Objectives: Minimal-access kidney transplant is not a new approach, however this approach is a good option for obese patients because access is difficult and often associated with wound complications and prolonged recovery.

Materials and Methods: Minimal-access kidney transplant uses an inguinal incision that is placed 4–6 cm above the pubic bone that extends to 2.5-cm lateral to the mid-inguinal point. Once the skin and subcutaneous tissues are opened, the external oblique is split in the same direction as the wound. Then, the oblique and transverse abdominal muscles are split at the lateral edge of the wound, the abdominal muscles are separated from the lateral border of the rectus muscle, and the inferior epigastric vessels and round ligament are tied and cut. Mobilizing the peritoneum upward exposes the iliac vessels. Then, dissect the space between the urinary bladder and rectus muscle to create a pouch, which accommodates the kidney. The renal vessels are then clearly visible, while the kidney itself is hidden in the subrectus pouch. Suitable retractors are needed to perform these procedures. Then, arterial anastomosis can be performed. The clamps are released after testing the arterial and venous anastomoses. After securing hemostasis, the kidney can be left in the pouch, rotated laterally, or remain in the middle of the wound. Close only the external oblique muscle.

Results: This technique requires minimal assistance and a small incision. An illustrative photo and diagram are included along with the full demographic data of the patients.

Conclusions: Engrafting kidneys into obese patients via the minimal-access approach is feasible, safe, and demonstrates comparable outcomes to other methods; however, more studies are needed.

Key words : Renal transplant, Minimal access

Introduction

Minimal-access kidney transplant is not a new approach; however this approach is suitable for obese patients because access is difficult and often associated with wound complications and prolonged recovery.¹

Surgical technique
Minimal-access kidney transplant requires an inguinal incision 4 to 6 cm above the pubic bone to 2.5-cm lateral to the mid-inguinal point. Once the skin and subcutaneous tissue are opened, the external oblique is split in the same direction as the wound. The oblique and transverse abdominal muscles are then split at the lateral edge of the wound and separated from the lateral border of the rectus muscle, and the inferior epigastric vessels and round ligament are tied and cut. The peritoneum is then mobilized and the iliac vessels are dissected.

Next, dissect the space between urinary bladder and rectus muscle to create a pouch that will accommodate the kidney during anastomosis. The renal vessels should be clearly visible, while the kidney itself is hidden in the subrectus pouch. Suitable retractors are essential to perform these procedures. Start by performing arterial anastomosis, which can be performed using the classic eversion technique or from within. Venous anastomosis can be performed from within. The clamps are released after testing the arterial and venous anastomoses for any bleeding. Hilar bleeding points can be very easily accessed when the kidney is in subrectus position. After securing hemostasis, the kidney can be left in the pouch, laterally rotated, or maintained in the middle of the wound. The external oblique muscle is the only muscle that is closed.

Discussion

The hockey stick, inguinal Gibson, and midline incisions are standard incisions used during kidney transplant.^2,3

Surgeons have tried to use minimal-access surgery to perform transplants, however hurdles include the complexity of the required vascular anastomoses (which requires ample space to achieve adequate precision) and preventing graft thrombosis. Second, the short vessels associated with living donor and right kidneys are well-recognized surgical challenges of kidney transplant. Various approaches that use minimal incisions have been suggested as ways to achieve good accessibility and accuracy. The first approach was published in 2006 by Øyle, who suggested using a small groin incision (7-9 cm) to place the kidney in the lateral extraperitoneal space; anastomoses can then be performed from within.⁴ The second minimal approach was reported by Mun, who suggested using a laparoscopically assisted technique to help visualize the anastomosis within the narrow operating field.⁵ Then, the total laparoscopic renal transplant technique came to match the laparoscopic donor nephrectomy.⁶

All minimal techniques share certain contra­indications, including obesity, atherosclerotic vessels, repeat transplant, and a deep pelvis, and are associated with certain difficulties such as controlling bleeding points that result from the intrinsically limited maneuvers required to access the kidney from different angles. Deceased-donor kidneys are seldom used because they are associated with bleeding from the fat around the hilum.

Conclusions

Placing the kidney in the subrectus space while performing anastomosis allows the surgeon to accurately and safely perform kidney transplant via a small incision.

References:

1. Olarte IG, Hawasli A. Kidney transplant complications and obesity. Am J Surg. 2009;197(3):424-426.
2. Filocamo MT, Zanazzi M, Li Marzi V, et al. The approach by midline incision for extraperitoneal kidney transplantation. Transplant Proc. 2007;39(10):3077-3080.
3. Nanni G, Tondolo V, Citterio F, et al. Comparison of oblique versus hockey-stick surgical incision for kidney transplantation. Transplant Proc 2005;37(6):2479-2481.
4. Øyen O, Scholz T, Hartmann A, Pfeffer P. Minimally invasive kidney transplantation: the first experience. Transplant Proc. 2006;38(9): 2798-2802.
5. Mun SP, Chang JH, Kim KJ, et al. Minimally invasive video-assisted kidney transplantation (MIVAKT). J Surg Res. 2007;141(2):204-210.
6. He B, Hamdorf JM. Update on laparoscopic/robotic kidney transplant: a literature review. Transplant Res and Risk Manage. 2013;5:33-39.