Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 2630 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 421-425
Laparoscopic right donor nephrectomy: Endo TA stapler is safe and effective


Institute of Kidney Diseases and Research Centre, Ahmedabad, India

Click here for correspondence address and email

Date of Web Publication26-Apr-2010
 

   Abstract 

Although laparoscopic donor nephrectomy is now a well-accepted alternative to traditional open donor nephrectomy at many transplantation centers, there are always concerns regarding quality of graft and vessels after laparoscopic harvest, especially with right donor nephrectomy. Several methods of graft retrieval have been explored to achieve acceptable graft outcome. We share our initial experience at the Institute of Kidney Diseases and Research Center, Amedabad, India of laparoscopic right donor nephrectomy performed by subcostal open, and pure laparoscopic approach with the use of Endo TA stapler. Nine laparoscopic right donor nephrec­tomies were performed by the trans-peritoneal approach at our centre from January 2006 to March 2007. In the first five cases, the grafts were retrieved through subcostal incision (Group A) and the last four cases were performed purely laparoscopically by using Endo TA stapler device (Group B). None of the patients needed open conversion. The mean operative time and hospital stay were comparable in each group. The warm ischemia time was longer in pure laparoscopic group (415 seconds) than the subcostal open approach group (176 seconds). The serum creatinine of the recipients on day seven was comparable in both the groups. The recipient surgery was effectively performed with graft retrieved using Endo TA stapler device (Group B) without any compromise to the renal vein length. Our study suggests that the Endo TA stapler device is safe and provides all the benefits of minimally invasive surgery to the donor.

How to cite this article:
Devra AK, Patel S, Shah SA. Laparoscopic right donor nephrectomy: Endo TA stapler is safe and effective. Saudi J Kidney Dis Transpl 2010;21:421-5

How to cite this URL:
Devra AK, Patel S, Shah SA. Laparoscopic right donor nephrectomy: Endo TA stapler is safe and effective. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Sep 20];21:421-5. Available from: http://www.sjkdt.org/text.asp?2010/21/3/421/62697

   Introduction Top


Since the introduction of laparoscopic donor nephrectomy clinically in 1995, [1],[2] the procedure has been evaluated time and again, but now it is being accepted as a viable alternative to traditional open donor nephrectomy. The early series of laparoscopic right donor nephrectomy reported difficult recipient surgery due to short and thin renal vein resulting in graft throm­bosis. [2],[3] Several methods like graft retrieval through subcostal incision, [2] use of stapler de­vice, [4],[5],[6] and laparoscopic Satinsky clamp, [7] have been explored to achieve an acceptable graft outcome. We here by share our early expe­rience at the Institute of Kidney Diseases and Research Center, Ahmedabad, India, of right donor nephrectomy performed by both terminal subcostal open approach (initial cases) and pure laparoscopic approach with use of Endo TA stapler device.


   Patients and Methods Top


Nine laparoscopic right donor nephrectomies were performed by transperitoneal approach at our center from January 2006 to March 2007. All donors were either first degree relatives or spouse. The right kidney was selected due to the presence of multiple renal vessels on the opposite side. In the first five cases, the grafts were retrieved through a subcostal incision (Group A) and the last four cases were perfor­med pure laparoscopically by using Endo TA stapler device (30 mm with 2.5 mm staples, Au­to suture US surgical Norwalk CT) (Group B).

Operative steps

The pneumopeitoneum was established using a Veress needle; 10 mm trocar was placed above the umbilicus in the right para rectus line. Two additional working ports, one 10 mm at right subcostal and one 5 mm in right iliac region were kept. After reflecting the ascen­ding colon medially, the ureter-gonadal vein complex was dissected and followed cranially. At this time, an additional five mm port was kept in the epigastrium in the midline to retract the liver superiorly. The renal vein was iden­tified and the inferior vena cava above was adequately exposed. The renal artery was di­ssected and made free from all adjacent fibro­fatty tissue. The kidney was mobilized all around and dropped medially for adequate and complete dissection of renal artery and renal vein posteriorly.

Open subcostal approach (Group A)

The ureter was divided after distal clipping and free efflux of urine was ensured. A six cm subcostal incision was made incorporating the superior subcostal 10 mm port. The kidney was held at perirenal fat after which a right angle clamp was placed over the renal artery and a Satinsky clamp was placed over the inferior vena cava. The vessels were cut and the re­trieved kidney was sent for perfusion. The in­ferior vena cava was repaired with 5-0 prolene.

Pure laparoscopic approach (Group B)

After complete mobilization of kidney, a 12 mm port was kept below umbilicus in the line of the camera port. The Endo-TA stapler was introduced and adequate mobilization of the inferior vena cava was confirmed by placing it in position. Intravenous infusion of mannitol 1 mg/kg was started. The Pfennensteil incision for graft retrieval was made. The renal artery was secured with two Hem-o-lock clips pro­ximally and cut. Endo TA stapler device was now introduced and placed at the confluence of renal vein and inferior vena cava [Figure 1]. Keeping mild traction over lower pole of the kidney, to keep the renal vein straight and stre­tched, the stapler device was fired. The renal vein was then cut close to the staple line [Figure 2]. The graft was retrieved and sent for perfusion [Figure 3].


   Results Top


None of the patients needed open conversion. The mean operative time and hospital stay were comparable in both groups [Table 1]. In Group A, one patient needed blood transfusion intra-operatively due to slipped Satinsky clamp from inferior vena cava during graft retrieval. No intra-operative complications were noted in Group B patients. Although the warm ische­mia time was longer in Group B (415 seconds) than Group A patients (176 seconds), the se­rum creatinine of the recipients on day seven was comparable in both the groups. The recipient surgery was effectively performed with graft retrieved using Endo TA stapler device (Group B) without any compromise to the renal vein length [Figure 4],[Figure 5].


   Discussion Top


In right laparoscopic donor nephrectomy, the length of the renal vessel has always been a major concern, as the open approach facilitates removal of the inferior vena cava cuff along with the graft. Several technical modifications have been made in an attempt to overcome this issue.

The John Hopkins group, [2] suggested termi­nal subcostal open approach for the renal vein shorter than three cm in length. A conventional Satinsky clamp is placed across the vena cava, the vein was divided along with inferior vena cava cuff, and the cavatomy was repaired through this incision. Nevertheless, this semi­open approach does compromise the merits of total laparoscopic approach. Sometimes, it may be cumbersome to control the vascular pedicle, particularly if the incision does not correspond to the exact level of the vascular pedicle. We faced similar problem in one of our cases, where the Satinsky clamp slipped from the in­ferior vena cava and the patient needed blood transfusion intra-operatively.

The Cleveland Clinic group, [4] used the retro­peritoneoscopic approach for right donor ne­phrectomy. This group proposed the modified use of articulating Endo GIA stapler by placing it in the right lower quadrant, in an effort to maximize the renal vein length. They observed that, in this position, Endo GIA stapler could be placed over the renal vein, flush with the vena cava. We also kept the stapler port in the right lower quadrant as this provides an easy and effective application of the device over vena cava. From India, Modi et al [6] have used Endo TA stapler for the retro-peritoneoscopic donor nephrectomy and they found the device effective in obtaining a good vascular cuff of the inferior vena cava.

Turk et al, [7] used the modified laparoscopic Satinskty clamp to harvest the graft along with a caval cuff pure laparoscopically. The graft re­trieval was followed by intra-corporeal suturing of cavatomy. However, in our opinion this tech­nique carries a significant risk of vascular ca­tastrophe and also, the technique is difficult to be reproduced by other laparoscopic surgeons.

Recently, Harrison M. et al [5] have described a modified technique to use Endo TA stapler for pure laparoscopic right donor nephrectomy. Our technique is similar to theirs. We found good mobilization of the vena cava above and below the renal vein along with posterior mo­bilization of renal artery and renal vein, a very vital step. This mobilization helps in lifting the kidney upward, and makes confluence of renal vein stretched and straight, while applying the stapler device.

In our experience of nine trans-peritoneal do­nor nephrectomies, the recipient outcome was similar with both the approaches of graft re­trieval. The long warm ischemia time of 415 seconds with pure laparoscopic approach had no adverse effect on recipient outcome and was comparable to other published data. The donor outcome in respect to operative time and hos­pital stay were also comparable.


   Conclusion Top


This small study presents our early experience of trans-peritoneal right donor nephrectomy through a terminal subcostal and by pure lapa­roscopic approach. We found the EndoTA sta­pler device safe and effective to perform pure laparoscopic right donor nephrectomy.

 
   References Top

1.Ratner LE, Cisek LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995;60: 1047-9.  Back to cited text no. 1      
2.Mandel AK, Cohen C, Montgomery RA, Ka­voussi LR, Ratner LE. Should the indication of the right kidney be the same as for the open procedure: Anomalous left renal vasculature is not a contraindication to laparoscopic donor nephrectomy. Transplantation 2001;71:600-64.  Back to cited text no. 2      
3.Ratner LE, Kavoussi LR, Chavin KD, Mont­gomery R. Laparoscopic live donor nephrec­tomy: Technical consideration and allograft vas­cular length. Transplantation 1998;65:1657-8.  Back to cited text no. 3      
4.Gill IS, Uzzo R, Hobart MG, et al. Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and auto­transplantation. J Urol 2000;644:1500.  Back to cited text no. 4      
5.Harrison M, Abrahams MD, Maxwell V, et al. Pure laparoscopic right donor nephrectomy: Step-by-step approach. J Endourol 2004;18: 221-5.  Back to cited text no. 5      
6.Modi P, Kadam G, Devra A. Obtaining cuff of inferior vena cava by use of the Endo-TA stapler in retroperitoneoscopic right-side donor nephrectomy. Urology 2007;69(5):832-4.  Back to cited text no. 6      
7.Turke IA, Deger S, Davis JW, et al. Laparos­copic live donor right nephrectomy: A new technique with preservation of vascular length. J Urol 2002;167:630.  Back to cited text no. 7      

Top
Correspondence Address:
Shailesh A Shah
1st Floor, Harikrupa Towers, B/H Gujarat College, Nr Govt. Ladies Hostel, Ahmedabad - 380006
India
Login to access the Email id


PMID: 20427862

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]

This article has been cited by
1 Comparison of the right and left laparoscopic live donor nephrectomies: A clinical case load
Gures, N. and Gurluler, E. and Berber, I. and Karayagiz, A.H. and Kemik, O. and Sumer, A. and Cakir, U. and Gurkan, A.
European Review for Medical and Pharmacological Sciences. 2013; 17(10): 1389-1394
[Pubmed]
2 Renal vein lengthening using gonadal vein reduces surgical difficulty in living-donor kidney transplantation
Feng, J.-Y. and Huang, C.-B. and Fan, M.-Q. and Wang, P.-X. and Xiao, Y. and Zhang, G.-F.
World Journal of Surgery. 2012; 36(2): 468-472
[Pubmed]



 

Top
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusion
    References
    Article Figures
    Article Tables
 

 Article Access Statistics
    Viewed2574    
    Printed101    
    Emailed0    
    PDF Downloaded686    
    Comments [Add]    
    Cited by others 2    

Recommend this journal