Portal de Periódicos da CAPES

LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: TECHNICAL CONSIDERATIONS AND ALLOGRAFT VASCULAR LENGTH

1998; Wolters Kluwer; Volume: 65; Issue: 12 Linguagem: Inglês

10.1097/00007890-199806270-00021

1534-6080

Lloyd E. Ratner, Louis R. Kavoussi, Kenneth D. Chavin, Robert A. Montgomery,

Organ Transplantation Techniques and Outcomes

In their Brief Communication in the September 15, 1997, issue of Transplantation, Kuo et al. (1) describe a technique for the management of renal allografts with multiple short renal arteries. However, the authors give the false impression that the laparoscopic live donor nephrectomy operation has a propensity to result in an allograft with suboptimal arterial length. This has not been our experience. Laparoscopic live donor nephrectomy was designed to yield a kidney that enabled the recipient operation to be performed utilizing standard techniques(2). Laparoscopic live donor nephrectomy was only first attempted in humans after Gill et al. (3) demonstrated in a porcine model that adequate vascular length could be obtained on a consistent basis. In our series of more than 70 laparoscopic live donor nephrectomies, including 9 cases with multiple renal arteries, renal arterial length has not been problematic. Mean renal arterial lengths (±SD) for single right renal arteries, single left renal arteries, and multiple renal arteries have been 3.0±0.7 cm, 3.3±0.7 cm, and 3.5±0.9 cm (P=NS), respectively. Unlike that described by Kuo et al.(1), in no case was a problematic renal arterial length of ∼1 cm encountered. In all cases with multiple renal arteries, the arteries were spatulated and anastomosed to one another in a side-to-side fashion, creating a single common orifice. With this back-table technique, adequate arterial length was preserved in all cases, and use of saphenous vein grafts was not necessary. Obtaining sufficient vascular length with the laparoscopic live donor operation requires attention to several technical details. First, proximal dissection of the renal arteries should be completely to their origin at the aorta. Second, the kidney should be gently retracted anterolaterally while stapling or dividing the renal arteries. Third, renal arteries should be stapled individually unless their origins are in extreme proximity to one another. In our experience, reloading the endo-GIA stapler to accomplish this takes ∼30 sec and does not substantially contribute to the warm ischemic time. Retraction of the kidney and positioning of the stapler should be"rehearsed" before the vessels are divided so that optimal conditions for obtaining maximal vascular length can be determined. If these principles are adhered to, adequate vascular length will be obtained consistently when the left kidney is removed laparoscopically. Also, Kuo et al. (1) seem to imply that the laparoscopic donor operation be limited to the "exclusive removal of the left kidney." This is also misleading. Laparoscopic live donor nephrectomy can be performed on the right side with the following caveats. First, the right-sided operation is technically more difficult because retraction of the liver is usually required. Second, and most important, venous length is problematic. Application of the endo-GIA stapler to the right renal vein results in loss of approximately 1.0-1.5 cm of vein when compared with the open operation. Additionally, in our series of laparoscopic live donor nephrectomies, right and left renal vein lengths have averaged (±SD) 2.5±0.7 cm and 4.7±1.0 cm, respectively (P<0.001). A short, thin right renal vein can make the recipient operation difficult. We have experienced allograft renal vein thrombosis and recipient external iliac vein thrombosis in the peritransplant period with this scenario. Therefore, we advocate extreme caution when using the laparoscopic operation on the right side. In general, when employing the laparoscopic approach, multiple left renal arteries are less problematic than a right kidney. If a right-sided operation is planned, either three-dimensional computed tomography (3-D CT) scanning or magnetic resonance angiography should be performed preoperatively to fully assess the venous anatomy. We have found 3-D CT to be particularly useful in identifying venous anomalies and multiple renal veins. Also, we recommended that the laparoscopic operation be modified. Rather than employing an infra- or periumbilical incision for extraction of the kidney, a small (6-8 cm) right upper quadrant transverse incision can be used. This allows for complete dissection of the kidney laparoscopically, avoids a flank incision, and enables the renal vessels to be divided in a similar fashion to the open operation. A Satinsky clamp can be placed across the inferior vena cava to allow for maximal venous length to be obtained. This approach promises to offer the advantages of both the laparoscopic and the open operations. Lloyd E. Ratner Louis R. Kavoussi Kenneth D. Chavin Robert Montgomery Department of Surgery; Johns Hopkins Medical Institutions; Baltimore, Maryland 21287-8611