Shortages of cadaveric donors combined with high incidence of obesity in Saudi Arabia have forced the re-examination of living donor selection to include obese donors who are otherwise healthy. Open nephrectomy in obese donors carries higher risk of surgical complications in the peri-operative period. Even in the era of laparoscopic surgery, obesity is still a challenge due to intra operative technical difficulties. We present a case of a super obese donor who underwent hand assisted laparoscopic left donor nephrectomy (HADN). The patient is a 33-year-old male with a body mass index (BMI) of 55 kg/m2, who was interested in donating a kidney to his cousin. He was the only member of the recipient family that was willing to donate a kidney. His history and physical examination were completely normal except for the obesity. The risks of the procedure, risk of peri-operative morbidities/mortality associated with surgery on obese patients, and the risk of possible future kidney disease were explained to the patient on several clinic visits. The laboratory investigations included normal glucose tolerance test, lipid profile, creatinine clearance, and absence of proteinuria. Flow-cytometry crossmatch was negative. CT angiogram revealed the presence of double renal arteries bilaterally, and stress echocardiogram was normal. Due to the patient’s body habitus, we modified our surgical port sites (Figure). Our usual midline incision was shifted to the patient’s left lower quadrant to be able to reach the left kidney. Muscle splitting technique was performed. An additional 5 millimeters trocar (total 3) was inserted during the surgery to assist with bowel retraction. His surgery took a longer period of time (205 minutes, average being 143 minutes) with higher than our average blood loss (250 milliliters, compared to 119 milliters), due to the presence of aberrant retroperitoneal blood vessels. We encountered these aberrant blood vessels mainly posterior to the kidney, and despite using the Harmonic scalpel (Ethicon Endo-Surgery, Inc.) one artery bled that required clipping. The presence of the hand helped in the immediate control of the arterial bleeder, and also in the dissection of the difficult retroperitoneum due to the presence of excessive amounts of adipose tissue. The warm ischemia time was 180 seconds and the cold ischemia time was 45 minutes. Both arteries were implanted separately in the recipient external iliac artery with excellent perfusion and immediate diuresis. Post-operatively, deep vein thrombosis prophylaxis and aggressive pulmonary toilet were implemented, and his course was uneventful. He was discharged home on postoperative day 4. Patient wounds healed without any complication. Eighteen-month follow-up revealed normal blood pressure and creatinine levels, and absence of proteinuria. The recipient renal function remained within normal values. Accepting healthy otherwise obese donors can increase the pool of living donation. HADN is feasible in super obese donors with modification of surgical port sites, and we believe is superior to open nephrectomy in regards to wound and post-operative complications. We also believe that it is superior to pure laparoscopic nephrectomy in dissection and control of bleeding as obese donors have more retroperitoneal fat and aberrant blood vessels.
Volume : 6
Issue : 4
Pages : 96
Saad Specialist Hospital, Alkhobar, Kingdom of Saudi Arabia