Year : 2010 | Volume
: 21 | Issue : 3 | Page : 421--425
Laparoscopic right donor nephrectomy: Endo TA stapler is safe and effective
Amit K Devra, Suhag Patel, Shailesh A Shah
Institute of Kidney Diseases and Research Centre, Ahmedabad, India
Shailesh A Shah
1st Floor, Harikrupa Towers, B/H Gujarat College, Nr Govt. Ladies Hostel, Ahmedabad - 380006
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;21:421-425
|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 Aug 20 ];21:421-425
Available from: http://www.sjkdt.org/text.asp?2010/21/3/421/62697
Since the introduction of laparoscopic donor nephrectomy clinically in 1995, , 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. , Several methods like graft retrieval through subcostal incision,  use of stapler device, ,, and laparoscopic Satinsky clamp,  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
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).
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].
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].
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,  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,  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  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,  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  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.
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.
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