CHAPTER 46: Minimally Invasive Live Donor Nephrectomy

INTRODUCTION

Living organ donation has been a pillar of transplantation since its inception. The earliest attempt at live donor kidney transplant, as we know it now, was performed in Paris, in 1953, by the team of Jean Hamburger, where a mother donated a kidney to her son. The son had developed renal failure after removal of his solitary kidney following severe traumatic injury. No immunosuppression was used, and the graft had satisfactory function for 3 weeks before being rejected, and the recipient eventually died.

The recipient operation, developed by Rene Kuss in 1951, was essentially the same extraperitoneal approach as that used for the historical identical twin case of Murray and Merrill in Boston in 1954 and up to the present day. The donor operation, however, has evolved over the years.

Live donor nephrectomy is the most common donor operation in the transplant field. In Western countries, the number of living donors exceeds the number of deceased donors; however, deceased donor transplants still account for over 60% of kidney transplantation. In Asia and the Middle East, deceased donor kidney transplant is not well established, and living donor transplants account for over 90% of kidney transplants.

Open donor nephrectomy, seldom used now, is associated with considerable morbidity: postoperative pain, slow recovery, slow return to work, pneumothorax, and wound complications including hernia and chronic pain.

The most commonly utilized approaches currently include:

1. Mini incision open donor nephrectomy

2. Conventional laparoscopic transperitoneal donor nephrectomy

3. Hand-assist laparoscopic donor nephrectomy

4. Retro-peritoneoscopic donor nephrectomy (pure laparoscopic and hand assist)

5. Laparoendoscopic single site (LESS) donor nephrectomy

6. Robotic laparoscopic donor nephrectomy

7. Natural orifice transluminal endoscopic surgery (NOTES)

The introduction of laparoscopic donor nephrectomy by Ratner and Kavoussi in 1995, was a milestone in donor surgery. The first hand-assist laparoscopic donor nephrectomy was performed in 1998, and the first series of retroperitoneoscopic donor nephrectomies using hand assistance were reported in 2002. Most recently, LESS donor nephrectomy, robotic surgery, and NOTES were introduced.

Advantages of the laparoscopic approach

1. Reduced analgesic requirement

2. Shorter length of hospital stay

3. Early return to work

4. Superior cosmetic results

5. Increased acceptance of the donor operation leading to expansion of the donor pool

Disadvantages of LDN

1. Increased operative time

2. Longer WIT

3. Steep learning curve

4. Increased cost and need for special equipment

DONOR EVALUATION AND CONSENT

Donor evaluation is based on several principles as follows:

1. Donor safety

   • A comprehensive evaluation process should be able to reduce the potential risks to the donor to a minimum.

   • The process of organ donation always involves some harm to the donor. Operative pain, loss of wages, and a scar from surgery are unavoidable sequelae of donation. However, major setbacks to the physical and psychological well-being of the donor should be avoided. Significant complications include ...