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Retroperitoneal Single-port Donor Nephrectomy through Lumbotomy Incision: An Experience of 30 Cases
All the surgeries were performed by a single surgeon to eliminate Table 1: Results
the learning curve bias. Thirty patients consented for translumbar Mean age (years) 44.7 ± 11.4
RPLDN out of the 82 donor nephrectomies assigned to that M:F 9:21
particular surgeon. Patients were explained about the risks/benefits BMI (kg/m ) 21.72 ± 3.57
2
associated with single-port retroperitoneal donor nephrectomy
through lumbotomy incision. In postoperative period, all patients Side (LT:RT) 26:4
were administered tramadol thrice daily and then as required. Duration (minutes) 170.3 ± 52
Visual analog scale (VAS) was used to evaluate the severity of pain WIT (minutes) 4.71 ± 1.2
on postoperative day (POD)0 and POD1. Kidney wt (g) 131.6 ± 25.5
The study was approved by the Institutional Ethics Committee. Analgesic requirement (mg) 370 ± 105
VAS POD0 4.83 ± 1.73

sIngle -port retroperItoneAl trAnsluMbAr VAS POD1 3.0 ± 1.23
donor nephrectoMy Hospital stay (days) 2.6 ± 0.6

Patients were placed in full lateral position and retroperitoneum
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accessed with a non-muscle cutting approach. Once the of dissection. No blood transfusion was required in any patient.
retroperitoneum was entered, Gerota’s fascia was opened as far as Peritoneum was breached in three patients but the peritoneal
possible and lower pole of kidney is reached. Dissection was carried rent was closed after removing the Alexis port and surgery was
out anterior to psoas till ureter and gonadal vein were identified in completed retroperitoneally. No patient had surgical site infection
the retroperitoneal fat. and none had postoperative hernia or bulge at operative site
An Alexis wound retractor was applied to the incision with a till the last follow-up. Additional 5 mm port for retraction was
sterile surgical glove rolled over the inner ring of the retractor, so required in the two of the first three cases, but subsequent cases
that the fingers project out of the outer ring of the Alexis wound were completed without any additional port. Most patients
retractor, creating an airtight retroperitoneal compartment. (28/30) had a VAS score of <4, and did not require any additional
Three fingers of the glove were used to insert one 10 mm camera analgesics beyond POD0. Patients were started orally on the same
port, one 10 mm working port, and one 5 mm working port and day and could ambulate comfortably on the next day.
pneumoretroperitoneum obtained.
Further dissection was carried out laparoscopically. Ureter was dIscussIon
lifted off the retroperitoneal tissues and gonadal vein was dissected
till its drainage into renal vein avoiding injury to the ureter and its The first experience of laparoscopic nephrectomy using a single
17
adventitia and ligated. Gonadal artery if encountered was also ligated. incision was reported in three patients in 2007. The attractiveness
As one reached renal hilum, pulsations of renal artery could be seen of single-site approach later led to many reports of living donor
18–20
and lumbar vein was visualized in front of the artery. Lumbar vein was nephrectomies via LESS surgery. All these were performed
controlled after which renal artery was seen which was dissected till using the transperitoneal approach in comparison to the traditional
its origin. After that, tissue around the renal vein was dissected and retroperitoneal route for ODN. Most reports of serious complications
adrenal vein was identified. following LDN are related to the transperitoneal approach causing
At this stage, lower pole of the kidney was separated from bowel/visceral injuries or intestinal obstruction. Therefore, an
the peritoneum when the kidney which was hanging from the ideal approach to the donor surgery should be a retroperitoneal
peritoneum started to fall down. Dissection was carried out on the approach. A non-muscle cutting single-site incision will not only
surface of kidney to free it from the surround fat till renal vein was avoid immediate and long-term intraperitoneal complications
seen anteriorly. Adrenal vein was identified and divided, adrenal but also reduce pain associated with the operation. With this in
gland was dissected and separated from the upper pole of the mind, lumbotomy approach was used to perform the single-site
kidney and left in situ. nephrectomy in the living donors at our center.
Ureter was divided once the kidney and renal vessels were free. As hypothesized, the main benefit of this approach in our
Renal artery and renal vein were separately ligated with two experience was early convalescence. This was possible as the
Hemolok clips each as is the usual practice at our center and cut approach through the lumbar fascia avoids muscle cutting or
with scissors. Kidney was retrieved into the Alexis wound retractor, splitting resulting in less postoperative pain, which impacts
and taken out with the retractor. analgesic requirements and the hospital stay. Single-site surgery
has been shown to be less painful than multiple ports approach
21
results (tAble 1) for donor nephrectomy in a recent Cochrane review as well.

Shoulder pain due to irritation of diaphragm by carbon dioxide gas
Mean age of donors was 44.7 ± 11.4 years, majority of the donors was expectedly absent in this group of patients leading to a more
were females (M:F 9:21) as is usual trend at our center. Average comfortable postop recovery.
duration of surgery was 170.33 ± 52 minutes, the duration of surgery The retroperitoneal technique also reduces the risk of
decreased with increasing experience. Majority of nephrectomies intraperitoneal injury and leads to faster recovery of gastrointestinal
22
were left sided (LT:RT 26:4). function as was seen in our study too. It helps to resume early
23
Four patients (13.3%) had double renal arteries and one oral feeding and reduces risk of intestinal adhesion and is also
patient had double renal vein. In one patient, retrieval was beneficial for patients with the history of previous abdominal
performed by an open approach after extending the upper surgery. Retroperitoneal technique has less deleterious effect on
part of the incision. This patient had bleeding from avulsion of ventilation and hemodynamic parameters that can be problematic
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a small tributary at the base of right renal vein after completion with rising intra-abdominal pressure in transperitoneal approach.

62 World Journal of Laparoscopic Surgery, Volume 13 Issue 2 (May–August 2020)