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Hand Assisted Retroperitoneoscopic Live Donor Nephrectomy: Operative Technique And Clinical Outcomes. The Largest Single Institution Experience of 200 Consecutive Cases.
Satya Allaparthi, MRCS,MD, Sayeed Malek, MD, Stefan Tullius, MD,PhD, Sanjaya Kumar, MD.
Brigham and Womens Hospital, Boston, MA, USA.

BACKGROUND:
Our objective was to access the feasibility of an entirely retroperitoneal laparoscopic technique utilizing hand assistance, for both left and right sided live donor nephrectomy. This technique should allow the surgeon to place the hand and laparoscopic instruments, simultaneously, in the retro peritoneum during the procedure.
METHODS:
This is a report of the data collected prospectively in the last 200 consecutive live donor nephrectomise that have been performed using our HandAssisted Retro-Peritoneoscopic technique . A 6 cm muscle splitting incision is made in the ipsilateral lower quadrant. Under direct vision, the retroperitoneal space is developed bluntly. The lap disc/Gelport device is inserted followed by two 12mm and one 5 mm port. Using the hand and the laparoscopic instruments the retroperitoneal space is developed further and the kidney is completely mobilized. Pneumo-retroperitoneum is maintained at 10-12 mm Hg. A TA 30 endovascular stapler +/- clips are used to secure the artery and vein. The kidney is removed through the hand port incision. The entire procedure is performed through the retro peritoneum.
RESULTS:
Of the 200 donors, 143(71.5%) were on the left and 57(28.5%) on the right. Mean age was 44.3years (Range: 21-76), mean BMI was 26.5(18-37)kg/m2,. Thirty eight patients (19%) had multiple (2) renal arteries each. One patient had 3 renal arteries. Two donors had a retro-aortic renal vein. Two had a circumaortic left renal vein. One patient has a duplicated IVC. One donor had a completely duplicated collecting system. Average operative time was 174 (range: 90-260) minutes. Mean warm ischemia time was 162 (60-390) seconds. There was one major intra-operative complication, a ureteral injury. There were two minor intra-operative incidents. One minor IVC injury repaired intra corporeally and one colonic serosal injury secondary to cautery managed conservatively. Average estimated blood loss was 91(50-200) ml. There were no transfusions. There were no open conversions. All allografts functioned immediately following revascularization. Post operatively, 4 patients had a pneumothorax (less than 10%), managed conservatively, 4 patients had a superficial wound infection and one a small rectus hematoma. There were no major Clavein grade 4 or 5 complications in our series. Average hospital stay was 3.2(1-6) days. The average duration of post discharge narcotic analgesic use was 4(0-11) days and any analgesic use was 9(0-16) days
CONCLUSIONS:
To our knowledge, this is the largest single institution series describing the safety and efficacy of the Hand Assisted Retro-peritoneoscopic Live Donor Nephrectomy. The technique incorporates the advantages of the surgeons hand in the retroperitoneum and that of laparoscopic surgery. The procedure has minimal morbidity and the donors’ convalescence is short. It is a reliable technique. It can be safely used for both, left and right sided donor nephrectomy.


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