Clinical Trials

Open procedure

Laparoscopic

Organ Donation

Laparoscopic surgery is performed by inflating the abdomen with carbon dioxide gas to create a space between the abdominal wall and the organs. Using short (½ inch) incisions, narrow trocars are inserted through the abdominal wall so that instruments can be slid through them to perform the maneuvers necessary for the operation. All this is viewed directly on a video monitor, which receives its picture from a video camera attached to the laparoscope. The hand-assisted technique utilizes a short, lower abdominal midline incision for the surgeon’s hand. This site is later used to remove the kidney.

"The big advantage to the laparoscopic procedure, in general, is it’s less invasive. You go through much less muscle. With the open nephrectomy, you really have to go through quite a bit of muscle going through the flank and that really slows patients down as far as recovery goes."

 

Dr. Stephen Katz

As kidney transplant waiting lists continue to grow, surgeons are hopeful the use of the less-invasive technique of laparoscopy may eventually become the standard procedure, decreasing recovery time and encouraging more people to become living donors. The technique for the laparoscopic donor nephrectomy was pioneered at John Hopkins Medical Center and the University of Maryland in 1998. Since then, hospitals across the country have added the technique to their surgical repertoire. The hand-assisted laparoscopic donor nephrectomy utilizes a small midline incision that serves both as a portal for the surgeon’s hand and as the site for removal of the kidney. Two other small incisions are used for trocars, narrow tubes used to insert the laparoscopic instruments and camera.

All of these procedures were performed using the hand-assisted approach, which utilizes an incision to remove the kidney as a portal for the surgeon’s hand throughout the procedure. “With the hand-assisted technique, you put the hand in almost from the beginning to aid you with the dissection and to be able to feel where the arteries are,” said Katz. “The anatomy is a little bit more straight forward when you can feel with your hand, because we’ve been at this for a while—I’ve probably done a couple of hundred nephrectomies—so it helps having been in that area and being familiar with that anatomy with my hand. It can really show me a lot.

“It can help me stay out of trouble. So we think the hand-assisted is a much safer way of doing these.”

The size and position of incisions for the hand-assisted approach are nearly identical to the closed laparoscopic technique and still offer an improved cosmetic effect as well as reduced recovery time, compared to an open nephrectomy.

“You have to make an incision anyway and it has to be big enough to get the kidney out,” Katz points out. “And my hand is pretty small, so I can get away with making an incision that’s about the same as for a closed procedure, but with the added benefit and safety of having my hand in there. If we get into bleeding or problems that typically people run into laparoscopically that then cause them to open up and make a big incision, it’s much safer if you can see the bleeding point and put your finger on it until you can make the big incision and get out of trouble.”

Katz says from a surgeon’s perspective, making the transition from an open to a closed procedure is easier when utilizing the hand-assisted technique.

“For those of us who have been trained in the open technique and are changing to the laparoscopic technique, it’s nice to have that safety factor of having the hand in there,” said Katz. “And studies have shown that the technique shortens the output time (the time required to remove the kidney from the body), hand-assisted compared to closed, which I think is very important.”

But why convert to the laparoscopic technique from the tried and true open method?

“The big advantage to the laparoscopic procedure, in general, is it’s less invasive. You go through much less muscle,” Katz said. “With the open nephrectomy, you really have to go through quite a bit of muscle going through the flank and that really slows patients down as far as recovery goes. The laparoscopic patients tend to recover quicker, they go home quicker, they’re back to their full activities quicker and they’re feeling good again much sooner compared to the open nephrectomy.

“With the open technique it really was a month or two months of relatively limited activity. If you went back to work before then, it was really pretty limited.” Using the hand-assisted technique in a donor nephrectomy, the surgeon has the benefit of touch, while the use of the laparoscope allows the patient to experience a much less-invasive procedure and enjoy a much shorter recovery period.

Because of the faster recovery time, typically two to three weeks less than the recovery time for an open procedure, some transplant facilities are noting dramatic increases in live donors. John Hopkins reports a 100 percent increase in live donor transplants since pioneering the laparoscopic procedure more than three years ago. The hospital also reports that live donor transplants account for 55 percent of all renal transplants at the facility.

John Hopkins has even encountered a number of altruistic donor kidney transplants since the advent of the laparoscopic technique. The first was performed in 1998. The donor was an organ procurement nurse. She said she hoped, by her example, to demonstrate that being a live kidney donor was a safe and rewarding way to help the thousands of patients waiting for transplants. Since her donation, there have been more than 100 individuals who have expressed interest in donating their kidney to a stranger and four additional altruistic donor transplants have taken place at John Hopkins.

Ideal candidates for laparoscopic donor nephrectomies should be relatively young, with no history of heart problems, and few, if any, previous abdominal surgeries, Katz said. Imaging studies are used to determine if the donor has any anatomical abnormalities (such as more than one renal artery) that may make navigating the surgery laparoscopically more difficult.

“We have to be careful, according to the anatomy of the artery and vein, so we don’t have too many vessels to have to try to work with,” Katz said. “For example, if you have an artery with a very early branch, in the open technique, you could probably get that as one vessel, but laparoscopically it would most certainly be two and you’d either have to put the arteries together to sew into the recipient’s one or you’d have to use two separate implantations into the recipient. So it can be more complicated with the laparoscopic approach.”

While the laparoscopic approach has many advantages, some less-desirable aspects of the procedure include the increased likelihood of adhesions with abdominal entry; higher risk of damage to other organs by utilizing the abdominal, rather than flank approach; and shorter blood vessels which can make the anastomosis of the transplant more challenging.

Medical illustrations by Scott Holmes