Donor Nephrectomy

Living kidney donation represents an important source for patients with end-stage renal disease (ESRD), and has emerged as an appealing alternative to cadaveric donation. Furthermore, within the last decade, lapa-roscopic donor nephrectomy has replaced the conventional open approach, and has gained surgeon and patients acceptance.

The first laparoscopic living donor nephrectomy was attempted to alleviate the shortage of kidneys for transplantation and to reduce the hospitalization and recuperation time associated to with open nephrec-tomy [28]. The outcomes reported for the laparoscopic technique were similar to the open operation, adding all the advantages of minimally invasive procedures [29]. The reduction of postoperative pain, shorter hospital stay, better cosmetic results, and shorter convalescence time are increasing the acceptance of the donors with the subsequent expansion of donor pool [30, 31].

We started performing the robotic hand-assisted living donor nephrectomy utilizing the da VinciĀ® Surgical System (Intuitive Surgical, Sunny Valley, Calif.) in January 2001. Our technique is hand-assisted using the

LAP DISC (Ethicon, Cincinnati, Ohio) (Fig. 9.5). The utilization of a hand-assisted device like the LAP DISC allows for faster removal of the kidney to decrease warm ischemia time [32]. Another advantage of having the hand inside the abdomen is rapid control in case of bleeding, and avoidance of excessive manipulation of the kidney, which is otherwise required in the removal of the kidney with an extraction bag. The robotic system provides the benefits of a minimally invasive approach without giving up the dexterity, precision and intuitive movements of open surgery.

A helical CT angiogram with three-dimensional reconstruction of the kidney is performed on all patients to evaluate abnormalities in the parenchyma, the collecting system, and renal vascular anatomy. The reconstruction is a useful roadmap to identify the presence of multiple renal arteries. The room setup is critical in our current operation (Fig. 9.6). Two assisting surgeons are required; one surgeon has his or her right hand inside the patient, and the second surgeon exchanges the robotic instruments and assists the operative surgeon through the 12-mm trocar.

Since the beginning of our experience, we have implemented the policy of routinely harvesting the left kidney, regardless of the presence of vascular anomalies, to take advantage of the longer length of the left renal vein. The presence of multiple renal arteries or veins has not been a problem for robotic-assisted approach. We performed a study with 112 patients who underwent robotic-assisted LLDN, where the patient population was divided into two groups based on the

Operating Room Setting
Fig. 9.6 Operating room set up for nephrectomy and adrenalectomy

presence of normal renal vascular anatomy (group A: n = 81, 72.3%) or multiple renal arteries or veins (group B: n = 31, 27.7%). No significant difference in mortality, morbidity, conversion rate, operative time, blood loss, warm ischemia time, or length of hospital stay was noted between the two groups. The outcome of kidney transplantation in the recipients was also similar in the two groups.

Since we started in 2000, we have improved on our operative technique. We have noticed a statically significant decrease in the operative time (p < 0.0001), suggesting experience and confidence of the surgical transplant team. The average operative time dropped from an initial 206 min (range: 120-320 min) in the first 50 cases to 156 min (range: 85-240 min) in the last 50 cases (p < 0.0001). The mean warm ischemia time was 87 s (range: 60-120 s). The average estimated blood loss was 50 ml (range: 10-1,500 ml). The length of hospital stay averaged 2 days (range: 1-8 days). One-

year patient and graft survivals were 100 and 98%, respectively. In conclusion, our data demonstrates that robotic hand-assisted donor nephrectomy is a safe and effective procedure.

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