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Keywords:

  • Kidney;
  • laparoscopy;
  • recipient surgery;
  • transplantation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anastomosis was 65 (range 62–72) min, mean operative time was 3.97 (range 3.5–5) h, mean blood loss was 131.25 mL (range 45–350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.


Abbreviations: 
LKT

laparoscopic kidney transplantation

OKT

Open kidney transplantation

LDN

Laparoscopic donor nephrectomy

ODN

Open donor nephrectomy

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

Laparoscopic donor nephrectomy (LDN) was performed first time in 1995 (1). Since then many centers have adopted LDN as the standard of care. In comparison to open donor nephrectomy (ODN), LDN has advantages of less pain, early ambulation, better cosmesis and rapid convalescence (2–6). Despite the physiological changes that occur due to pneumoperitoneum, early and late outcome of renal allograft transplantation have not shown significant difference between ODN and LDN groups (7). The advantages to the donor are clearly due to small size of wound and location of wound in the lower abdomen.

Until now, the recipient has always undergone open surgery for transplantation. Type and length of wound is variable but most commonly, a modified Gibson's incision is made in lower abdomen for kidney transplantation. Risk factors for wound complications are well defined in general surgery literature (8). Kidney recipients have several additional risk factors, most notably immunosupression. To minimize wound related problems and morbidity in recipients, we aimed to evaluate feasibility and safety of laparoscopic kidney transplantation (LKT).

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

With the permission of Internal Review Board of the Institution in January 2010, four patients underwent LKT by a surgeon who has extensive experience of LDN and also laparoscopic suturing technique including laparoscopic ureteral reimplantation. Permission for LKT was given only for kidneys available from deceased donors. Left kidney was used for permission of Internal Review Board of the Institution in January 2010, four patients underwent LKT by a surgeon who has extensive experience of LDN and also laparoscopic suturing LKT and right kidney was used for OKT in other four recipients. All left kidneys were transplanted in left iliac fossa while right kidneys transplanted in right iliac fossa. LKT procedure was carried out in the following way.

All allografts had single renal artery and vein. Histidine—tryptophane–ketoglucarate solution was used for perfusion and cold preservation of the kidney.

Procedure for LKT

General anesthesia was given to the recipient. Patient was placed in supine position with both hands secured on the side of the patient close to the body. A central venous line was secured in the neck. Pneumoperitoneum was created by inserting Veere's needle through umbilicus and three ports were placed in right mid clavicular line in lower abdomen and a fourth port was placed at the umbilicus (Figure 1). Patient now was positioned in 20° Trendlenberg position. Peritoneum over the left external iliac vessels was incised and incision was extended up to mobilize lower part of left colon. Dissection of both external iliac artery and vein was performed and lymphatics were sealed by Force Triad® vessel sealing system. External iliac vessels were dissected as distally as possible to have maximum length available for vascular anastomosis. Two vessel loops were used to occlude the external iliac vein proximally and distally and a pair of endoshears was used to make the venotomy. Venotomy was extended for appropriate length and its lumen was irrigated by normal saline.

image

Figure 1. Port placement. Umbilical port was used for retraction of bowel while three lateral ports on the other sides were used for vascular anastomosis. For ureteral reimplantation, laparoscope was shifted to the upper lateral port.

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A 7 cm incision in the skin crease was made in the iliac fossa of the recipient. External oblique aponeurosis fibers were incised. Attachments of internal oblique and transversus abdominis muscle at the lateral border of rectus sheath were divided. Transversalis fascia was opened and renal allograft was placed into the peritoneal cavity. The wound was closed rapidly and pneumoperitoneum was reestablished.

The kidney was positioned appropriately close to the left external iliac vessels and, renal vein anastomosis with previously opened external iliac vein was carried out in end to side fashion. The first stitch in both veins was placed at the distal angle and knot was tied. No suture was placed at the proximal ends. Continuous running sutures were placed on the veins till the proximal angle and the needle was parked on the fascia of psoas major muscle. A new suture was inserted and anastomosis was started again at the distal end with new knots. Continuous running sutures were carried out till the proximal end. Both threads were tied at the proximal end of veins to complete the anastomosis. External iliac artery was similarly occluded and arteriotomy was performed by indigenously prepared knife (9). The wall of artery was trimmed to have an appropriate size hole for anastomosis of Carrel's patch. A 5/0 polypropylene suture was used for both arterial and venous anastomosis (Figure 2A,B). After anastomosis were tested and no leak was found, graft was allowed to perfuse. Pnemoperitoneum pressure was reduced to 8 mm Hg for better perfusion of the renal allograft.

image

Figure 2. (A) Renal vein (RV) anastomosed to external iliac vein (EV) in end to side fashion.

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image

Figure 2. (B) Renal artery (RA) with Carrel's patch anastomosed to external iliac artery (EIA) in end to side fashion. Note use of vessel loop and hem o lok clip to control EIA.

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Ureteroneocystostomy was performed by modified Lich-Gregoir method. In brief, bladder was made partially full and an incision in posterior bladder wall was made and peritoneum and detrusor muscle were divided. Mucosa was dissected and a small rent was created at the apex of the mucosa. Bladder mucosa was anastomosed to full thickness of wall of ureter by interrupted stitches of 4/0 polyglactin without using stents. Detrusor muscle was sutured over the ureter using the same suture material. The kidney was lifted and placed in the left iliac fossa over the psoas muscle and previously opened peritoneum was closed in part to keep the kidney in extraperitoneal position. A drain tube (Valleylab,Tyco Healthcare, Gosport, UK) was placed through lower most 5 mm size port and abdomen was deflated. Ports were removed and wounds closed.

Surgical technique of OKT: A 15–20 cm long incision was placed through skin and muscular layers for wide exposure of external iliac vessels. Extension of right renal vein was performed from inferior vena cava during bench surgery. Right kidney vessels were anastomosed in end to side fashion as described above. Ureteroneocystostomy was done by Lich's technique.

Postoperatively, patient was monitored in intensive care unit for 1 day. Drain tube was removed on 2nd or 3rd postoperative day and Foley catheter was removed on 7th postoperative day. Both gray scale ultrasonograpy and color doppler study was performed on 1st day of transplantation and thereafter as and when needed.

Immunosuppressant regimen used included tacrolimus, mycofenolate mofetil and prednisolone. The primary end point was completion of vascular anastomosis and ureteral reimplantation and secondary end point was to observe creatinine clearance.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

Donor and recipient demographic data and operative parameters are shown in Table 1. All were expanded criteria donors and two had raised serum creatinine value at the time of procurement of kidneys. However, their serum creatinine value at the time of admission to the intensive care unit was within normal limits.

Table 1.  Demography of donors and recipients and intraoperative data
NoDonorRecipient
Age/sexS. Creatinine (mg/dL) at time of procurementAge/Sex/BMI (Kg/m2)Cold Ischemia time (hours)Anastomosis time (minutes)Operation time (hours)Estimated blood loss (mL)
LKTBMIOKTBMILKTOKTLKTOKTLKTOKTLKTOKT
165/M2.448/M18.652/M21.51413724052.535040
262/F1.231/M20.426/M23.84460363.52.410080
365/M1.925/M21.321/F19.94.2462303.52.53080
465/M1.245/M22.417/F20.311.510.566383.92.845100

LKT was carried out in left iliac fossa. It was 2nd kidney transplantation for two recipients. Mean operative time was 3.97 (range 3.5–5) h, and mean blood loss was 131.25 mL (range 45–350) mL. Figure 3 shows comparison of the outcome in terms of serum creatinine value recipients of LKT and OKT from the same donors. Mean length of wound was 7 cm in laparoscopic group and 18.4 cm in open surgery group. The mean cumulative length of all incisions was 11 cm in LKT group. Delayed graft function was defined as need for dialysis in 1st week of transplantation. One recipient had delayed graft function both in laparoscopy and open surgery groups; both received a kidney from a deceased donor having serum creatinine value of 2.4 mg/dL at the time of procurement of kidney (donor no. 1). One recipient (patient no. 3) in the open surgery group died on 28th postoperative day due to bacterial meningitis with a functioning renal allograft. No patient had rejection at 6 months of follow up. However, both recipients who received kidney from 1st deceased donor are having slow rise in serum creatinine value.

image

Figure 3. Graph showing serum creatinine value up to 6 months of all recipients in both groups.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

Laparoscopic suturing techniques have been described for various urological and vascular surgeries. Vascular injury during laparoscopic ablative surgery are often managed by intracorporeal suturing without conversion to open surgery (10–13). Feasibility of laparoscopic vascular reconstructive surgeries like repair of abdominal aortic aneurysm and renal artery aneurysms have been described more recently (14–16). Such experience clearly underscores laparoscopy as an attempt to reduce the wound related morbidity for urological and vascular surgery.

In kidney transplantation an incision is usually required to place the allograft either extraperitoneally or transperitoneally. At our institution, incision for kidney transplantation is usually 16–20 cm long. Feasibility and safety of kidney transplantation through 7 cm size incision is described (17). However smaller size incision requires excessive retraction of the wound which causes bruising and trauma to the muscles. Further, in patients with high body mass index it is difficult to visualize pelvic vessels despite having maximum retraction which makes dissection and vascular anastomosis cumbersome. Prolonged and excessive retraction causing damage to femoral nerve, injury to muscles and drying of the wound may cause wound related problems especially in obese recipients. In fact, LKT would be a boon to the patients with high BMI since an incision just to insert the renal graft need to be placed. Additional port placement may be required but that is still a better bargain than a larger incision for OKT. Compared to mini-incision ODN, LDN has a distinct advantage in terms of analgesic drug requirement and overall recovery (18). At present, studies related to comparison between laparoscopic and mini-incision open kidney transplantation are not available.

Ligation or clipping of lymphatics around the external iliac vessels is a standard practice for kidney transplantation surgery to avoid perigraft lymph collection in postoperative period. Recent reports in experimental animals have shown the effectiveness of LigaSure® vessel sealing system to occlude major lymphatics (19). We have used Force Triad®, an advanced version of LigaSure® (Valleylab), to seal lymphatics around the external iliac vessels. We did not find any postoperative perigraft collection.

We do not routinely use ureteric stents during OKT. Technique of ureteroneocystostomy in LKT was similar to that used in open transplant and hence we did not use stents. The ureter was handled by a stay suture at its end to avoid direct grasping the ureter by laparoscopic instruments and thereby avoiding trauma to its wall.

Recently case reports of LKT and robotic kidney transplantation have been published (20,21). In our technique there are some differences in selection of donor, method of vascular control during anastomosis and port placement. Vessel control was performed by laparoscopic bulldog clamps in previously described cases. We have used vessel loops and hem o lok clips to control the vessels (22). We believe that suture material may get entangled with bulldog clamps during procedure of anastomosis and create surgical nuisance. Further, a gel port was used in previous report of LKT (20). We believe that time to place gel port and time to suture a small wound would not be significantly different. Further, gel port at wound site would of no help except in the emergency situation when rapid exploration is require. Gel port just to maintain pneumoperitoneum is an expensive affair without much benefit.

Placement of left kidney on left side of recipient gives more anatomical orientation of renal graft blood vessels. The renal vein remains medially and the artery on lateral side, giving better orientation of the position of vessels during anastomosis. We believe this position helps avoiding kinking or torsion of vessels. Since it was our initial experience, we deliberately did not select right kidney with reconstructed renal vein from inferior vena cava. Multiple suture lines may leak and gives additional problem of bleeding intraoperatively. Our first patient had bleeding from the surface of the kidney since we removed all the fat from it; careful use of electrocautery on the surface of the kidney help in controlling the bleeding. Subsequently, careful preparation of the kidney on the bench was performed which has helped in reducing the blood loss.

We had opportunity to compare outcome of LKT and kidneys from same deceased donor used for conventional open surgery kidney transplantation. Time of vascular suturing, operative time and blood loss were more in LKT group than in open kidney transplant group. Clearly, more refinement in technique and skill of vascular suturing is required. However, at 1 month and 6 months follow up, serum creatinine values in both groups were comparable.

In conclusion, laparoscopic kidney transplantation is technically feasible and safe. Larger studies comparing open and laparoscopic kidney transplantation are required to assess long term outcome and benefit of this new procedure.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References

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

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Disclosure
  9. References