Inguinal Incision as an Successful Route To Extract the Kidney During Laparoscopic Retroperitoneal Live-donor Nephrectomy

Abstract Objectives Evaluate the advantages of inguinal incision in extracting the kidney during retroperitoneal laparoscopic live-donor nephrectomy(LDN). Methods From May 2008 to June 2011, 58 cases of retroperitoneal LDN were performed at our hospital, all data were analyzed retrospectively. All donors were grouped as a test group (n=32, inguinal  incision) and a control group (n=26, lumbar 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 and incision complications. Results All 58 cases of retroperitoneal LDN 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 a test group, the mean hospital stay was shorter, P < 0.01; and cosmetic satisfaction was higher P < 0.01, the incidence rates of abdomen asymmetry(9/28), incision hernia(4/28), wound infection(5/28) and wound faulty union(6/28) of the control group was higher than that of the test group. The inguinal incision is a safe and practical graft retrieval incision in retroperitoneal laparoscopic donor nephrectomy and can be generally applied.烟台毓璜顶医院泌尿外科王科

 

Key words: Laparoscopic live-donor nephrectomy; Renal transplantation; Inguinal incision; retroperitoneal

 

Introduction

Since the first laparoscopic donor nephrectomy (LDN) was performed by Ratner in 1995, LDN has been gradually accepted as a safe procedure in recent years, and has increased the potential number of living kidney donors. Compared with open-donor nephrectomy(ODN), LDN results in fewer postoperative complications, less pain, shorter hospital stay, earlier recovery, and ideal cosmesis without differences in renal function or allograft survival.2-4 LDN can be performed transperitoneally or retroperitoneally on either side, the risk of bowel injury and intestinal obstruction is higher in transperitoneal LDN, retroperitoneal LDN has the advantages of limiting the risk of damage to intra-abdominal organs and providing direct access to the renal artery and vein, it has been performed in many countries, especially in china. 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.

 

From May 2008 to June 2011, we performed 32 cases of retroperitoneal LDNs with inguinal incision as graft retrieval incision. We retrospectively compared the differences of inguinal incision and lumbar incision for retroperitoneal LDN.

 

Materials and Methods

Donors and recipients

From May 2008 to June 2011, 58 cases of retroperitoneal LDN s were performed at our center. Obese donors, donors with an lumbar operation history of the same side as the donor kidney 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 17 men and 41 women (age range, 23-67 years, mean age, 38.6 years) and a kinship relationship developed between donor and recipient.

 

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=32) and a control group (n=26). According to graft retrieval incision, inguinal incision was used in test group, lumbar incision was used in control group.

 

Among the 58 recipients, 37 men, 21 women (age range 16-68 years; mean age, 37.5 years), no renal transplant contradictions were found.

Live-donor nephrectomies procedure(left)  

The patient was placed in a right lateral position. The port A(posterior axillary line maintained under the 12th rib) was created, 2 cm incision was made by knife, them long forceps was used to dissociate subcutaneous tissue, muscle, and lumbar fascia, finger could feel inner face of the rib, self-made gasbag was inserted, 500-800ml gas was incharged, kept for 3-5minutes(Figure 1). Port B(anterior axillary line maintained under the 12th rib) was created by finger guidance，port C(middle axillary line maintained above the iliac crest) was created, 10 trocar was inserted(Figure 1). 12 cm trocar was inserted on the port A, lumbar fascia was sutured first, muscle and skin were sutured then.

 

Entering retroperitoneal cavity, extraperitoneal and perirenal fasica adipose tissue was separated sharply with ultrasonic knife from superior to interior, from anterior to posterior, then peritoneal reflection and Gerota fascia was identified clearly. Gerota fascia was dissected near to peritoneal reflection, exceeding upper pole of kidney, lower 3-4cm inferior to lower pole of kidney. The perirenal fat tissue was dissected from lateral border near to renal hilum on the front of kidney first, then the real part. On the level of inferior pole of kidney, dissection must be performed carefully, ureter could be recognized and was mobilized. Renal vessel sheath was opened，then renal artery and vein were mobilized completely. Adrenal gland was detached from kidney finally. The ureter was sectioned close to the crossover with the iliac vessels.

 

For the test group, kidney was pulled out from inguinal incision, a 5-cm to 7-cm skin incision was made 2 cm apart from the inguinal ligament (Figure 2), skin, subcutaneous tissue, oblique externus abdominis muscle membrane were cut open, endoabdominal fascia and obliquus internus abdominis were left intact. For 12 cases, extract bags was placed into retroperitoneal cavity from 12cm trocar which was inserted by inguinal incision, then kidney body was loaded in bag. The renal artery and vein were ligated, endoabdominal fascia and obliquus internus abdominis were slitted, extract bag with kidney was pulled out from inguinal incision. For 20 cases, inguinal incision was about 6-7cm long, kidney was pulled out by operator hand.

 

For the contrast group, lumbar incision was created from A to B, about 7-9cm long, external oblique muscle and internal oblique muscle were cut, transverse abdominal muscle back fascia was left intact. After the renal artery and vein were ligated, transverse abdominal muscle fascia was slitted, kidney was pulled out by operator hand from lumbar incision.

 

Clinical data

All live-donor nephrectomies’ operative time, operation blood loss, ischemia time, hospital stay and incision complications were recorded and compared. Incision complications included abdomen asymmetry, incision hernia, wound infection and wound faulty union. All donors and recipients were followed-up for at least 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 58 cases of retroperitoneal LDN 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 and incision complications were reported in Table 1. 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 < 0.01; and cosmetic satisfaction was higher P < 0.01.

 

In the control group, the incidence rates of abdomen asymmetry(9/28), incision hernia(4/28), wound infection(5/28) and wound faulty union(6/28) was higher than that of the test group.

 

Discussion

Since the first laparoscopic donor nephrectomy (LDN) was performed by Ratner in 1995, LDN has been gradually accepted as a safe procedure in recent years, and has increased the potential number of living kidney donors.1,5 Since May 2004, all live-donor nephrectomies have been performed by laparoscopy at our hospital. LDN seem to be at least as safe and efficacious as open-donor nephrectomies(ODN).6-9 Compared with ODN, LDN has shown superior results in postoperative pain, less complications, satisfactory cosmesis, and  fast recovery.9-13 There are no significant differences in cost-effectiveness and graft function between LDN  and ODN.14-16 In addition, the longer warm ischemia time during live-donor nephrectomies shows no significant deleterious effect on graft survival.17-20

 

LDN can be performed transperitoneally or retroperitoneally on either side. Due to adequate working space and easy dissection, LDN was done transperitoneally at many centers. However, the risk of bowel injury and intestinal obstruction is higher in transperitoneal LDN. Retroperitoneal LDN was performed firstly by Yang et al in 1995,21 because it has the advantages of limiting the risk of damage to intra-abdominal organs and providing direct access to the renal artery and vein, it has been performed in many countries, especially in china.21-24 Many studies showed that Retroperitoneal LDN was safe and feasible as transperitoneal LDN, was less invasive than transperitoneal LDN. 25-27

 

The aim of LDN is to decrease operative trauma on the donor and guarantee graft quality as much as possible. The incision trauma also plays an important role for the donor to decide donation at some degree, especially for young women. From a cosmetic standpoint, the midline or subcostal scar is often prominent, and can not be concealed by lingerie or swimwear.28 Compared with lumbar incision and upper abdomen incision, the inguinal incision has the advantages of thinner muscle, less trauma, less dehiscence, quick recovery, better cosmesis and less complications.28 Our study showed that inguinal incision did not increase operative time, blood loss, but decreased hospital stay, incision complication rate of abdomen asymmetry, incision hernia, wound infection and wound faulty union.

 

The inguinal incision is a safe and practical graft retrieval incision in retroperitoneal LDN and can be generally applied.

 

References

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2.         Nicholson ML, Kaushik M, Lewis GR, et al. Randomized clinical trial of laparoscopic versus open-donor nephrectomy. Br J Surg. 2010; 97(1): 21-28.

3.         Antcliffe D, Nanidis TG, Darzi AW, Tekkis PP, Papalois VE. A meta-analysis of mini-open versus standard open and laparoscopic living donor nephrectomy. Transpl Int. 2009; 22(4): 463-474.

4.         Nanidis TG, Antcliffe D, Kokkinos C, et al. Laparoscopic versus open live-donor nephrectomy in renal transplantation: a meta-analysis. Ann Surg. 2008; 247(1): 58-70.

5.         Gill IS, Carbone JM, Clayman RV, et al . Laparoscopic live donor nephrectomy. J Endourol 1994; 8: 143-148.

6.         Simforoosh N, Basiri A, Tabibi A, et al. Comparison of laparoscopic and open-donor nephrectomy: a randomized controlled trial. BJU Int. 2005; 95(6): 851-855.

7.         Shokeir AA. Open versus laparoscopic live-donor nephrectomy: a focus on the safety of donors and the need for a donor registry. J Urol. 2007; 178(5): 1860-1866.

8.         Kok NF, Weimar W, Alwayn IP, et al. The current practice of live-donor nephrectomy in Europe. Transplantation. 2006; 82(7): 892-897.

9.         Kok NF, Dols LF, Hunink MG, et al. Complex vascular anatomy in live kidney donation: imaging and consequences for clinical outcome. Transplantation. 2008; 85(12): 1760-1765.

10.     Simforoosh N, Basiri A, Shakhssalim N, et al. Effect of warm ischemia on graft outcome in laparoscopic donor nephrectomy. J Endourol. 2006; 20(11): 895-898.

11.     Ratner LE, Kavoussi LR, Sroka M, et al . Laparoscopic assisted live donor nephrectomy a comparison with the open approach. Transplantation 1997; 63: 229-233.

12.     Flowers JL, Jacobs S, Cho E, et al . Comparison of open and laparoscopic live donor nephrectomy. Ann Surg. 1997; 226: 483-90. 

13.     Kuo PC, Plotkin JS, Johnson LB. Is living donor nephrectomy a "23-hr stay" procedure?  Transplantation 1999; 68: 1064-5.

14.     Demyttenaere S, Feldman LS, Fried GM. Effect of pneumoperitoneum on renal perfusion and function: a systematic review. Surg Endosc. 2007; 21(2): 152-160.

15.     Aguiar WF, Passerotti CC, Claro JF, et al. Mini-incisions by lombotomy or subcostal access in living kidney donors: a randomized trial comparing pain, safety, and quality of life. Clin Transplant. 2007; 21(2): 269-276.

16.     Mjøen G, Øyen O, Holdaas H,et al. Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry. Transplantation. 2009; 88(11): 1273-1279.

17.     Patel S, Cassuto J, Orloff M, et al. Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States. Transplantation. 2008; 85(4): 561-565.

18.     Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med. 2009; 360(5): 459-469.

19.     Andersen MH, Mathisen L, Veenstra M, et al. Quality of life after randomization to laparoscopic versus open living donor nephrectomy: long-term follow-up. Transplantation. 2007; 84(1): 64-69.

20.     Kok NF, Adang EM, Hansson BM, et al. Cost effectiveness of laparoscopic versus mini-incision open-donor nephrectomy: a randomized study. Transplantation. 2007; 83(12): 1582-1587.

21.     Yang SC, Park DS, Lee DH, et al. Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J Urol 1995; 153: 1884-1886.

22.     Jacobs SC, Flowers JL, Dunkin B, et al. Living donor nephrectomy. Curr Opin Urol. 1999; 2: 115?120.

23.     Ishikawa A, Suzuki K, Saisu K, et al. Endoscopy-assisted live donor nephrectomy: comparison between laparoscopic and retroperitoneoscopic procedures. Transplant Proc 1998; 30: 165?167.

24.     Hemal AK, Singh I. Minimally invasive retroperitoneoscopic live donor nephrectomy: Point of technique. Surg Lap Endos Tech 2001; 11: 341-343.

25.     Dong J, Lu J, Zu Q, et al. Retroperitoneal laparoscopic live donor nephrectomy: report of 105 cases. J Huazhong Univ Sci Technolog Med Sci. 2011; 31(1): 100-102.

26.     Kohei N, Kazuya O, Hirai T, et al. Retroperitoneoscopic living donor nephrectomy: experience of 425 cases at a single center. J Endourol. 2010; 24(11): 1783-1787.

27.     Dimitri Liapis, Alexandre De La Taille, Guillaume Ploussard, et al. Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years. World J Urol. 2008; 26(6): 523?530.

28.     Wang K, Wan FC, Gao ZL, et al. Inguinal Oblique Incision as an Alternative Route To Extract the Kidney During Laparoscopic Donor Nephrectomy. Experimental and Clinical transplantation. 2011; 9(5)：315-318

Figure legends

Figure 1. Patient position and port and graft retrieval incision for live-donor nephrectomies

A: 12-mm trocar for laparoscope; B: 5-mm trocar for work port; C: 10-mm trocar for work port.  Incision, inguinal incision for extraction of donor kidney.

 

Figure 2. Inguinal oblique incision was created before renal artery obstructi