EXPERIMENTAL AND CLINICAL TRANSPLANTATION

The available scientific literature has described the tangible benefits of operations using new 3-dimensional laparoscopic systems. The purpose of this report was to describe the first experience of pure 3-dimensional laparoscopic living-donor nephrectomy for transplant in the Republic of Kazakhstan. A living-donor kidney transplant was performed in a 21-year-old male patient with the father as the donor. The operation was performed with general anesthesia using a 3-dimensional endo-videoscopic stance with flexible camera (Olympus, Tokyo, Japan). The time of warm ischemia was 130 seconds, and the total operation time was 280 minutes. The postoperative period proceeded smoothly, without any complication. The patient was discharged on day 3 after transplant with normal levels of creatinine and urea. The recipient’s surgery was typical, and no complications or difficulties in performing anastomosis were encountered. With further accumulation of experience, 3-dimensional laparoscopic nephrectomy from living donors could become a new criterion standard.

Key words : 3-Dimensional imaging, Kidney transplant, Living-donor renal transplant

Living-donor kidney transplant (LDKT) has become a common surgical procedure due to the scarcity of deceased donors. Over the past decades, survival of the graft after LDKT has greatly increased. Since the mid-1990s, laparoscopic donor nephrectomy has been a more widely performed operation in transplant surgery. With introduction in practice of laparoscopic donor nephrectomy, several transplant centers have reported increased numbers of LDKT procedures.^1-4

In the early 1990s, 3-dimensional (3D) visualization technology was introduced in endoscopy to facilitate video laparoscopic surgery, which recently became routine with advantages of clear stereoscopic visualization. The available scientific literature has described the tangible benefits of operations using new 3D laparoscopic systems.^5-7 Currently, in the Commonwealth of Independent State countries, including the Republic of Kazakhstan, the technique of 3D laparoscopic nephrectomy is at the implementation stage.

The purpose of this report was to describe the first experience of pure 3D laparoscopic living-donor nephrectomy for transplant in the Republic of Kazakhstan.

The recipient was a 21-year-old male patient with chronic kidney disease (stage V). He had been receiving hemodialysis for 8 months. The donor was his 52-year-old father who had no chronic diseases. Computed tomography of the abdomen revealed that the vascular anatomy of the donor on both sides was typical; it was decided to remove the left kidney. The operation was performed with general anesthesia using a 3D endo-videoscopic stance with flexible camera (Olympus, Tokyo, Japan). The patient was positioned on the right side with a bend of the body at 45 degrees. Three trocars were used: one trocar 2 cm below the belly button (10 mm) for the camera, a second trocar (5 mm) placed along the lateral edge of the left rectal muscle at a level of 2 cm below the belly button, and a third trocar (12 mm) in the left iliac region.

The surgical technique was performed per standard protocol. Kidney vessels were isolated through their origins after exposure of the left kidney with the intersection of the gonadal vein and adrenal vessels. The ureter was transected distally at the level of the iliac vessels. After complete mobilization of the left kidney, a 5-cm-long incision in the left iliac region was made to the peritoneal layer for subsequent removal of the graft. The renal artery and vein were transected by a linear vascular suturing apparatus, and the kidney was extracted from the abdominal cavity through incision in the iliac region and transferred to the “back table.” After examination of the renal fossa, the trocars were removed, and the incision was closed layer-by-layer without leaving drainage to the abdominal cavity.

The warm ischemia time was 130 seconds, and the total operation time was 280 minutes. No blood loss and intraoperative complications were observed. The postoperative period proceeded smoothly without any complications. The patient was discharged on day 3 after transplant with normal levels of creatinine and urea. The recipient’s surgery was typical, and no complications or difficulties in performing anastomosis were encountered.

This is the first report showing the use of a pure 3D laparoscopy for donor nephrectomy in Kazakhstan. The 3D laparoscopic technology used by us allows us to clearly visualize tissues during dissection, and it far surpasses standard 2-dimensional (2D) laparoscopy in terms of better and deeper tissue vision.⁸ Moreover, 3D imaging reduces the risks of dizziness and headache during operation,⁹ as the state of the surgeon can indirectly affect the course of the entire operation. The 3D laparoscopic system provides a more accurate overview and thereby can reduce operating time by 15% to 30%, with minimized blood loss compared with standard 2D laparoscopy.¹⁰ This is an indisputable advantage for living donor operations. From an economic point of view, the use of 3D technology is much less expensive than using robot-assisted devices not only with living-donor transplant but also in other areas of surgery.

We believe that, for 3D laparoscopic donor nephrectomy, additional studies are needed to establish the advantages of this technique, which can replace the standard 2D technique in the future.

The 3D laparoscopic imaging system could provide a better spatial orientation and a more complete and accurate differentiation of tissue and organs elements compared with a 2D system. With further accumulation of experience, 3D laparoscopic nephrectomy from living donors could become a new criterion standard.

Volume: 18 Issue: 1 January 2020 - Supplement - 1

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