概要
Single port laparoscopic surgery is changing the standard of care in surgical care like nothing since the laparoscopic technique was introduced 20 years ago. We present out technique of single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in 100 patients.
Abstract
In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.
Protocol
Single Port Donor Nephrectomy:
- Place patient in the right lateral decubitus position with left side up
- Operating surgeon will stand facing abdomen with the assistant camera driver standing to the surgeons right and caudad
- Measure 5 cm incision over umbilicus on stretch
- Create incision at umbilicus and enter the abdominal cavity.
- Place the Alexis Wound Retractor
- Place Appropriate Laparoscopic Ports in Gel Point Seal (2 5mm ports and 1 15mm port) as disrected and shown in video
- Place Gel Point seal on Alexis Retractor and Insuffolate the abdomen
- Mobilize the Descending Colon off of the Retroperitoneum
- Mobilize the Spleen from lateral to medial to create plane between the spleen and the upper pole of the kidney
- Dissect the Ureter and Gonadal Vein from the level of the Iliac vessels up to the lower pole of the kidney
- Follow the Gonadal Vein to the Renal Vein in the area of the Hilum. The Gonadal vein can be ligated and divided near the Renal Vein if needed
- Identify and divide any Lumbar Veins
- Identify and Divide the Adrenal Vein between clips
- Dissect the Renal Vein Circumferentially
- Identify the Renal Artery and dissect it circumferentially
- Mobilze the entire kidney off of the retroperitoneum
- Pace a 5-12mm Port where the lower 5mm port had been placed in the Gel Point Seal
- Ligate and divide the Ureter and Gonadal Vein at the Iliac Vesselswith an Endo-GIA stapler
- Ligate the renal artery with an Endo-TA vascular stapler and then divide with endoshears
- Ligate and divide the renal vein with an Endo-GIA stapler
- Place the kidney in and large Endocatch bag
- Remove the Gel Point Seal and the Alexis Retractor
- Remove the kidney from the Abdominal Cavity
- Replace the Gel Point Seal
- Survey for hemostasis and replace the Descending Colon in the appropriate location along with the spleen
- Close the abdominal wall fascia and then the skin incision
- Place dressing
Discussion
The Single Port Donor Nephrectomy is a viable next step in the evolution of donor nephrectomy. At times, steps in the procedure have to be accomplished out of order due to the challenges inherent in the single port which limits side to side retraction and mobility as discussed in the video. The cosmesis is excellent and patients return to activities very quickly. As the procedure evolves new instruments will be developed that will aide in the accomplishment of more of more and more complex tasks through the single port entry.
開示
The authors have nothing to disclose.
Acknowledgements
We would like to acknowledge Applied Medical for supporting this work through and unrestricted educational grant which allowed us to produce the video and publish.
参考文献
- Canes, D., Berger, A., Aron, M. Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol. 57, 95-101 (2010).
- Skrekas, G., Papalois, V. E., Mitsis, M. Laparoscopic live donor nephrectomy: a step forward in kidney transplantation. JSLS. 7, 197-206 (2003).
- Giessing, M. Laparoscopic living-donor nephrectomy. Nephrol Dial Transplant. 19, iv36-iv40 (2004).
- Eng, M. The role of laparoscopic donor nephrectomy in renal transplantation. Am Surg. 76, 349-353 (2010).
- Kommu, S. S., Kaouk, J. H., Rane, A. Laparo-endoscopic single-site surgery: preliminary advances in renal surgery. BJU Int. 103, 1034-1037 (2009).
- Canes, D., Desai, M. M., Aron, M. Transumbilical single-port surgery: evolution and current status. Eur Urol. 54, 1020-1029 (2008).
- Desai, M. M., Berger, A. K., Brandina, R. Laparoendoscopic single-site surgery: initial hundred patients. Urology. 74, 805-812 (2009).
- Ganpule, A. P., Dhawan, D. R., Kurien, A. Laparoendoscopic single-site donor nephrectomy: a single-center experience. Urology. 74, 1238-1240 (2009).
- Gill, I. S., Canes, D., Aron, M. Single port transumbilical (E-NOTES) donor nephrectomy. J Urol. 180, 637-641 (2008).
- Raman, J. D., Bensalah, K., Bagrodia, A. Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology. 70, 1039-1042 (2007).
- Raybourn, J. H., Rane, A., Sundaram, C. P. Laparoendoscopic single-site surgery for nephrectomy as a feasible alternative to traditional laparoscopy. Urology. 75, 100-103 (2010).
- Dindo, D., Demartines, N., Clavien, P. A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240, 205-213 (2004).
- Bargman, V., Sundaram, C. P., Bernie, J. Randomized trial of laparoscopic donor nephrectomy with and without hand assistance. J Endourol. 20, 717-722 (2006).
- El-Galley, R., Hood, N., Young, C. J. Donor nephrectomy: A comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy. J Urol. 171, 40-43 (2004).
- Velidedeoglu, E., Williams, N., Brayman, K. L. Comparison of open, laparoscopic, and hand-assisted approaches to live-donor nephrectomy. Transplantation. 74, 169-172 (2002).
- Raman, J. D., Bagrodia, A., Cadeddu, J. A. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol. 55, 1198-1204 (2009).
