Retroperitoneoscopic Live Donor Nephrectomy

The retroperitoneal approach to laparoscopic live donor nephrectomies initially evolved as an alternative technique to address concern with the low rates of right-sided laparoscopic donor nephrectomy in most series, an apparent reflection of the increased degree of technical difficulty harvesting the right kidney by the transperitoneal approach. As such, most reported series of retroperitoneoscopic donor nephrectomy involve the right kidney (42-45), although a small series of successful left-sided retroperitoneoscopic donor nephrectomy has recently been reported (46).

In performing retroperitoneal laparoscopic live donor nephrectomies, the patient is placed in the flank position, and the operating table is flexed to maximize the space between the iliac crest and the 12th rib. The retroperitoneal space is created by making a 15-mm incision inferior to the tip of the 12th rib through the lum-bodorsal fascia. The space is expanded with blunt finger dissection and then a balloon dilator. Balloon dilation is performed anterior to the psoas muscle and outside of and posterior to Gerota's fascia. A three-port technique is used, with the primary 12-mm port placed at the site of entry. Another 12-mm port is placed anteriorly near the anterior axillary line approximately 3 cm cephalad to the iliac crest. A posterior 5-mm port is placed at the junction of the lateral border of the paraspinal muscles and the 12th rib (42).

The renal hilum is identified posteriorly, and the renal artery is isolated and mobilized from the renal hilum to its retrocaval location. The renal vein, along with a segment of inferior vena cava, is skeletonized. The ureter within the periureteral sheath is dissected distally into the pelvis.

An important technical consideration with the retroperitoneal approach is maintaining the attachments of the anterior kidney to the parietal peritoneum during most of the procedure.

Similar to the intact posterolateral attachments during the transperitoneal approach, this prevents the kidney from flopping posteriorly and obscuring the surgeon's view of the renal hilum.

During preparation for extraction, a muscle-splitting Gibson incision is made and developed to the transversalis fascia, avoiding disruption of the pneumoretroperitoneum (47). The renal artery and renal vein are divided in standard fashion. An articulating vascular stapler is positioned parallel to and flush with the vena cava as in the transperitoneal operation, ensuring procurement of the entire length of the right renal vein. Once the renal hilum is secured, the anterior attachments are rapidly divided to free the allograft completely. The intact fascial layer at the Gibson incision is divided, and the retroperitoneum is entered to quickly extract the kidney manually (47). The ureter is then transected using the incision for distal exposure.

The pure retroperitoneoscopic approach does have certain advantages over transperitoneal laparoscopic live donor nephrectomies. It allows rapid and direct access to the renal hilum, obviating the need to mobilize the liver, ascending colon, and duodenum. The right renal artery is effectively skeletonized in a retrocaval location, ensuring optimal arterial length for transplantation.

The pure retroperitoneoscopic approach does have certain advantages over transperitoneal laparoscopic live donor nephrectomies (48-50). It allows rapid and direct access to the renal hilum, obviating the need to mobilize the liver, ascending colon, and duodenum. The right renal artery is effectively skeletonized in a retrocaval location, ensuring optimal arterial length for transplantation.

The right renal vein and adjacent vena cava can be dissected under direct vision. Intra-abdominal adhesions in patients with prior abdominal surgery are avoided. Because the peritoneal cavity is not violated, iatrogenic injury to intraperitoneal organs and the likelihood of postoperative paralytic ileus are reduced.

Disadvantages of the pure retroperitoneoscopic approach to live donor nephrec-tomy include a longer warm ischemia time of the allograft, because anteriomedial kidney attachments are not divided until after the renal vessels have been transected. Identification of landmarks is limited, and dissection in obese patients with large amounts of retroperitoneal fat can be quite difficult. Although hand-assisted retroperi-toneoscopic live donor nephrectomy has been reported, the smaller working space limits the surgeon's ability to effectively use his/her hand to optimize dissection (48).

The largest experience with retroperitoneal laparoscopic live donor nephrec-tomies is reported by Ng et al. (45). In this series, right retroperitoneal laparoscopic live donor nephrectomies is compared with left transperitoneal laparoscopic live donor nephrectomies in a consecutive single-institutional experience. Operative times were significantly less with the retroperitoneal approach, whereas hospital stay, analgesic use, and donor-recipient creatinine were similar in both groups. Despite a statistically significant longer warm ischemia time with the retroperitoneal technique, recipient functional outcomes at one week and one month were similar in both groups (45).

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