Objectives: The aim of this article is to compare different mini-incision donor nephrectomy techniques in the literature.
Materials and Methods: We did a literature search using PUBMED using the search term “donor nephrectomy.” We compared different surgical techniques using different parameters like length of incision, length of operation, pain medications required after the operation, site of the operation, and intraoperative and postoperative complications.
Results: We found 7 different surgical techniques of mini-invasive donor nephrectomy. Hakim and associates described the smallest initial incision size of 4 cm. There also are limited data on the analgesia requirements in 4 of the series, and 3 series that describe the requirements vary.
Conclusions: These techniques offer advantages and disadvantages to the donor and the kidney. We hope to encourage further work. Ideally, there must be a working discussion, long-term outcomes of donor kidney and recipient, as well as accurate pain records, both quantitative and qualitative, and a discussion of time to mobilization.
Key words : Transplant, Living, Kidney
Kidney transplant offers the best prognosis for end-stage renal failure patients, and live donation is the optimal way to increase the number transplants (1). Historically, a nephrectomy was performed through a 15- to 25-cm flank incision often involving a rib resection. This procedure confers many disadvantages including hyperesthesia, development of incisional hernia, a long recovery time, and a poor cosmetic result. Minimally invasive laparoscopy for donor nephrectomy was first performed in 1995 (2), with resulting advantages of reduced blood loss, less pain, and a faster recovery time. Consequently, it gained wide acceptance among donors and transplant surgeons. However, European surgeons have been more reluctant to perform laparoscopic nephrectomy than US surgeons (3), possibly because of technical concerns, and partly because of evidence suggesting higher costs and complication rates. Recent data shows most European transplant centers continue to perform open in preference to laparoscopic donor nephrectomy (4).
The development of laparoscopic donor nephrectomy has stimulated the development of less-invasive techniques, such as the mini-invasive donor nephrectomy, which involves a smaller incision and obviates the need for rib resection. Recent studies have shown that mini-invasive donor nephrectomy has excellent results in terms of safety, cost effectiveness, donor recovery, and cosmesis (5, 6).
This review article seeks to compare different mini-invasive donor nephrectomy techniques in the literature. We did a literature search using PUBMED using the term “donor nephrectomy.” We present the techniques below.
Mini-incision, muscle-splitting open donor nephrectomy
Kok and colleagues (7) have been performing donor nephrectomies using a muscle-splitting mini-incision since 2000. The technique involves the patient being placed in a lateral decubitus position with the operating table maximally flexed. The incision is described as being horizontal, 10 to 12 cm in length, anterior to the 11th rib, and extending toward the umbilicus. The fascias of the external and internal oblique and transverse abdominal muscles are divided with scissors before the muscle fibers themselves are split longitudinally, rather than cut. Exposure is facilitated by the Omnitract mechanical retractor (Omnitract Surgical, St. Paul, MN, USA), the peritoneum is displaced, and Gerota’s fascia opened over the lateral aspect of the kidney. The kidney is then dissected free. The ureter, renal vein, and artery are identified and encircled with vessel loops. The gonadal, lumbar, and adrenal vascular branches are divided as necessary. Once mobilization of the kidney and related structures are complete, the ureter is divided. Five thousand units of heparin are then administered intravenously before the renal artery and vein being clamped and ligated. The kidney is removed, and the divided muscle layers are closed individually.
Anterior Vertical Mini-Incision
Neipp and associates (8) describe this technique that is also described in 2 more papers: Schnitzbauer and associates (9) and Jackobs and associates (10). The patient is placed in a supine position. A vertical anterior 6- to 10-cm incision is made lateral to the rectus muscle, below the costal arch. The abdominal muscles are divided in layers, and the peritoneum is retracted medially to expose the kidney in its retroperitoneal position. A self-retaining retractor may be used to aid exposure. The renal fascia is incised and the perirenal fat dissected. The ureter is dissected, ligated, and divided as distal as possible. The renal vein and artery are separated. The renal vein is closed at the caval junction by running a suture using 5-0 Prolene, while the renal artery is tied using a double ligature.
Finger-assisted donor nephrectomy technique
This approach has previously been described by our unit (11). The patient is positioned in the lateral decubitus position, with the table maximally flexed. An initial, 4-cm, transverse incision is made anterior to the tip of the 11th rib. All muscle layers and the lumbodorsal fascia are divided in line with the incision. The peritoneum is reflected medially to expose Gerota’s fascia. Two Hakim retractors (Bolton Surgical, Sheffield, UK), with intrinsic light sources (designed for the purpose of this procedure), are positioned superiorly and medially to gain adequate exposure for dissection, using a headlight to optimize vision. Gerota’s fascia is incised longitudinally. Dissection of the ureter, conserving the periureteric tissue, is performed to obtain maximum length of ureter, suitable for reimplantation. The dissected ureter is encircled with a vessel loop and divided using the ETS-FLEX endoscopic articulating linear vascular cutter (Ethicon Inc).
Next, dissection of the upper pole is started. A Lahey right-angled tissue forceps, in combination with a diathermy extension, is used to divide capsular attachments, beginning at the anterior and postero-lateral margins, before freeing the upper pole. The upper pole is mobilized first to prevent further upward migration of the kidney toward the pleura. Handling of the kidney is kept to a minimum to complete mobilization of the organ laterally and inferiorly.
Next, the vascular structures are exposed. The renal artery and vein are isolated and freed from the surrounding lymphatics and encircled with vessel loops. The gonadal and lumbar veins are dissected and, if required, these may be divided between Liga clips. The renal artery and vein are individually divided using a reloadable ETS-FLEX vascular stapler.
The wound bed is inspected and meticulous hemostasis achieved. Closure is achieved in 3 layers using monofilament absorbable suture. The skin is closed with an absorbable subcuticular suture. The final median length of the incision is 6.8 cm (experience with 359 cases).
Mini-Invasive Donor Nephrectomy Through Transverse Incision
Morrissey and associates at Rhode Island Hospital described this technique (12). The patient is placed in a semilateral position with 20 degrees flexion of the operating table. An 8- to 10-cm transverse incision is made anterior to the 11th rib to the lateral border of the rectus muscle. Then, the rectus sheath is incised, followed by mobilization and retraction of the intact rectus muscle. Retroperitoneal dissection over the psoas muscle toward the distal ureter is then performed. The transversalis fascia is incised laterally followed by gentle and blunt dissection to accommodate a retractor in the inferior aspect of the incision. The peritoneum is retracted medially using an Omnitract retractor (Omnitract Surgical).
Dissection of the ureter from the hilum to the iliac vessels is undertaken. Gerota’s fascia is incised longitudinally along the lateral aspect of the kidney. Any vascular attachments around the kidney are divided (aside from any renal arteries and veins) and the renal pedicle is exposed by creating a plane between the colon and retroperitoneal tissue. Liga clips (Hemolock clip, Pilling weck, Fort Lauderdale, FL, USA) are then applied to control the renal vessels. The renal vein is divided below the adrenal branch, and the renal artery is divided 5 mm from the aorta. The ureter is clipped and divided 2 to 3 cm above the iliac bifurcation. The midaxillary line over ribs 10, 11, 12, and the incision, are then infiltrated with bupivacaine (0.5%). The muscles are closed into 2 layers, and the skin is closed with absorbable sutures.
Microinvasive Donor Nephrectomy
Mital and associates (13) describe this technique. The patient is positioned in a lateral decubitus position. The operating table is flexed to 30° and placed at a 20°-Trendelenburg tilt. The incision is made 6 to 8 cm from the tip of the 10th rib to the edge of the rectus abdominis muscle. The muscles are split in line with their fibers to minimize postoperative pain.
Using Deaver retractors, the peritoneum is pushed medially. The ureter is separated from the retroperitoneal tissues preserving the periureteric vessels to preserve its blood supply. Then, the kidney is mobilized within Gerota’s fascia; and the adrenal, as well as gonadal veins, are ligated with an automatic surgical clip applier and divided. The renal vein is then dissected to its junction with the inferior vena cava. The renal artery is dissected to the aorta. The ureter is double-clipped at the point where it crosses the iliac artery and divided proximally. The patient is given 5000 IU of IV heparin. The renal artery is divided after applying 2 or 3 surgical clips at its origin from the aorta. An Ethicon Proximate TX30V 30-mm reloadable vascular linear stapler is placed across the renal vein close to the inferior vena cava and also the renal artery. After securing hemostasis, the wound is closed in 3 layers, 1 running monofilament suture for each muscle layer. A field block is placed by infiltration of 0.25% bupivacaine locally and regionally.
Mini-Nephrectomy Through a Posterior Transcostal Approach
Shenoy and associates (14) described this technique. The patient is positioned in lateral decubitus with the kidney rest raised between the iliac crest and the lower border of the rib cage. The 12th rib is palpated, and a 6- to 8-cm incision is marked along the course of the rib, starting 2 to 3 cm anterior to the lateral border of the sacrospinalis muscle. A Wheatlander retractor (Aesculap, Inc., San Francisco, CA, USA) is applied for maximum exposure. The latissimus dorsi and serratus posterior inferior muscles are divided to expose the 12th rib.
The periosteum is dissected with electrocautery and retracted medially. The rib is divided to the lateral border of sacrospinalis. A Bookwalter retractor (Codman, Inc., Raynham, MA, USA) is set up with the vertical post applied to the table on the side of the operating surgeon. A large ring is positioned, parallel to the donor, as close to the skin surface as possible, with the incision centered in its middle. Modifying the use of the Bookwalter retractor helps obtain adequate exposure of the area of dissection. One or 2 blades are placed on the same or adjacent sides of the incision to skew it to the area of dissection. The upper pole, lower pole, ureter, hilum, and posterior portion of the renal pelvis are dissected sequentially. The lumbodorsal fascia and extraperitoneal fat are encountered. This fat pad is excised to create a working space around the kidney, and to allow longitudinal incision of Gerota’s fascia. Perinephric fat is dissected at the middle of the kidney posteriorly and extended superiorly to release the upper pole. A self-retaining, right-angle blade is applied to retract the upper edge of the abdominal wall to facilitate dissection of the upper pole. A hand-held sweetheart retractor is used to displace the kidney caudally to aid dissection. The retractor blade is applied to the inferior edge of the abdominal wall incision after the perinephric fat in the posterior inferior part of the kidney has been excised. A sweetheart retractor blade is applied to retract the peritoneum medially. The kidney is then gently retracted upward with a self-retaining Deaver blade. The ureter is encircled with a vessel loop, preserving the periureteric plexus of vessels. With gentle traction on this loop, the ureter is dissected to a point 2 cm beyond the site where it crosses the external iliac vessels. Monopolar electrocautery, with a long tip, is used for this dissection, together with a Debakey vascular forceps and occasionally, a right-angled forceps.
The gonadal vein is traced to its insertion into the renal vein. The perinephric pad of fat anterior to the kidney is excised, and the peritoneum is retracted medially by repositioning the self-retaining sweetheart blade. The gonadal vein is divided between medium-sized Liga clips, leaving a generous stump on the renal vein. The upper pole of the kidney is retracted downward and medially with a Deaver blade. The sweetheart blade retracts the peritoneum medially. The dissection of the adrenal vein is done, and the vessel clipped and divided, and the renal artery is dissected to its origin. The ureter is divided first using large Hemolock clips (Weck Closure Systems, Inc., Research Triangle Park, NC, USA). Vascular clamps are applied to the renal artery and vein before their division. The kidney allograft now lies free in the retroperitoneum. The Deaver blade is removed. A ring forceps is used to grab the upper pole of the kidney to deliver it upward through the incision.
The renal vein stump is sutured first with a 5-0 polypropylene continuous suture, followed by closure of the renal artery in a similar way. A laparoscopic knot pusher is used to place knots, because it is almost impossible to slide the knot down manually because of the small size of the incision.
The lumbodorsal fascia is closed with continuous sutures as a first layer. The serratus posterior inferior and the latissimus dorsi are closed with interrupted 0-Vicryl (Ethicon, Somerville, NJ, USA) figure-8 sutures. The subcutaneous tissue is closed with 3-0 continuous Vicryl, and a subcuticular skin closure is performed with a 4-0 absorbable monofilament suture.
Rha and associates describe this technique (15). The patient is placed in flank position and a 5- to 7-cm incision is made on the lateral side of abdomen. After cutting the subcutaneous tissues, the abdominal muscles are split along their fibers. A 10-mm laparoscopic trocar is placed in the space between peritoneum and the fascia on the lower left side of the major incision and connected to an upper deck of retractors. A 30°-angle laparoscope is connected to a video monitor to maximize the view. A Mount retractor system (Thompson Surgical, Traverse, MI, USA) is applied to secure the surgical field. Using surgical instruments such as a laparoscopic grasper sand scissors, endoclips, and other laparoscopic tools, the ureter is reached, and the peritoneum covering it is retracted medially by a piercing peritoneal retractor. The kidney is dissected, starting from its lower pole, before moving on to its lateral margin, the upper pole, and finally, the adrenal gland. The lumbar and adrenal veins are ligated with extracorporeal knots.
Next, the ureter is divided, and the kidney area is covered with a disposable plastic EndoCatch bag in preparation for removal of the kidney by minilaparotomy. Warm ischemia time is reduced via this technique by simultaneously moving the kidney and cutting off the renal hilum. The renal artery is secured with endoclips while the renal vein is sutured with 5-0 Prolene. A drain is inserted in the area of dissection.
Findings (see Table)
All authors of the various techniques above have not described any selection or discriminating criteria of candidates for mini-invasive donor nephrectomy. Possible areas of interest would include obesity, age, side of donor kidney, and number of blood vessels. However, there are some data on the size of donor. The mean body mass indexes of Neipp and associates (8) and Hakim and associates (12) were 26 ± 4 and 27.1 ± 5.4. Neil and associates’ technique (7) (muscle-splitting donor nephrectomy) and Hakim and associates (12) have been described as being used for donors with body mass index of up to 41 and 44.
Side of donor kidney
Neil and associates (7) describe removing 33 right kidneys in their series that account for 55% of all the described series. The remaining authors performed more left-sided than right-sided nephrectomies (see the Table). Removal of the left or right kidney made no significant difference in terms of complications for either the donor or the recipient in any of the described techniques.
Thus, from the limited data presented to date, there are no apparent limiting criteria. However, the literature will benefit from a further publication of a series describing donor factors and exclusion criteria. Blood loss is described in 3 series and is noted to be lowest in the Hakim series (12), suggesting that despite the use of the smallest incision, there is no safety concern, mainly because of the use of the stapling device.
Neipp and associates (8) used a 6- to 10-cm, para-rectal, vertical incision, while other techniques used transverse incisions starting from different points. Hakim and associates (12) describe the smallest incision with a median value of 6.8 cm (range, 3.5-15 cm). Other transverse incisions range between 5 to 15 cm. A transverse incision seems to have a more-favorable cosmetic result than a vertical one.
Length of surgery
Hakim and associates (12) have shortest time to remove the kidney with a median of 80 minutes (range, 29-180 minutes), while Neils and associates’ (7) median time is 189 minutes (range, 60-196 minutes). Time to remove the kidney has not been mentioned by other authors. Median values for skin-to-skin surgical times in minutes vary from 117 minutes (Hakim and associates; 12) to 158 minutes (Neils and associates) (7). None of authors stated whether all of the procedures were performed by the same surgeon.
Intraoperative and postoperative complications
Neils and associates (7) describe minor intraoperative complications in 4 patients in the form of intraoperative bleeding, with mean blood loss of 210 mL (range, 30-1400 mL). Eight patients had minor postoperative complications in form of hematoma, prolonged nausea, urinary tract infection, infected left eye, blood transfusion, and incisional hernia. No major intraoperative or postoperative complications occurred.
Neipp and associates’ series (8) describes 2 patients who had bleeding (3%). One patient had a wound infection (1.4%), and 1 patient had an incisional hernia (3%) as described in the postoperative complications.
Hakim and associates (11) describe 10 patients (4.7%) who had minor postoperative complications. Two patients, both with a body mass index of > 35, developed basal atelectasis postoperatively, requiring antibiotic treatment for subsequent chest infections. Five patients developed symptomatic urinary tract infections, treated with antibiotics. Two male patients went into urinary retention, requiring reinsertion of the urinary catheter. Two patients developed wound infections, treated with oral antibiotics. During follow-up, 2 patients presented with an incisional hernia and went on to have an elective repair, using a mesh technique.
Morrissey and associates (13) have not reported any intraoperative or postoperative complications. Mital and associates’ complications (14) have included 3 cases of postoperative temperature due to atelectasis and 2 cases of urinary retention (8%). Shenoy and associates (15) and Rha and associates (16) have not reported complications in their series. Importantly, there is no reported mortality associated with any of these procedures and no organ loss.
Hakim and associates (12) use opiate patient-controlled analgesia pumps in the immediate postoperative period for 24 hours, in conjunction with intravenous paracetamol every 6 hours. However, they have not discussed the median amount of opiate required by the patients. Morrissey and associates (13) describe a mean opioid use of 2.3 ± 0.7 mg with only 2 patients requiring oral narcotics beyond 2 weeks. Mital and associates (14) used morphine 68.36 ± 45.85 mg, while the mean morphinelike substance in Rha and associates’ technique (16) needed was 23 ± 11 mg.
Shenoy and associates (15) prescribed opioids for 5 days, and none of their patients needed pain medications after 14 days after surgery. None of the authors reported persistent pain in any patient. Neil and associates (7) and Neipp and associates (8) have not mentioned any pain medication requirements.
Morrissey and associates (13) and Mital and associates (14) describe the shortest hospital stay of 3.2 ± 0.8 days and 54.81 ± 14.12 hours. Neil and associates’ (7) median hospital stay is 4 (2-9 days) while Neipp and associates (8) had mean of 7.9 ± 3.2 days. Hakim and associates (12) kept donors for at least for 5 days, although this is due to a departmental policy to allow donor and recipient time together. The average hospital stay of Shenoy and associates’ (15) patients was 3 days. There are no figures from Rha and associates (16) regarding hospital stay.
In this era of minimal access surgery, the smallest and safest technically possible incision, causing the least amount of pain, is always going to be the incision of choice. We (12) describe the smallest initial incision size of 4 cm, and the median value is 1 cm less than the only other described median value.
From a cosmesis point of view, an assessment of scar appearance and wound size after a given time period, when healing has occurred would be desirable and relatively easy to perform.
Importantly, there are also limited data on the analgesia requirements in 4 of the series, and the 3 series that describe the requirements vary (14-16). None of the papers describe any qualitative work on pain perception in the short or long term, and there are no data on time to mobilization. The use of validated endpoints would be useful, as well as using subtler points, such as time to return to work, and use of oral analgesia. This also would help to determine the best technique and is extremely important in the ongoing debate in the choice between open versus laparoscopic donor nephrectomy.
Length of surgery is documented only by 2 authors (12, 15), but it varies. However, there are no data on whether this is due to the operator or the technique. Future work must discuss this point, as well as distinguishing between work done by trainees or fully qualified surgeons. Further, a slightly longer operation at the expense of a shorter warm ischemic time could be argued as desirable, but there is no evidence to date that a longer warm ischemia time in live donor affects outcome (17).
These techniques offer advantages and disadvantages, both to the donor and to the kidney. We hope that by publishing this paper, we can encourage further work. There must be a work discussing long-term outcomes of donor kidney and recipient, as well as accurate pain records—both quantitative and qualitative—and a discussion of time to mobilization. There have been no reported deaths after an open, live-donor nephrectomy since 1991, but 8 deaths and 15 graft losses after laparoscopic nephrectomy (which also takes longer and can have a higher complication rate) have occured (18).
Hence, different methods of open surgery must be discussed and evaluated to ensure the best techniques are established to allow for optimum donor and graft survival. This is particularly important when obtaining informed consent, where donors must be informed of the relative pros and cons of open versus laparoscopic nephrectomy. Further, these techniques may be used with modern local anesthetic delivery systems, such as “the pain buster,” which may reduce time spent in hospital. It is the authors’ opinion that an open mini-nephrectomy is the technique of choice, but there is no doubt that there is a need for an international registry to allow collation of these various techniques to allow for an evidence-based decision to be made.
Volume : 8
Issue : 3
Pages : 189 - 195
The West London Renal and Transplant Centre, Imperial College Healthcare NHS
Trust, London, UK
Address reprint requests to: Professor Nadey Hakim, The West London Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital Du Cane Road, London, W12 0QT
Phone: +44 208 383 5164
Fax: +44 208 383 5169
Table. Demographic, operative and post operative details of different MIDN techniques.