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LAPAROSCOPIC LIVE DONOR NEPHRECTOMY

DD Gaur

 

INTRODUCTION
aparoscopic live donor nephrectomy is being regularly performed all over the world.1 The procedure being less invasive is more readily accepted by the prospective donor. However, the laparoscopic procedure has not yet become universally available due to a long learning curve, lack of training facilities and lack of experienced laparoscopic surgeons. Though, the laparoscopic procedure is reasonably safe, one has to tide over the initial period of learning, when the complication
rate is naturally going to be a bit higher.2 Because of this higher complication rates during the early phase and its medico-legal implications, there are only a few centers in the country, where laparoscopic live donor nephrectomy is regularly performed. We hereby, present our experience of retroperitoneoscopic live donor nephrectomy.

 

METHODS
The laparoscopic live donor nephrectomy can be performed either by the transperitoneal or the retroperitoneal approach. Most centres all over the world are using the transperitoneal approach, as it is easier to learn. However, due to its being
a transperitoneal approach, it is more invasive and hence, we at the Bombay Hospital prefer the retroperitoneal approach.

Twenty retroperitoneal laparoscopic live donor nephrectomies have been performed during the last decade. The procedure was performed under general anaesthesia, using three ports in the lumbar region. The kidney was retrieved through a
7 cm incision in the lumbar or suprapubic region.

RESULTS
The proedure was found to be less painful and the use of analgesics was limited to the first operative day. The mean operative time was 2.5 hours, the blood loss 100 ml and the patient was ambulatory the same evening.

The patients accepted the oral feeds the same day and were discharged from the hospital between 3 and 5 post-operative days.

There were no major complications both in the donor and the recipient, except for a renal vein tear. This required conversion to open surgery but the transplanted kidney functioned normally.

DISCUSSION
Compared to the open surgical procedure, laparoscopic live donor nephrectomy has de.nite advantages for the donor. It is less painful, a shorter hospitalization is required and the patient can return to work earlier.2 It also produces a better cosmetic result. Because it is patient friendly, the number of live donor nephrectomies have increased by more than 50% in the United States, as shown by a recent survey.3,4

Apart from the long learning curve and the initial problems faced by the laparoscopic surgeon, there is one more disadvantage of the laparoscopic technique. The warm ischaemia time for the laparoscopic procedure is almost double that for the open technique. However, a recent study conducted in the USA, has conclusively proved that this does
not really affect the function of the transplanted kidney.5 The other disadvantage of laparoscopic live donor nephrectomy is the much longer operative
time. This is one of the reasons why we regularly do not use this approach for most of our donor nephrectomies. Recently, hand assisted laparoscopic live donor nephrectomy has become popular as it is
equally minimally invasive and both the operative and the warm ischaemia times are reduced. The preferred minimally invasive approach for a simple operative procedure on the kidney, ueter or the adrenal has gradually shifted from the
transperitoneal to the retroperitoneal laparoscopic approach following the report of the balloon technique of retroperitoneoscopy by Gaur.6 Surprisingly, most of the laparoscopic live donor nephrectomies have been performed
transperitoneally and retroperitoneal laparoscopic live donor nephrectomy, though a relatively simple procedure due to the lack of in.ammatory adhesions, still remains a rarely practised minimally invasive operative procedure. During an open surgical procedure, the hand provides touch, pressure and tactile feedbacks which makes the procedure much simpler compared to a laparoscopic procedure. It was for this reason that the use of hand for complex laparoscopic procedures or for those requiring enlargement of the incision for an intact organ removal was initiated by Wolf et al 4 years ago.7 subsequently, hand assisted laparoscopic surgery has become a fairly well established procedure. However, the use of
hand for laparoscopic live donor nephrectomy has been limited to the transperitoneal approach and not a single report of its being used for the retroperitoneal approach has been published in the medical literature, except for a recent report.

ANTIOXIDANT VITAMINS IN PREVENTION OF CARDIOVASCULAR DISEASE
Vitamin E provided no benefit in overall mortality, cardiovascular death, or cerebrovascular accident. b carotene led to a small but significant increase in all-cause death, and a small increase in cardiovascular death.

Lancet, 2003; 2017.

 

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