Objectives: Evaluate the advantages of inguinal oblique incision in extracting the kidney during laparoscopic donor nephrectomy.

Materials and Methods: From April 2005 to June 2009, sixty-seven cases of transperitoneal laparoscopic live-donor nephrectomies were performed at our hospital, all data were analyzed retrospectively. All donors were grouped as a test group (n=37, inguinal oblique incision) and a control group (n=30, paramidline or subcostal incision) according to graft retrieval incision selection. Donors were compared with regard to operative time and warm ischemia time, operative blood loss, hospital stay and cosmetic satisfaction. Recipients were compared with regard to graft function and 1-year graft survival rate.

Results: All 67 cases of transperitoneal live-donor nephrectomies were successfully accomplished, without donor death, serious complications, and conversion to open surgery. There were no differences in mean operation time, mean blood loss, mean warm ischemic time, graft function, and 1-year graft survival rate between the groups. But in the test group, the mean hospital stay was shorter, P < .01; and cosmetic satisfaction was higher P < .01.

Conclusions: The inguinal oblique incision is a safe and practical graft retrieval incision in live-donor nephrectomies, and can be thought to be applied generally.

Key words : Laparoscopic donor nephrectomy, Renal transplantation, Inguinal oblique incision

Introduction

Laparoscopic donor nephrectomies have increasingly gained popularity since the first live-donor nephrectomy performed by Ratner in 1995.¹ Compared with open-donor nephrectomies, live-donor nephrectomies result in fewer postoperative complications, less pain, shorter hospital stay, earlier return to work, and ideal cosmesis without differences in renal function or allograft survival.^2-4 Graft retrieval incision also plays an important role in encouraging kidney donation and ensuring better cosmetics, especially for young ladies who intend to donate a kidney. Compared with paramidline and subcostal incision, inguinal incision has advantages of thinner muscle, less trauma, less dehiscence, quicker recovery, and better cosmesis. From April 2005 to June 2009, we performed 37 cases of laparoscopic transperitoneal live-donor nephrectomies with inguinal oblique incision as graft retrieval incision. We retrospectively compared the differences of inguinal incision and other incision for live-donor nephrectomies.

Materials and Methods

Donors and recipients
From April 2005 to June 2009, sixty-seven cases of laparoscopic live-donor nephrectomies were performed transperitoneal at our center. Obese donors, older donors, donors with an abdomen operation history of the same side as the donor kidney, and donors with multiple arteries were excluded. All donors were informed about our study and signed the informed consent form. Prior to the study, the protocol was approved by our local institutional ethics committee, and conforms with the ethical guidelines of the 1975 Helsinki Declaration. Written, informed consent was obtained from all of the subjects. Among the donors, there were 20 men and 47 women (mean age, 38.5 years; age range, 24-59 years) and a kinship relationship developed between donor and recipient (Table 1).

Before the operation, all donors underwent a complete examination, including isotope nephrography and kidney arteriography with 3-dimensional reconstruction. All donors were grouped as a test group (n=37) and a control group (n=30). According to graft retrieval incision, inguinal incision was used in test group, paramidline incision or subrib incision was used in control group.

Among the 67 recipients, 41 men, 26 women (aged 17-67 years; mean, 39.7 years), no renal transplant contradictions were found.

Live-donor nephrectomies procedure
The patient was placed in a 70-degree lateral decubitus position and secured to the table. The port A is created blindly with a 10-mm Trocar parallel to umbilicus pararectus abdominis (Figure 1), 30-degree laparoscope was inserted. The pneumoperitoneum was maintained in 12 mm Hg. Under direct vision of the laparoscope, port B (anterior axillary line maintained under the 12th rib) and port C (medioclavicular line maintained under the rib) were created (Figure 1).

The paracolic sulci peritoneum was opened, the colon was pulled away from kidney completely, drooping naturally, then the kidney abdominal side was exposed sufficiently. The upper pole of left kidney was initially and preferentially dissected, separating it from the adrenal gland. The ureter and gonadal vessels were identified, close to the crossover of the iliac vessels. The dissection continued, cranial and always medial to the gonadal vein (aiming to preserve the ureteral vascularization), until the left renal vein. The ligation was then performed with metallic clips, with subsequent sectioning of the gonadal vein close to the renal vein, as well as an eventual lumbar vein. Similarly, dissection, clipping, and subsequent sectioning of left adrenal vein were performed, largely exposing the superoanterior aspect of the renal vein on this side. The renal artery was then dissected close to the aorta, completing the circumferential dissection of the left renal vein. The perirenal fat tissue was dissected completely. The ureter was sectioned close to the crossover with the iliac vessels.

After the donor kidney was dissected completely, with the renal artery and vein being carefully mobilized (Figure 2), a 6- to 7-cm skin incision was made 2 cm apart from the inguinal ligament (Figure 3), skin, subcutaneous tissue, oblique externus abdominis muscle membrane were cut open, obliquus internus abdominis was pulled away along the fiber course, endoabdominal fascia and peritoneum were left intact. The renal artery and vein were ligated on proximal end by 2 Hem-o-loc clips, and then kidney was cut off and moved quickly to the lower abdomen. Laparoscope and other instruments were removed, the endoabdominal fascia and peritoneum were opened, and the kidney was pulled out.

Clinical data
All live-donor nephrectomies’ operative time, operation blood loss, ischemia time, and hospital stay, were recorded and compared. All donors and recipients were followed-up for at least 3 and 12 months. Donors were asked to complete a questionnaire about incision satisfaction on 1 month and 3 months postoperatively. Incision satisfaction included not satisfactory (1), satisfactory (2), and very satisfactory (3).

Statistical Analyses
Statistical analyses were performed with SPSS software for Windows (Statistical Product and Service Solutions, version 10.0, SSPS Inc, Chicago, IL, USA). Categorical variables were compared with the chi-square test; continuous variables were compared with the Mann-Whitney U test. A value for P < .05 was considered statistically significant.

Results

All 67 cases of transperitoneal live-donor nephrectomies were successfully accomplished, without donor death, serious complications, or conversion to open surgery.

Demographics, operative time, blood loss, and warm ischemia time, 1-year graft survival rate are reported in Table 2, graft function was shown in Figure 4. There were no differences in mean operation time, mean blood loss, mean warm ischemic time, graft function, and 1-year graft survival rate between the groups. But in the test group, mean hospital stay was shorter, P < .01; and cosmetic satisfaction was higher P < .01.

Discussion

Live-donor kidney transplant is superior to deceased donor kidney transplant because of better recipient and graft survival rates, better cost-effectiveness, and improved life quality of the recipient.⁵ The open-donor nephrectomy is classic method to procure a kidney from a donor through a waist and abdomen incision.

In 1995, the first live-donor nephrectomies were performed by Ratner; since then live-donor nephrectomies have been gradually accepted as a safe procedure. Live-donor nephrectomies seem to be at least as safe and efficacious as open-donor nephrectomies.^5-10 Now, various earlier contraindications to a laparoscopic donor nephrectomy, such as a right donor kidney, multiple vessels, and anomalous vasculature, have been outdated with increased experience. In 2003, the percentage of laparoscopies in the United States was approximately 67%.⁷ Live-donor nephrectomies have become the standard method for procuring kidney grafts of living donors in many centers.

Compared with open-donor nephrectomy, live-donor nephrectomies have shown superior results in postoperative pain, cosmesis, and recovery.^{8, 9} There are no significant differences in complication rates, cost-effectiveness, and graft function between live-donor nephrectomies and open-donor nephrectomy.^4-7 In addition, the longer warm ischemia time during live-donor nephrectomies shows no significant deleterious effect on graft survival.^13-16

The aim of live-donor nephrectomies is to decrease operative trauma on the donor and guarantee graft quality as much as possible. The donor incision is important for the donor to decide donation at some degree, especially for young women. Compared to transverse incisions, longitudinal incisions, including midline (median) and paramedian incisions, were thought to cause incision dehiscence and hernias.¹⁷ From a cosmetic standpoint, the midline or subcostal scar is often prominent, and cannot be concealed by lingerie or swimwear. Some researchers have reported that muscle-splitting lateral paramedian incisions have a lower incidence of incisional hernias compared with midline incisions.¹⁸

Suprapubic incision is a good means of harvesting a kidney during live-donor nephrectomies, because it does not require the cutting of recti muscles, it is easily hidden by skin and hair, with good recovery and cosmesis; but it may cause a cosmetic problem for Chinese people who have less skin hair in this part compared with Western people.

Compared with paramidline and subcostal incision, the inguinal oblique incision has the advantages of thinner muscle, less trauma, less dehiscence, quick recovery, and better cosmesis. Our study showed that inguinal incision did not increase operative time, blood loss, but decreased hospital stay and donor’s incision satisfaction.

The inguinal oblique incision is a safe and practical graft retrieval incision in live-donor nephrectomies and can be generally applied.

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