernia, wound infection and wound dehiscence for all donors. The donors were asked to complete a questionnaire about incision satisfaction at 3 months after surgery. Incision satisfaction was rated as (1) not satisfied, (2) satisfied and (3) highly satisfied. For the recipients, the serum creatinine was recorded at 1 day, 3 days, 1 week, 4 weeks and 1 year after surgery.
600
**
Test group Control group
500 400 300
*
200 100 0 1 day
3 days
1 week
4 weeks
1 year
Fig. 5. The recipient’s serum creatinine at 1 day, 3 days, 4 week and 1 year after surgery. *P < 0.05, **P < 0.01.
dehiscence (1/10) occurred only in the control group (Table 2). The serum creatinine in the test group was lower at day 1 (P < 0.01) and day 3 (P < 0.05) after surgery, but there was no statistical difference at 1 week (P < 0.1), 4 weeks (P < 0.1) and 1 year (P < 0.1) after surgery (Fig. 5).
Discussion Since the first successful renal transplantation in humans in 1954,8 renal transplantation has become the first option for end-stage renal diseases. A major bottleneck for renal transplantation is the shortage
652
of organs. Increasing numbers of living donor kidney transplants are being performed worldwide, and the major ethical issue in living donation is the trauma and risk to donors.9 To minimize morbidity to donors, surgical practice has improved from traditional open nephrectomy, through mini-incision muscle splitting open nephrectomy, to minimally invasive laparoscopic techniques.10 Since May 2004, all live donor nephrectomies have been performed by laparoscopy at our hospital.11 Compared with open nephrectomy, LDN shows superior results in post-operative pain, fewer complications, satisfactory cosmesis and faster recovery.12,13 The transperitoneal LDN is widely applied at many centres owing to its adequate operational working space and easy dissection.1 However, the risk of bowel injury, intestinal obstruction and intestinal adhesion is challenging transperitoneal LDN.11 Since the first attempt in 1995,14 the retroperitoneal LDN has been performed in many countries.10,15 The retroperitoneal LDN provides direct access to the renal pedicle without disturbing intraabdominal organs.4,5,11 Graft retrieval incision is important in encouraging kidney donation and ensuring better cosmesis, especially for young ladies. From a cosmetic standpoint, the lumbar or subcostal scar is often conspicuous and cannot be concealed by lingerie or swimwear. To solve these problems, we have performed inguinal incision as a successful route to extract the allograft in both transperitoneal and retroperitoneal LDNs at previous studies.6,7 Although the surgical trauma is less, the warm ischaemia time in the LDNs is longer than open surgery.16 Warm ischaemic time is a risk factor for the occurrence of slower graft function recovery.17,18 To facilitate the operational manipulation and minimize the warm ischaemia time, we improved the retroperitoneal LDN technique from ‘pure’ laparoscopic to hand-assisted manipulation through inguinal incision in the present study. There are some advantages of the new modification: (i) shortening the warm ischaemia time. In our previous retroperitoneal LDN, the endo-abdominal fascia and obliquus internus abdominis were slit after the renal vessels were transected; in the modified surgical process, the endo-abdominal fascia and obliquus internus abdominis were slit before the renal vessels were ligated. Thus, the warm ischaemia time was shortened tens of seconds. (ii) Facilitating the ligation of renal vessels. When handling the renal vessels, the hand held up the kidney and pulled the vessels gently. Then we had more space to ligate the vessels at a maximal length. A hand is more skilful than a laparoscopic instrument. (iii) Benefiting the early graft function recovery. In the present study, the recipients’ serum creatinine of day 1 and day 3 was lower in the test group than that in the conventional retroperitoneal LDN group. (iv) The inguinal incision has advantages of less trauma, quicker recovery, better cosmesis and fewer complications as reported previously.7 The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneal LDN, and has the potential to be popularized in future.
Yu et al.
References 1. Banga N, Nicol D. Techniques in laparoscopic donor nephrectomy. BJU Int. 2012; 110: 1368–73. 2. Nicholson ML, Kaushik M, Lewis GR et al. Randomized clinical trial of laparoscopic versus open donor nephrectomy. Br. J. Surg. 2010; 97: 21–8. 3. Yuan H, Liu L, Zheng S et al. The safety and efficacy of laparoscopic donor nephrectomy for renal transplantation: an updated meta-analysis. Transplant. Proc. 2013; 45: 65–76. 4. Troppmann C, Daily MF, McVicar JP, Troppmann KM, Perez RV. The transition from laparoscopic to retroperitoneoscopic live donor nephrectomy: a matched pair pilot study. Transplantation 2010; 89: 858–63. 5. Ma L, Li G, Huang Y et al. Retroperitoneoscopic live-donor right nephrectomy: a Chinese single center. Exp. Clin. Transplant. 2011; 9: 20–5. 6. Wang K, Wan FC, Gao ZL et al. Inguinal oblique incision as an alternative route to extract the kidney during laparoscopic donor nephrectomy. Exp. Clin. Transplant. 2011; 9: 315–8. 7. Wang K, Liu DF, Wang L et al. Inguinal incision as a successful route to extract the kidney during laparoscopic retroperitoneal live-donor nephrectomy. Exp. Clin. Transplant. 2013; 11: 396–9. 8. Murray G, Holden R. Transplantation of kidneys, experimentally and in human cases. Am. J. Surg. 1954; 87: 508–15. 9. Matas AJ, Delmonico FL. Living donation: the global perspective. Adv. Chronic Kidney Dis. 2012; 19: 269–75. 10. Dols LF, Kok NF, Ijzermans JN. Live donor nephrectomy: a review of evidence for surgical techniques. Transpl. Int. 2010; 23: 121–30. 11. Gao ZL, Wu JT, Liu YJ et al. Comparison of transperitoneal and retroperitoneal laparoscopic living donor nephrectomy. Chin Med J (Engl) 2007; 120: 2314–6. 12. Hiller J, Sroka M, Holochek MJ, Morrison A, Kavoussi LR, Ratner LE. Functional advantages of laparoscopic live-donor nephrectomy compared with conventional open-donor nephrectomy. J. Transpl. Coord. 1997; 7: 134–40. 13. Flowers JL, Jacobs S, Cho E et al. Comparison of open and laparoscopic live donor nephrectomy. Ann. Surg. 1997; 226: 483–9, discussion 9–90. 14. Yang SC, Park DS, Lee DH, Lee JM, Park K. Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J. Urol. 1995; 153: 1884–6. 15. Kohei N, Kazuya O, Hirai T et al. Retroperitoneoscopic living donor nephrectomy: experience of 425 cases at a single center. J. Endourol. 2010; 24: 1783–7. 16. Greco F, Hoda MR, Alcaraz A, Bachmann A, Hakenberg OW, Fornara P. Laparoscopic living-donor nephrectomy: analysis of the existing literature. Eur. Urol. 2010; 58: 498–509. 17. Shao MJ, Ye QF, Ming YZ et al. Risk factors for delayed graft function in cardiac death donor renal transplants. Chin Med J (Engl) 2012; 125: 3782–5. 18. Hellegering J, Visser J, Kloke HJ et al. Deleterious influence of prolonged warm ischemia in living donor kidney transplantation. Transplant. Proc. 2012; 44: 1222–6.
© 2014 Royal Australasian College of Surgeons
Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy Shengqiang Yu, Changping Men, Lingling Liu, Guanglei Li, Dongfu Liu, Zhenli Gao and Ke Wang Urology Department, Yantai Yuhuangding Hospital, Medical College of Qingdao University, Yantai, China
Key words hand assisted, inguinal incision, live donor nephrectomy, renal transplant, retroperitoneal laparoscopy. Correspondence Dr Ke Wang, Urology Department, Yantai Yuhuangding Hospital, Medical College of Qingdao University, Yantai 264000, China. Email: [email protected] S. Yu MD; C. Men MD; L. Liu MD; G. Li MD; D. Liu MD; Z. Gao MD; K. Wang MD. Shengqiang Yu and Changping Men contributed equally to this work. Accepted for publication 21 January 2014. doi: 10.1111/ans.12561
Abstract Background: Retroperitoneoscopic live donor nephrectomy has been performed in many countries. The purpose of this study was to evaluate the inguinal incision as a route for hand-assisted manipulation and allograft retrieval. Methods: From April 2011 to June 2012, a prospective clinical study of 21 cases of retroperitoneal live donor nephrectomy was performed at our hospital. All donors were grouped in a test group (n = 11, inguinal incision) or a control group (n = 10, lumbar incision). The operative time, warm ischaemia time, blood loss, hospital stay, cosmetic satisfaction, incision complications, and recipient’s serum creatinines were compared between groups. Results: All 21 cases of retroperitoneal live donor nephrectomy were accomplished successfully without serious complications. There was no difference in blood loss and operative time between groups. The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group. The abdominal asymmetry (4/10) and wound dehiscence occurred only in the control group. The recipient’s serum creatinine was lower in the test group at 1 day (P < 0.01) and 3 days (P < 0.05) after transplantation. Conclusion: The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneoscopic live donor nephrectomy, and has a potential to be generally applied in the future.
Introduction The laparoscopic technique has been widely used for living donor nephrectomy (LDN).1 Compared with open donor nephrectomy, LDN has advantages of less trauma, less intra-operative blood loss, less post-operative complications, and shorter hospital stay, without differences in renal allograft function.2,3 With the rapid development of laparoscopic technique, retroperitoneal LDN gained increasing popularity with lower risk for early and late intraperitoneal donor complications.4 The retroperitoneal LDN provides direct access to the renal artery and vein, without disturbing intra-abdominal organs.4,5 The graft retrieval incision is also important in encouraging kidney donation and ensuring better cosmesis, especially for young ladies who intend to donate a kidney. Our previous study6,7 has shown that inguinal incision is a safe and ideal graft retrieval route in both transperitoneal and retroperitoneal LDN. In this study, we further improved the retroperitoneal LDN techniques with a novel hand-assisted approach in handling the renal vessels. © 2014 Royal Australasian College of Surgeons
From April 2011 to June 2012, we performed 21 cases of retroperitoneal LDN with inguinal incision (11 cases) or lumbar incision (10 cases), and compared the clinical outcomes between groups.
Methods Donors and recipients From April 2011 to June 2012, 21 consecutive renal transplantations were performed from living donors in our hospital. All living donor nephrectomies were performed by a retroperitoneoscopic approach. Donors underwent standard pre-donation medical assessment. Obese donors with body mass index >30, older donors (age >60 years), donors with a history of abdominal surgery on the ipsilateral side and donors with bilateral multiple arteries were excluded. All patients were informed of the study and gave their consent. The 21 pairs of donor–recipient were divided to a test group (n = 11) and a control group (n = 10). An inguinal incision (as a hand-assisted route ANZ J Surg 84 (2014) 649–652
650
Yu et al.
Table 1 Demographic parameters of donors and recipients
(a)
Parameters
Test group
Control group
P-value
Number of patients Donor’s age (years) Donor’s sex (male/female) Donor’s BMI (kg/m2) Recipient’s age (years) Recipient’s sex (male/female) Recipient’s BMI (kg/m2)
11 41.1 ± 8.3 7/4 25.0 ± 3.2 34.2 ± 10.5 7/4
10 39.6 ± 9.4 6/4 24.8 ± 3.4 34.6 ± 11.2 5/5
— 0.704 — 0.871 0.931 —
23.2 ± 1.9
22.8 ± 1.9
0.642
BMI, body mass index.
(b)
Fig. 1. Patient position and incisions for live donor nephrectomies. Port A for a 12-mm trocar, port B for a 5-mm trocar and port C for a 12-mm trocar.
Fig. 2. The renal vessels were clipped with the assistance of hand. (a) The renal artery was pulled gently by fingers, then was clipped with two Hem-o-lok clips at the proximal end just close to the abdominal aorta. The finger, renal artery and abdominal aorta were pointed out by arrows. (b) The renal vein was handled similarly to the artery. The finger, renal vein and abdominal aorta were pointed out by arrows.
and allograft retrieval pathway) was used in the test group, and a lumbar incision was used in the control group. Donor parameters are listed in Table 1. The protocol was approved by our local institutional ethics committee and conforms to the ethical guidelines of the 1975 Declaration of Helsinki.
Live donor nephrectomies procedure All donors were placed in a lateral decubitus position. The heparin or mannitol was not administered during the surgery. As previously reported,7 port A (12-mm trocar) was placed at the posterior axillary line under the 12th rib; port B (5-mm trocar) was placed at the anterior axillary line under the 12th rib; port C (10-mm trocar) was placed at the mid-axillary line above the iliac crest (Fig. 1). The kidney, ureter and renal vessels were dissected and mobilized, and the ureter was transected at the level of the iliac vessels.7 For the test group, the renal vessels were dissected with hand assistance from the inguinal incision. A 5–7-cm skin incision was made 2 cm above the inguinal ligament (Fig. 1). The skin, subcutaneous tissue, oblique externus abdominis muscle, endo-abdominal fascia and obliquus internus abdominis were incised. The surgical assistant’s hand was introduced through this incision directly. The
Fig. 3. The kidney was taken out by hand from inguinal incision. The inguinal incision and kidney were pointed out by arrows.
retroperitoneal cavity was sealed again by the assistant’s wrist or upper arm to maintain CO2 pressure. The allograft was retracted by hand with the surveillance of laparoscopy. The renal artery was gently ligated with two Hem-o-lok clips at the proximal end just © 2014 Royal Australasian College of Surgeons
Inguinal incision in nephrectomy
651
Table 2 Characteristics and surgical outcomes of the test and control groups Parameters Donor kidney laterality (right/left) Operative time (min) Blood loss (mL) Warm ischaemia time (s) Donor hospital stay (days) One-year graft survival rate (%) Abdomen asymmetry Wound faulty union Incision satisfaction 3 months after surgery (1/2/3)†
Test group (n = 11)
Control group (n = 10)
P-value
9/2 76.5 ± 7.1 45.9 ± 10.9 62.9 ± 4.3 4.5 ± 0.7 100 0/11 0/11 1/3/7
8/2 74.2 ± 7.7 47.5 ± 12.1 87.2 ± 6.1 6.5 ± 0.8 100 4/11 1/11 6/3/1
— 0.494 0.754 0.000 0.000 — — — 0.018
†Incision satisfaction was rated as (1) not satisfied, (2) satisfied and (3) highly satisfied.
close to the abdominal aorta and divided with scissors (Fig. 2a). The renal vein was handled similarly (Fig. 2b). This allowed maximal length of allograft vessels. The kidney was retrieved rapidly by the hand from the inguinal incision (Fig. 3). For the control group, a lumbar incision was created from port A to B; the external and internal oblique muscles were cut, and the endo-abdominal fascia and obliquus internus abdominis was left intact. After the renal artery and vein were ligated and divided, then the endo-abdominal fascia and obliquus internus abdominis was incised, and the kidney was retrieved by the operator’s hand or endobag from the lumbar incision.7
Fig. 4. The inguinal incision scar of test group at 3 months after surgery.
Clinical data
Statistical analysis Statistical analyses were performed with SPSS software (SPSS 22.0.0 trial version, IBM, New York, NY, USA). Categorical data were compared with chi-square test; measurement data were compared with the Student’s t-test. P < 0.05 was considered statistically significant.
Results All 21 cases of retroperitoneal LDN were performed successfully, without donor death, serious complications or conversion to open surgery. There was no difference in blood loss, operative time and 1-year graft survival rate between groups (Table 2). The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group (Table 2). The inguinal incision scar at 3 months after surgery is shown in Figure 4. There were no incisional herniae or wound infections in all donors. The abdominal asymmetry (4/10) and wound © 2014 Royal Australasian College of Surgeons
700
Serum creatinine (µmol/L)
All the donors and recipients were followed up for at least 12 months. For the donors, the operative time, operative blood loss, warm ischaemia time and hospital stay were recorded and compared. Incisional complications included abdominal asymmetry, incisional hernia, wound infection and wound dehiscence for all donors. The donors were asked to complete a questionnaire about incision satisfaction at 3 months after surgery. Incision satisfaction was rated as (1) not satisfied, (2) satisfied and (3) highly satisfied. For the recipients, the serum creatinine was recorded at 1 day, 3 days, 1 week, 4 weeks and 1 year after surgery.
600
**
Test group Control group
500 400 300
*
200 100 0 1 day
3 days
1 week
4 weeks
1 year
Fig. 5. The recipient’s serum creatinine at 1 day, 3 days, 4 week and 1 year after surgery. *P < 0.05, **P < 0.01.
dehiscence (1/10) occurred only in the control group (Table 2). The serum creatinine in the test group was lower at day 1 (P < 0.01) and day 3 (P < 0.05) after surgery, but there was no statistical difference at 1 week (P < 0.1), 4 weeks (P < 0.1) and 1 year (P < 0.1) after surgery (Fig. 5).
Discussion Since the first successful renal transplantation in humans in 1954,8 renal transplantation has become the first option for end-stage renal diseases. A major bottleneck for renal transplantation is the shortage
652
of organs. Increasing numbers of living donor kidney transplants are being performed worldwide, and the major ethical issue in living donation is the trauma and risk to donors.9 To minimize morbidity to donors, surgical practice has improved from traditional open nephrectomy, through mini-incision muscle splitting open nephrectomy, to minimally invasive laparoscopic techniques.10 Since May 2004, all live donor nephrectomies have been performed by laparoscopy at our hospital.11 Compared with open nephrectomy, LDN shows superior results in post-operative pain, fewer complications, satisfactory cosmesis and faster recovery.12,13 The transperitoneal LDN is widely applied at many centres owing to its adequate operational working space and easy dissection.1 However, the risk of bowel injury, intestinal obstruction and intestinal adhesion is challenging transperitoneal LDN.11 Since the first attempt in 1995,14 the retroperitoneal LDN has been performed in many countries.10,15 The retroperitoneal LDN provides direct access to the renal pedicle without disturbing intraabdominal organs.4,5,11 Graft retrieval incision is important in encouraging kidney donation and ensuring better cosmesis, especially for young ladies. From a cosmetic standpoint, the lumbar or subcostal scar is often conspicuous and cannot be concealed by lingerie or swimwear. To solve these problems, we have performed inguinal incision as a successful route to extract the allograft in both transperitoneal and retroperitoneal LDNs at previous studies.6,7 Although the surgical trauma is less, the warm ischaemia time in the LDNs is longer than open surgery.16 Warm ischaemic time is a risk factor for the occurrence of slower graft function recovery.17,18 To facilitate the operational manipulation and minimize the warm ischaemia time, we improved the retroperitoneal LDN technique from ‘pure’ laparoscopic to hand-assisted manipulation through inguinal incision in the present study. There are some advantages of the new modification: (i) shortening the warm ischaemia time. In our previous retroperitoneal LDN, the endo-abdominal fascia and obliquus internus abdominis were slit after the renal vessels were transected; in the modified surgical process, the endo-abdominal fascia and obliquus internus abdominis were slit before the renal vessels were ligated. Thus, the warm ischaemia time was shortened tens of seconds. (ii) Facilitating the ligation of renal vessels. When handling the renal vessels, the hand held up the kidney and pulled the vessels gently. Then we had more space to ligate the vessels at a maximal length. A hand is more skilful than a laparoscopic instrument. (iii) Benefiting the early graft function recovery. In the present study, the recipients’ serum creatinine of day 1 and day 3 was lower in the test group than that in the conventional retroperitoneal LDN group. (iv) The inguinal incision has advantages of less trauma, quicker recovery, better cosmesis and fewer complications as reported previously.7 The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneal LDN, and has the potential to be popularized in future.
Yu et al.
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