Donor Nephrectomy: Laparoscopic Techniques

JIM C. HU

ERIC G. TREAT

According to the National Institute of Diabetes and Digestive and Kidney Diseases, more than 871,000 people were being treated for end-stage renal disease, with 398,861 having some form of dialysis and 172,553 having a working transplanted kidney at the end of 2009 (1). The Scientific Registry of Transplant Recipients (SRTR) reported 16,811 kidney transplants were performed in 2011; 5,768 were from living donors (2).

Laparoscopic donor nephrectomy was first performed in 1995 (3). The generally accepted benefit of decreased hospital stay and postoperative pain associated with laparoscopic versus open donor nephrectomy may facilitate the acceptance of a unique surgery that leaves the patient in worse health postoperatively.

DIAGNOSIS

Strict guidelines and international standards have established that all donors have complete medical and psychosocial evaluation as well as evaluation by an independent donor advocate (4,5,6). At our institution, patients routinely see a nephrologist, surgeon, psychiatrist, and social worker. Medical evaluation includes a complete history and physical: urine tests: urinalysis, urine culture, 24-hour urinary protein excretion, and glomerular filtration test estimates; blood tests: complete blood count, coagulation screen (partial thromboplastin time, prothrombin time), serum electrolytes, urea, creatinine, liver function tests, fasting serum glucose, glucose tolerance test, lipid panel, and alkaline phosphatase; serology testing: HIV, hepatitis B and C, tuberculosis, syphilis, Epstein-Barr virus, and cytomegalovirus; compatibility testing: blood group type, human leukocyte antigen typing, and cross-matching; cardiopulmonary workup: chest X-ray and electrocardiogram. Other testing is performed as indicated. Every screened donor eventually has a multidetector computerized tomographic angiography/urography with reconstructions for evaluation of the kidneys and vascular anatomy. Any questionable findings on medical, surgical, and psychosocial evaluation are discussed in a multidisciplinary committee prior to proceeding with donation.

INDICATIONS FOR SURGERY

Healthy patients aged older than 18 years are eligible for donation. Medical contraindications to kidney donation are summarized in Table 5.1 (7). The decision-making process may be quite complex and multifactorial.

Relative surgical contraindications to transperitoneal laparoscopic donor nephrectomy include prior abdominal surgery (reoperative abdomen), intraperitoneal mesh, and other general contraindications to transperitoneal laparoscopy; however, most of these (e.g., peritonitis, cirrhosis, bowel obstruction) would have excluded the potential donor from donating based on medical evaluation alone.

Donor renal vascular and urologic anatomy is important in determining which kidney (left or right) to remove. Leaving the donor with the optimal kidney is the primary indication for choosing a particular side. For example, removing a kidney with a cyst, small cortical scar, or similar defect would be preferred. Typically, transplant surgeons prefer a left kidney due to longer renal vein length. The number of renal arteries and veins should also be considered. Having three or more arteries may lead to increased donor or recipient surgical complications or poorer graft outcomes; however, it is no longer considered an absolute contraindication (8,9). Duplicated ureteral anatomy is not contraindicated unless there is underlying renal deficiency of the associated kidney.

ALTERNATIVE THERAPY

Alternative procedures include hand-assisted laparoscopic, single-site laparoscopic, robotic-assisted laparoscopic, and “mini-incision” open and traditional open flank nephrectomy. Some centers have advocated extracting the kidney through a vaginal incision.

SURGICAL TECHNIQUE

Preparation

The patient undergoes a gentle bowel preparation the day before surgery with a clear liquid diet and a magnesium citrate suspension. All patients receive preoperative antibiotics and sequential compression devices (pulsatile stockings) for prophylaxis. After administration of general anesthesia with the patient in supine position, an orogastric tube to decompress the stomach (helpful for optimal splenic reflection during left laparoscopic donor nephrectomy [LDN]) is placed, abdominal hair is clipped, and Foley urethral catheter is inserted. Additionally, the Pfannenstiel incision is marked in the supine position (lower transverse incision approximately 8 cm in length, 3 cm above the symphysis pubis). Marking the incision site prior to positioning alleviates the distortion of gravity from the patient’s pannus in keeping the incision midline and cosmetically even.

TABLE 5.1 MEDICAL CONTRAINDICATIONS TO KIDNEY DONATION

Absolute Contraindications

Both age younger than 18 years and mentally incapable of making an informed decision

Uncontrollable hypertension or history of hypertension with evidence of end-stage organ damage

HIV

Diabetes

Active malignancy, or incompletely treated malignancy

High suspicion of donor coercion

High suspicion of illegal financial exchange between donor and recipient

Evidence of acute symptomatic infection (until resolved)

Diagnosable psychiatric conditions requiring treatment before donation, including any evidence of suicidality

Relative Contraindications

Hypertension in a Caucasian younger than age 50 years

Hypertension in a Caucasian older than age 50 years on more than one antihypertensive medication

Hypertension in a non-Caucasian at any age

Impaired fasting glucose with other features of the metabolic syndrome (low HDL and high triglycerides) in a <50-year-old

Bleeding disorders

BMI >35

Clinically significant cardiovascular disease

Significant history of thrombosis or embolism

Clinically significant pulmonary disease

Microalbuminuria >30 mg/day, proteinuria (protein in the urine) >300 mg/24 hours, excluding postural proteinuria

Creatinine clearance or isotopic GFR within 1 standard deviations for age and gender

History of cancer, including metastatic

History of nephrolithiasis

Untreated or active substance abuse

Lack of or insufficient family, caregiver, social, and/or economic support

Strained donor/recipient relationship

BMI, body mass index; GFR, glomerular filtration rate; HDL, high-density lipoprotein.

Positioning

The patient is positioned into a modified flank position (modified lateral decubitus). Starting with the patient supine with the contralateral arm abducted 90 degrees onto an arm board, the surgical team rotates the head, shoulders, torso, hips, and legs approximately 75 to 90 degrees perpendicular on the operating table. An axillary role placed just below the axilla relieves undue pressure on the shoulder and helps prevent brachial plexus injury. A back roll (rolled bedsheet) provides support for the lateral positioning. The inferior contralateral leg is flexed 90 degrees at the knee and the superior ipsilateral leg left straight and padded. We place the ipsilateral arm in a neutral position along the lateral torso in an adducted, anatomic position shown in Figure 5.1. To date, no positioning injury, neurapraxias, or complaints have been noted in patients positioned with the arm in this neutral position at our institution. Moreover, this positioning eliminates the need for an airplane, and if immediate open conversion is required, there is adequate space for a subcostal incision. Alternatively, the ipsilateral arm may be extended and abducted, supported by an airplane armrest over the contralateral arm. This position may limit laparoscopic motion range when panning into the pelvis. A moderate amount of table flexion allows for separation of the iliac crest from the lower rib cage. We minimize table flexion because overall it contributes only little benefit to the dissection and exaggerated flexion may lead to back pain postoperatively. Similarly, we do not elevate the kidney rest. Once positioned, 4-inch cloth tape secures the patient to avoid shifting. After prepping and draping, mannitol 12.5 g is administered intravenously.

Left-Sided Laparoscopic Donor Nephrectomy

Insufflation and Initial Trocar Placement

Pneumoperitoneum is obtained using a Veress needle placed midline and 0.5 cm superior to the umbilicus. Alternative sites, such as Palmer point, 3 cm below the middle of the left costal margin, or an open trocar placement technique may be used if there are concerns for significant adhesions from prior surgery.

After achieving 15 mm Hg of CO₂ insufflation pressure, the laparoscopic trocars are placed along the left rectus margin. We use 5-mm trocars, which obviate the need to close the fascia of the trocar sites with Endo Close devices that often snare the rectus muscle and may result donor discomfort. An optical obturator, 5-mm trocar with a 0-degree scope, is advanced under direct vision at the junction of the rectus border and costal margin (approximately 1 cm inferior to rib). This will serve as the camera port throughout the case. In the absence of satisfactory Veress needle placement and insufflation, we use the aforementioned approach for our initial trocar placement cautiously under direct laparoscopic vision, without pneumoperitoneum.

Once visual access to the peritoneal space is gained, we switch to the 30-degree, 5-mm scope and place the next two 5-mm trocars under direct vision. Figure 5.1 demonstrates the standard linear port configuration. The second 5-mm trocar is placed approximately 9 cm inferior to the initial trocar in the same line along the lateral boarder of the rectus muscle. The third 5-mm trocar is placed approximately 9 cm inferior to the second trocar however is slightly more lateral to the rectus margin by 1 to 2 cm to allow for better triangulation and reach to the kidney’s upper pole. This trocar should be positioned in a horizontal plane lateral at approximately the same level as the umbilicus, and if it is too caudad, the range to dissect and reflect the spleen medially may be compromised.

Reflection of Colon and Retroperitoneal Exposure

The surgeon and assistant stand on the patient’s ventral side, the assistant controls the camera and laparoscope through the most cephalad trocar while the surgeon works through the two caudad trocars. Dissection begins with careful inspection of the surrounding anatomy. The stomach needs full decompression with the orogastric tube. A more distended stomach is at greater risk for injury during the lateral dissection of the spleen
for medial reflection. The transverse and descending colon are identified, and commonly, the colon and/or omentum at the splenic flexure tend to be tented or have adhesions to the anterior abdominal wall. These are released using sharp dissection; however, care must be taken not to follow this dissection too laterally, which will result in premature release of the lateral attachments of the kidney and inadvertent incision of Gerota fascia, resulting in loss of countertraction during the medial upper pole and hilar dissection.

FIGURE 5.1 Patient positioning, port configuration, and extraction site incision. The skin incision is transverse, and the deeper fascia incision is midline and vertical.

To gain retroperitoneal exposure, the white line of Toldt is incised approximately 1 cm lateral to the descending colon. In thinner individuals, this is demarcated by the lateral border of the mesenteric fat, which has a more yellowish hue compared to retroperitoneal adipose tissue (Fig. 5.2). The incision is carried caudally to the pelvic brim. Then, moving cephalad over the kidney, care is taken only to incise the peritoneal layer to preserve an anatomic approach and not enter the deeper attachments or Gerota fascia. Inadvertent entry into Gerota fascia over the kidney will obscure the hilar dissection because the fascia (and perinephric fat) will fall medially over the hilum. This incision is carried cranially, 1 cm lateral border of the spleen, well above the kidney. Often the peritoneal tissue overlying the kidney contains vascular supply so we switch to thermal ligation using a LigaSure (Covidien, Norwalk, Connecticut).

Once the peritoneum is incised, a combination of sharp or blunt dissection is used to release the loose attachments and sweep the peritoneum and mesentery medially. Spinning a laparoscopic Kittner medially while maintaining lateral countertraction with a blunt-tip grasper is very effective to avoid an inadvertent peritoneal window. Additionally, arterial pulsations within the mesenteric fat often serve as a landmark to shift the
dissection more laterally. During this maneuver, below the lower pole, the psoas muscle is one of the first structures to be identified lateral to the ureter and gonadal vein and cephalad to the common iliac artery. With more medial reflection of the peritoneum, the gonadal vein is identified coursing just under Gerota fascia. This plane between the peritoneum and Gerota fascia is carried cranially, lateral to the tail of the pancreas and approximately 1 cm lateral to the spleen. The prior incision of the peritoneum needs to be carried up superiorly well above the spleen to ensure the spleen is released medially to allow adequate exposure for the medial upper pole dissection. Care is taken not to release the attachments too far medial to the edge of the adrenal gland because the effects of gravity aid in medial traction via these attachments of the adrenal gland later in the procedure. The stomach may be encountered and must be avoided during this step, and a commonly present prominent diaphragmatic vein serves as the landmark for the upper extent of the dissection (Fig. 5.3).

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