Portal de Periódicos da CAPES

Comparison of transperitoneal and retroperitoneal laparoscopic living donor nephrectomy

2007; Lippincott Williams & Wilkins; Volume: 120; Issue: 24 Linguagem: Inglês

10.1097/00029330-200712020-00031

2542-5641

Zhenli Gao, Jitao Wu, Yujie Liu, Chunhua Lin, Lin Wang, Lei Shi, Changping Men, Peng Zhang, Diandong Yang, Ke Wang,

Ureteral procedures and complications

Since its introduction in 1995, laparoscopic living donor nephrectomy (LDN) has been shown to alleviate postoperative pain, shorten hospital stay, reduce loss and improve cosmesis while hastening the recovery of normal activities of donors.1-3 However, there has been much controversy over minimally invasive surgery with transperitoneal or retroperitoneal approach for nephrectomy. In this non-randomized retrospective study, we analyzed some parameters of the donors who had undergone transperitoneal LDN compared with those who had had retroperitoneoscopic nephrectomy. METHODS Patients In this study, we evaluated 47 donors undergone laparoscopic LDN with transperitoneal (n=19) or retroperitoneal (n=28) approach for renal transplantation from February 2005 to April 2007. All donors were examined preoperatively by helical computed tomography (CT), arteriography with three-dimensional reconstruction, and isotope nephrography. Surgical techniques Retroperitoneoscopic donor right nephrectomy is similar to the left.4 Briefly, the donor was placed in a lateral decubitus position. Four retroperitoneoscopic ports were inserted in a retroperitoneal space made by a self-made dilation balloon. After the isolation of the kidney, a 7 cm skin incision was made along the axillary line. The renal artery and vein were controlled manually and ligated by Hem-o-lock clips. Then the kidney was swiftly removed from the incision. Laprascopic operation was performed transperitoneally on the opposite side in a 70° lateral decubital position to that of nephrectomy. The port A was established with a 10-mm trocar on the midpoint of the line between the umbilicus and the crest of the ilium. A pneumoperitoneum was then established and electronically maintained at a pressure of 12-14 mmHg. After the placement of an observation scope through port A, port B (medioclavicular line maintained under the 12 rib), port C (medioclavicular line at the level of the umbilicus) and port D (anterior axillary line under the 12 rib) were established (Fig. 1). The Gerota's fascia was opened and the kidney was identified. The perirenal fat tissue was dissected, and the renal vein was carefully mobilized to its origin with the vena cava. Gonadal, adrenal, and lumbar veins were ligated and transected. The renal artery was then exposed at its origin. Finally the fatty renal capsule was opened, and the kidney isolated. The ureter with adequate periureteral tissue was clipped and cut at the level of the iliac vessels. Before the transection of renal vessels, an incision was made to split the muscle but keep the peritoneum intact. The renal artery and vein were ligated by Hem-o-lock clips and then cut distally with a pair of laparaoscopic scissors. The peritoneum was opened and a dominant hand was placed through the incision on the iliac region to retrieve the kidney. The time of warm ischemic was measured from the placement of the first clip on the renal artery to the kidney in ice slush.Fig. 1.: Patient position and port placement for transperitoneal laparoscopic living donor nephrectomy.Investigative items The parameters of the donors in the transperitoneal and retroperitoneal groups included operative time, blood loss, warm ischemic time and hospital stay. The levels of serum creatinine of the recipients were measured at fixed intervals. Statistical analysis Differences between the two groups were evaluated using the SPSS 10.0 statistical software. Student's t test was used to compare continuous variables of the two groups. Categorical data were compared using the chi-square test. A P 0.05 for all values.DISCUSSION Renal transplantation from a live donor is a chronic of the treatments of choice for chronic renal failure. Laparoscopic LDN has been accepted in the transplantation because it is considered to be less invasive than open live donor nephrectomy. Long-term followup revealed no significant difference in recipient graft function and allograft survival after laprascopic donor and open donor nephrectomy.1,2 Laparoscopic LDN has been a standard surgery at many transplant centers. The retroperitoneoscopic technique is inferior to the transperitoneal approach in the establishment of topography, a smaller working space and a probably steeper learning curve. Few centers reported a large number of retroperitoneoscopic LDNs.5 In our study, the operative time and warm ischemic time with the transperitoneal approach were significantly shorter than those with the retroperitoneal approach. The hospital stay, blood loss and donor serum creatinine at discharge were not significantly different from those reported elsewhere.6 The longer warm ischemic time with the retroperitoneal approach was primarily due to the time for additional dissection required to mobilize the kidney from the peritoneum anteromedially after hilar transection. Sometimes the kidney cannot be removed from the retroperitoneum qiuckly because of thick muscle split incision on the waist. LDN by the transperitoneal approach is difficult to carry out because of enteric trauma and celiac infection.6,7 We did the transperitoneal operation in a 70° lateral decubital position, by which the colon may drop to the opposite side that can avoid the interference and trauma to the intestinal canal. We observed the operative area from various directions with a 30° laparoscope, thus preventing intestinal obstruction from wall edema caused by the friction of sight glass. Hand-assisted laparoscopic technique is optional for donor nephrectomy. Ruiz-Deya et al2 found the hand assisted laparoscopic surgery was more advantageous than the pure laparoscopic surgery which was characterized by longer incision, slower recovery of bowel function and longer hospital stay. But the expensive hand-assistant devices indicate the increase of patients' economic burden. Laparoscopic donor nephrectomy procedures were initially limited to the left side kidney owing to technical difficulties and renal vessel length. The right transperitoneal or retroperitoneal LDN using various techniques showed a rate of graft loss ranged from 0 to 6%.8 Technical difficulties of the right transperitoneal LDN are primarily due to the markedly different right-sided intra-abdominal and renal anatomy in contrast to the left side. A dedicated port is required for anterior retraction of the liver. The duodenum must be recognized and mobilized to expose the inferior vena cava adequately. More importantly, the short right renal vein usually covers the renal artery that is located posteriorly to it. Thus dissection of the right renal artery typically entails considerable traction on both the vein and the artery, causing technical difficulty and the potential for vasospasm. Shokeir et al9 suggested that the kidney with less function be chosen for donor nephrectomy regardless of anatomical considerations. In our hospital, the choice of the kidney to be used for donation is dependent on the functional and anatomical basis. In conclusion, laparoscopic LDN is a safe, feasible and effective procedure. Transperitoneal LDN offers a shorter operative time and a warm ischemic time compared with retroperitoneal operations with improved techniques.