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In 1951 René Kuss performed an unrelated living donor kidney transplant using for the first time an retroperitoneal approach to expose in the iliac fossa the iliac vessels and the bladder (1). Although his initial five cases all failed secondary to acute rejection, in 1954 Murray used his technique to perform the first successful living donor kidney transplant using an identical twin as the donor (2). This technique is still commonly used in clinical kidney transplantation, virtually unchanged despite 60 years of spectacular progress in other areas of solid organ transplantation. The technique allows easy access to the target vessels and the bladder without violating the peritoneal cavity, allows continuation of peritoneal dialysis if necessary and easy access to the graft for percutaneous biopsy, localizes urinary leaks and infection outside the peritoneal cavity and it is very well tolerated in terms of postoperative pain. It is clearly very hard to improve on such a safe and efficient procedure, and very few attempts have been made to modify it over the years.

The last 20 years have witnessed a widespread application of minimally invasive surgical techniques in all fields. In kidney transplantation the most influential contribution has been the development of laparoscopic donor nephrectomy, pioneered by Ratner in 1995 and now widely considered the procedure of choice in living donor kidney transplantation. However, until recently laparoscopic kidney transplantation has not been attempted.

‘Minimally invasive’ techniques, however, have been proposed to minimize the length of incision; several groups have been able to perform kidney transplantation through 6–7 cm lower quadrant incisions (3). In these cases, the vascular anastomosis and the uretero-neocystostomy have been performed conventionally, and the only claim to ‘minimally invasive’ is basically the reduced length of the wound. Of course these techniques are commonly applied in recipients of ideal body weight.

More recently, in 2010, a case report of laparoscopic kidney transplantation from Spain was published, and in the past several months, a technique for transabdominal fully robotic kidney transplantation in obese recipients was reported by a US center (4).

The small series of laparoscopic kidney transplants published by Modi et al. in this issue of AJT confirms the technical feasibility of a fully laparoscopic approach to complete all the steps of the standard kidney transplant procedure in the hands of experienced laparoscopic surgeons (5). Once the technical feasibility has been demonstrated, the next step is of course to identify the potential advantages of the laparoscopic or robotic approach over the standard open procedure. The main advantage proposed by the authors is the reduction in the overall length of the incision, even calculating the additional incisions at the trocar sites.

Although the body weight of the four recipients is not specified in the text, their figure clearly illustrates a very lean recipient. In this patient population, a superior result in term of overall length of the incision could be achieved using the minimally invasive technique cited above, which allows positioning of the graft in a preformed retroperitoneal pouch and direct vascular and ureteral anastomosis through a 6–7 cm incision, avoiding the trocar incisions. Furthermore, this technique preserves the ability of clamping the vessels and performing the anastomosis in the standard fashion, with the potential reduction of laparoscopic-related expenses and operative time. Indeed, given the simplicity of open techniques and the relatively low degree of postoperative pain and the maintenance of an intact peritoneum (which can also reduce postoperative pain), some might question the appropriateness altogether of laparoscopic approaches.

Fully laparoscopic or robotic techniques for kidney transplantation may have a great potential in the setting of morbidly obese patients. A recent article from Lynch et al. has clearly shown that obesity per se is not a risk factor for graft failure after kidney transplantation (6). In fact, obese individuals who did not develop surgical site infections (SSI) did as well as nonobese recipients. Unfortunately, obese recipients have much higher SSI rates and therefore did worse as a group. The authors concluded that their findings demonstrate the importance of avoiding SSI following renal transplantation.

Thus, the patients who might benefit the most from laparoscopic or robotic kidney transplantation are the morbid obese with high risk for SSI. Ideally, the site of the incision used to introduce the kidney in the abdominal cavity should be remote from the lower abdomen where the subcutaneous fat is invariably thicker.

While Modi et al. have demonstrated reasonable outcomes and proof of principle using laparoscopic techniques in their series, this may not necessarily represent an advance. On the other hand, for obese candidates, robotic or laparoscopic technology may offer some technical advantages in the execution of the vascular and urological anastomoses and in the reduction of postoperative morbidity. It remains to be seen whether laparoscopic approaches will offer significant advantages for the majority of transplant recipients.

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The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References

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