Laparoscopic Living donor nephrectomy. Transperitoneal and Retroperitoneal Technique. Safety and efficacy

Introduction: Kidney transplantation is considered the best replacement treatment for patient with end stage renal failure but the transplant community has to face the constant shortage of organs. For this reason programs have been developed to implement the transplants from living donors, that have been shown to have the best outcomes. The laparoscopic technique for kidney donation has almost completely supersede the open surgery being associated with short convalescence time and increased quality of life for the donor and equally effective results for the recipient. Within the different type of laparoscopic techniques the hand assisted one is at the moment the most utilised in UK. The retroperitoneoscopic techniques has been developed to try to minimise further more the potential complications of this type of surgery offering the intrinsic advantages of the conventional transperitoneal approach and potentially lower risk of intraperitoneal complications. Materials and Methods: At the Royal London Hospital in the period between July 2011 and July 2013 ninety-two Laparoscopic Hand Assisted Donor Nephrectomy (LHADN) have been performed of which 34 with retroperitoneal approach. Statistical Analysis: The data analysed were: Warm Ischemia Time (WIT), Length of operative time, Length of postoperative stay, Safety and incidence of complications in the donor. The aim of the study was to demonstrate the safety and efficacy of this technique and to compare the retroperitoneal approach with the transperitoneal hand assisted donor nephrectomy. Results: There were no significant differences within the two groups on the base of age and gender. In the retroperitoneal group the number of right nephrectomies was significantly higher (Side L/R (%) TP 55/3 - 94.8%/5.2% - RP 25/9 - 73.5%/26.5%). HARLDN was effectively and safely completed in 92 donors (100%). No conversion to open surgery was required, no intra or perioperative death was recorded. The skin to skin time despite numerically inferior in the retroperitoneal group (75 to 132 mins - median 102) was not significantly different from the operative time in the transperitoneal group (94 - 170 mins - median 114). The warm ischemia time (WIT), was identical in the two groups (median 97 sec TP vs. 96 sec RP). Length of stay (3 days) was identical in the two groups of patients while the major complication rate such us incisional hernia, bowel injury or intestinal obstruction (15% vs. 0%) was significantly higher in the transperitoneal group. The incidence of minor complications such as urinary tract infections, pulmonary infections or wound infections was identical in the two group. Discussion: In our experience we felt that the direct approach to the renal hilum and to the vascular structures of the kidney, allowed by the retroperitoneal access, can be a potential advantage in case of complex vascular anatomy. The retroperitoneal technique may be considered the elective approach for patients with previous abdominal surgery, since it allow to operate in a space surgically virgin avoiding long and potentially dangerous dissection of the intraabdominal adhesions. With the retroperitoneoscopic technique the access to the hilum and the vessels is more direct and the mobilization of the intraperitoneal organs is not needed, possibly leading to fewer incidences of postoperative ileus and damage to these organs. The downside of the technique is represented by the limited working space and the presence of few anatomical landmarks. Conclusions: the retroperitoneal laparoscopic live donor nephrectomy offers all the advantages of the laparoscopic approach plus an intrinsic advantage of the potentially lower risk for early and late donor intraperitoneal complications and can be electively used in patients with previous abdominal surgery avoiding potentially dangerous dissection of adhesions.