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Volume: 15 Issue: 5 October 2017

FULL TEXT

ARTICLE
Evaluation of Three-Dimensional Versus Conventional Laparoscopy for Kidney Transplant Procedures in a Human Cadaveric Model

Objectives: There are increased reports that kidney transplant can be performed by laparoscopic surgery. The further development of this technique could revolutionize human kidney transplant surgery. However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses. The emerging technology of the three-dimensional, high-definition laparoscopic system may facilitate the application of this technique. Therefore, in this study, we evaluated this system in performing kidney transplant surgery versus the two-dimensional laparoscopic system.

Materials and Methods: Four fresh-frozen human cadavers were used in this study, with 2 for the 3-dimensional and 2 for the 2-dimensional system. Kidneys were retrieved by using the retroperito­neoscopic technique for living donor nephrectomy from the same cadaver. The kidney graft was transplanted at the right iliac fossa using a laparo­scopic technique by extraperitoneal approach. The procedure was recorded, and the vessel anastomotic time was analyzed.

Results: Kidney transplant procedures were conducted successfully in the 3-dimensional, high-definition and the 2-dimensional groups. We recorded no significant differences in terms of vessel anastomotic time between the 2 groups. The total surgery time was shorter in the 3-dimensional, high-definition group than in the 2-dimensional group (P = .02).

Conclusions: This pilot study reinforces that kidney transplant with either the 3-dimensional, high-definition or 2-dimensional laparoscopy is feasible in a human cadaveric model. The operation was the same as open kidney transplant, but the procedure was performed by a laparoscopic approach with a smaller incision.


Key words : Three-dimensional high-definition laparoscopy, Two-dimensional laparoscopy

Introduction

Kidney transplant is a definitive treatment for end-stage kidney disease. Every year about 70 000 kidney transplants are performed in the world.1 The surgical technique for kidney transplant has essentially remained unchanged over the past 60 years since the original description in the 1950s,2 which requires a long incision (15-20 cm) in the lower abdomen. Over the past 3 decades, the application of minimally invasive laparoscopic surgery has demonstrated significant benefits of a smaller incision, less pain, quicker recovery, shorter hospital stay, and enhanced cosmesis over conventional open surgery.3-5 As laparoscopic techniques evolve, more and more complex surgeries can be performed successfully.6 Recently, there have been increased reports on kidney transplant procedures being safely performed by laparoscopic and even robotic surgery.7-9

The further development of laparoscopic techniques could help overcome the problems associated with conventional open surgery and revolutionize the surgical technique for human kidney transplant. In addition, an incision of reduced length (6-7 cm) may allow for earlier administration of an important immunosuppressive agent (sirolimus), with less risk of surgical wound complications.10 However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses, especially with conventional 2-dimensional (2D) laparoscopic systems, owing to the lack of depth perception and spatial orientation. The emerging technology of three-dimensional (3D) laparoscopic systems may be beneficial in performing these vascular anastomoses during kidney transplant procedures. A review of the literature has shown that 3D laparoscopy seems to improve the speed and reduce the performance errors compared with 2D laparoscopy.11 Aykan and associates have shown that 3D laparoscopic radical prostatectomy is associated with shorter operation time, less blood loss, and higher early continence rates than conventional 2D laparoscopy.12 However, an early randomized clinical trial on laparoscopic cholecystectomy did not show any evidence that 3D was superior to 2D.13 It is still unclear whether 3D laparoscopic equipment can improve the proficiency in performing complex laparoscopic surgeries as most of these studies have been conducted in simulated settings using tasks whose face validity might be questioned compared with human organ transplant.11 Therefore, the aim of this study was to evaluate a 3D, high-definition (3DHD) system versus a 2D laparoscopic system in performing a complex procedure of kidney transplant with a human cadaveric training model.

Materials and Methods

The use of 4 fresh-frozen human cadaveric bodies was approved by the institute’s ethics committee for this study. Two cadavers were used for laparoscopic kidney transplant with either the 3DHD system (3DHD group; n = 2) or the 2D laparoscopic system (2D group; n = 2). For the 3DHD group, the cadavers had had abdominal wall dissection previously during a separate training course. In the 2D group, 1 cadaver had had abdominal surgery previously with an obvious midline abdominal scar. The training model of kidney transplant by laparoscopic technique was previously established in our institution by the same surgical team.14

The 3DHD laparoscopic system (ConMed Linvatec, Frenchs Forest, Australia) consisted of a 10-mm outer diameter (0/30 degree) stereoscopic endoscope, a digital 3-dimensional high-definition camera, and a 32-inch 3-dimensional high-definition monitor. The 2D laparoscopic system (Storz Pro­fessional Image Enhancement System [SPIES], KARL STORZ Endoscopy, Sydney, Australia) allowed recognition of the finest tissue structures and provided clear images on the monitor. It consisted of a 10-mm outer diameter endoscope (0/30 degree). With the 3DHD system, the surgeon and assistant wear a pair of special glasses to view the 3D images on the screen.

The cadaver was first placed in the right lateral decubitus position, and a nephrectomy was per­formed on the left side by a retroperitoneoscopic approach. The renal artery and vein were identified and dissected. The kidney was dissected free from its attachments. The ureter was identified, dissected, and divided at the level of iliac vessels. A small incision was made at the left iliac fossa for delivery of the kidney graft. The renal artery and vein were divided after application of 2 Endoclips. The kidney graft was then removed and prepared on the back-table as per a living-donor kidney transplant procedure. In addition, a marking suture was placed at the inferior corner of renal artery and vein with a 6/0 Prolene suture (Figure 1). A ureteric stent was inserted into the ureter and secured with a fixation stitch with a 4/0 Chromic suture to the ureter (Figure 1). The kidney graft was wrapped in a tailored surgical pack in the 3DHD group (Figure 2) for easy handling during the implantation, but the kidney grafts were not wrapped in the 2D group. Subsequently, the cadaver was changed to a supine position with the right side elevated approximately 30 degrees by placing a wedge cushion under the right side of the body. In the 3DHD group, the contour of an Alexis port (Applied Medical, Stafford, Australia) was marked above the pubis. The camera port was marked superior and lateral to the umbilicus. The right-hand port was located lateral to the camera port. The left-hand port was inferior to the camera port, forming a triangular shape (Figure 3). A balloon dilator was inserted at the site of the camera port to the extraperitoneal space, and the working space was created by inflation of the balloon dilator. The balloon dilator was then replaced by a Hanson balloon port after establishment of the working space. Under vision, a 12-mm port and a 5-mm port were inserted for the right-hand and left-hand instruments, respectively.

The working space was expanded by dissection of the peritoneum medially in the superior and inferior areas. The external iliac artery and vein were identified, and a segment of these vessels was dissected in preparation for vessel anastomosis. At this stage, a 7-cm Pfannenstiel incision was created at the center of the marked contour of the Alexis port (Figure 3). The rectus muscle was separated in the midline, and the extraperitoneal space was accessed. The Alexis port was placed over the Pfannenstiel incision, and the working space was reestablished. The endoscopic bulldog (B Braun, Melsungen, Germany) was placed over the external iliac artery. The arteriotomy was performed by using a laparoscopic retractable scalpel (Figure 4a) (B Braun) followed by use of laparoscopic Potts scissors (Figure 4b) (B Braun). The kidney graft was delivered to the iliac fossa via the Alexis port. The kidney graft was oriented properly by checking the mark stitches. Two 5/0 Prolene sutures (each trimmed to 13 cm in length) were used for the renal artery to external iliac artery anastomosis in an end-to-side fashion, with one suture for the posterior side and another suture for the anterior side of the anastomosis (Figure 5). Heparinized normal saline was injected into the anastomosis before completion of the anastomosis. Two sutures were then tied at the corner. After that, the venotomy was made over the external iliac vein by using the Potts scissors. The renal vein was anastomosed to the external iliac vein in the same fashion (Figure 6) as to the renal artery. The quality of the vessel anastomoses was satisfactory on inspection. The bladder was then distended by instillation of methylene blue-stained normal saline. A 5/0 polydioxanone suture was used for ureteroneocystostomy with a preinserted ureteric stent in situ. The ureter was anastomosed at the posterior and lateral part of the bladder by a laparoscopic technique using the Lich-Gregoir method (Figure 7). The procedure was completed, and the wound was closed in layers.

To improve the proficiency in creation of the working space, some modifications were attempted in the 2D group. The balloon dilator was placed into the extraperitoneal space toward the pubis via the right-hand port at the lateral and inferior to the umbilicus. The working space was expanded while the balloon dilator was inflated under camera vision. After that, the Alexis hand port, 5-mm left-hand port, and 10-mm camera port were subsequently placed. The identification and dissection procedures of the iliac artery and vein were the same as in the 3DHD group. The techniques for renal artery and vein and ureter anastomosis were also the same as in the 3DHD group (Figures 8-12).

The procedure was video recorded to allow later review. The surgical time and anastomotic time were also recorded in a format identical to that usually used in our clinical kidney transplant practice. Measurements included the length of time taken to complete the various anastomoses and the total time taken to complete the procedures. Data were compared with t tests using SigmaPlot 12.5 (Systat Software Inc, San Jose, CA, USA).

Results

The kidney graft was procured successfully in both the 3DHD and 2D groups with satisfactory length of the renal artery, vein, and the ureter. The kidney graft was prepared in the same way as for a living kidney graft for each case with a single renal artery and vein and single ureter. The procedures for kidney transplant were conducted successfully with both the 3DHD and 2D laparoscopic systems. The position of the ports was satisfactory, without any problems during the procedure. The kidney graft was delivered to the right iliac fossa via the Alexis port. The mean time for anastomosis of the renal artery was 30 minutes in the 3DHD group and 39 minutes group in the 2D group (P = .13). The average time for anastomosis of the renal vein was 24 minutes in the 3DHD group and 30 minutes in the 2D group (P = .11). The mean time for anastomosis of the ureter was 20.5 minutes in the 3DHD group and 25 minutes in the 2D group (P = .07). The mean total surgery time was 182 minutes for the 3DHD group and 252 minutes for the 2D group (P = .02). The distant tunnel vision also affected the surgeon’s confidence when performing vessel dissection and anastomoses. It felt less tiring performing the whole procedure using the high-quality 2D image system.

Discussion

Surgical technique innovations with emerging technologies are inevitable with advancements of surgery. However, it is essential that, for the safe introduction of a new surgical technique, the potential negative effects are investigated and understood. With the introduction of a new surgical technique, it is essential that the innovation has measurable benefits and does not harm the patient. Over time, clinical experiences can contribute to these data.

We contend that the use of human cadavers is a critical step in the development of surgical techniques and training. With this model, the feasibility of a new technique can be explored in the realistic anatomic structure of the human body.15-18 Thus, the feasibility and safety of the procedure can be assessed by the investigators before its application in clinical practice. Our previous experience demonstrated that the establishment of a novel technique using the cadaveric model facilitated safe transition of a novel technique from the laboratory to the clinic.9

Laparoscopic surgery has been widely used in surgical clinical practice, replacing conventional open surgery due to its multiple benefits.19,20 Increasingly complex surgeries have been successfully performed using laparoscopic techniques.21,22 In general, conventional 2D laparoscopy has the limitation of lack of depth perception and spatial orientation. This disadvantage demands intensive training to achieve proficiency for the complex surgical procedures. It presents a significant hurdle for performing vascular anastomosis under the time constraint, especially for the implementation of kidney transplant by a laparoscopic technique. The 2D format also increases mental and vision fatigue. The design of 3DHD systems has aimed to improve depth perception and spatial orientation, which would thus enhance proficiency in the performance of complex surgical procedures. Some studies have found that 3DHD improves laparoscopic interventions with faster performance and higher precision without an increase in mental workload.11,23 The 3DHD system has improved performance in complex surgeries by experienced surgeons.24-26 In addition, other studies have demonstrated that the 3DHD system allows junior trainees to become proficient sooner, at least with respect to benchtop simulator tasks.27,28

The ConMed 3DHD system has bi-channeled laparoscopes, creating a unique image for the right and left eyes. The image will become blurred when one of the optical channels is not functioning. Furthermore, this 3DHD system offers the advantage of accurate depth perception and spatial orientation as a result of the input of 2 unique images for neural summation on a cortical level.29,30 It is hypothesized that proficiency of a surgeon may be improved by using 3DHD laparoscopic equipment for vessel anastomoses for kidney transplant procedures. Thus, the laparoscopic technique for kidney transplant could be widely applied.

In this small study, 3DHD laparoscopic equipment was evaluated in the context of performing kidney transplants on human cadavers. This complex procedure involves efficient anastomosis of the renal artery and vein so that warm ischemic damage to the kidney graft is minimized. The performance metrics for anastomosis of the renal artery and vein were satisfactory, and the total time for anastomosis of the vessels was about 60 minutes. The quality of the vessel anastomoses was also satisfactory, as assessed during the procedure in real time and on the review of the video recording. There was no obvious leakage when heparinized saline was injected into the anastomosis site at the completion of the anastomosis. The time for vessel anastomosis was shorter compared with the 2D laparoscopic system.

It had been expected that the 3DHD equipment would yield a superior visual view of the anatomic structures versus the 2D equipment. For a better orientation, however, it is recommended that the 3DHD should be kept in an upright direction. However, it may be possible and indeed necessary to disassemble and reassemble the camera after rotating the laparoscope. This however seems time con­suming in the context of vessel anastomosis under time pressures. In addition, the distant tunnel effect may cause a distraction when movement for handling the needle and placing sutures is necessary. Fatigue was obviously a result of overcoming the distant tunnel effect and wearing the 3D glasses. It was also a challenge to avoid violation of the stereoscopic window.

Advances in conventional 2D laparoscopic technology and associated instruments have played an important role in improving the performance of laparoscopic surgery. The Karl Storz SPIES system has provided an innovative high-definition system. It provides good quality of images and allows easy recognition of tissue structures. The bright red portions of the visible spectrum are filtered out, and the remaining color portions are expanded. There was less fatigue as a result of the enhanced quality of images and the quality of vessel anastomoses was satisfactory. There was no leakage observed after injection of heparinized normal saline after completion of vessel anastomosis. The surgery time was longer compared with the 3DHD system due to the technique refinement for creation of the extraperitoneal working space. It was felt more effective if the balloon dilator was inserted at the site of the right-hand port, which is lateral and inferior to the umbilicus, forming a triangular shape with the left-hand port and camera port. The Pfannenstiel incision can be made earlier to facilitate creation of the working space.

The limitations of this study include the variations in the anatomy of the pelvis between the cadaveric bodies. The proficiency of the procedure is still under exploration to establish optimal access for creation of the working space and improve the vessel anastomoses. Some instruments need to be refined to facilitate the efficiency for laparoscopic kidney transplant.

Conclusions

This pilot study reinforces the suggestion that kidney transplant by a laparoscopic technique via an extraperitoneal approach is feasible in a human cadaveric model. The operation for kidney transplant was the same as for an open kidney transplant, but the procedure was performed by laparoscopic technique, in which a smaller 7-cm Pfannenstiel incision is required for delivery of the kidney graft. The vessel anastomoses can be completed within the time constraints using either the 3DHD (ConMed) or 2D (Storz SPIES) system. The tunnel vision with the 3DHD system was a disadvantage during the performance of the procedure. The surgeons felt less tired when using the high-quality 2D image system. However, this cadaveric training model may play a pivotal role for transition of a laparoscopic kidney transplant technique to clinical practice.


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Volume : 15
Issue : 5
Pages : 497 - 503
DOI : 10.6002/ect.2016.0177


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From the 1Western Australia Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia; and the 2School of Surgery and 3Animal Care Services, The University of Western Australia, Perth, Australia
Acknowledgements: The authors have no conflicts of interest to declare. We thank the companies Applied Medical; ConMed, Linvatec Australia PTY LTD; B Braun Australia Pty; Covidien PTY LTD; and Karl Storz-ENDOSKOPE for providing sponsorship for this study. We also thank the staff in the Clinical Training and Education Centre for facilitation of the study. BH provided study design, performed surgery, and wrote the paper; LM and RD assisted with surgery; GM provided statistical analyses and manuscript preparation; JH provided study design and critical review of the paper.
Corresponding author: Bulang He, Western Australia Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia
Phone: +61 8 64574055
E-mail: bulang.he@health.wa.gov.au