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• W4254710220 abstract "EDITOR: Although kidney transplantation is nowadays considered the best therapeutic option for end-stage renal failure, organ shortage still represents the primary limiting factor. The average waiting time for a cadaveric kidney transplant at our institution was 3 yr in 1990 and is now 8-10 yr. Thus, there is renewed interest in alternative ways of increasing the supply of donors including the use of expanded criteria donors, non-heart-beating donors and living donors [1]. Since the first report of successful laparoscopic live donor nephrectomy in 1995 [2], this procedure, initially restricted to a few pioneer surgeons, is currently practised in a growing number of transplant centres throughout the world. We report a single-centre experience for laparoscopic donor nephrectomy for living related kidney transplantation. We reviewed the charts of all laparoscopic kidney donations and the related transplants performed between April 2000 and December 2001 and compared this population with that of a corresponding number of traditional surgery donors from our historical series. Left nephrectomy was used because of anatomical advantages about the length of the renal vessels. The procedures were performed by two surgeons with the aid of a robotic arm to hold the endoscope (AESOP 3000® robotic visualization system; Computer Motion, Santa Barbara, CA, USA). The anaesthesia technique was the same for both donors and recipients. After induction with fentanyl 0.2 mg, sodium thiopental 3 mg kg−1 and succinylcholine 1 mg kg−1, anaesthesia was maintained with sevoflurane in a 50% air/oxygen low-flow respiratory mixture; atracurium in a continuous intravenous (i.v.) infusion (0.01 mg kg−1 min−1) was used to achieve neuromuscular blockade. Remifentanil was given i.v. (0.15 μg kg−1 min−1). Because peritoneal CO2 insufflation can decrease blood flow to the kidneys (resulting in transient intraoperative kidney dysfunction and higher incidence of delayed graft function) [3], our laparoscopic donors received extra-intravascular volume loading (saline 0.9% 2 L) from the night before surgery. Intraoperatively, a positive fluid balance was maintained by colloids/crystalloids at a dose, exceeding surgical losses, of 10 mL kg−1 h−1; during the procedure, donor urine output of at least 100 mL h−1 was targeted, and loop diuretics or mannitol were also used to achieve this. Standard intra-operative monitoring, including arterial pressure and central venous pressure, was instituted. After completion of surgery, all donors were transferred to the intensive care unit. We analysed the data using SPSS® v.7.0 (SPSS Inc., Chicago, IL, USA). The significance of the between-group differences was assessed using t-, U- or χ2-tests as appropriate; P = 0.05 was considered as statistically significant. During the study period, 28 living donor laparoscopic nephrectomies were performed; they were compared with 27 donors whose kidneys were harvested by a traditional flank approach. No procedure required conversion to laparotomy, nor did any donor develop complications. No patients needed re-intervention, and all the surgical procedures were uneventful. Laparoscopic donors underwent a longer procedure with a lower estimated blood loss but intra-operatively received more i.v. fluids; they needed less postoperative analgesia with a shorter intensive care unit stay and overall hospitalization; they also showed a quicker return to solid oral intake and full return to work (Table 1).Table 1: Donors' intraoperative and early recovery data.Monitored cardiovascular variables were stable in both groups, the open donors showing lower central venous pressures at anaesthesia induction and at the end of surgery; they also had significantly lower PCO2 throughout the entire procedure. Those recipients who received a traditionally harvested graft were more often females (6 versus 1; P < 0.05) but did not differ for age (32.3 ± 8.8 versus 30.7 ± 8.2 yr; P = 0.6). Twenty-two procedures were single kidney transplants, whereas the remaining six were combined cadaveric pancreas and living donor kidney transplants. Diuresis resumed intraoperatively in all recipients irrespectively of the donation approach; early graft function did not differ among the two groups, although serum creatinine concentration declined earlier, but not significantly, in the recipients of kidneys procured by the open method: both the recipient groups reached their nadir serum creatinine by postoperative day 14. This difference did not affect the length of hospitalization or the ultimate graft function (P = 0.4); no recipient and no graft was lost. There was no significant difference in the number of dialysis treatments during recipients hospitalization (P = 0.5). Live donor kidney transplants have been associated with several major advantages over cadaveric transplants: avoidance of long waiting times for the recipient, superior human leukocyte antigen matching, shorter cold ischaemia duration and significant improvement of graft survival rate [3]. Donor nephrectomy is unique among major surgical procedures as it exposes an otherwise healthy subject to the risks of a major surgical procedure without any personal benefit. Laparoscopic living kidney donation, as a still expanding technique, has to meet two utmost conditions: the laparoscopic donor, when compared with the 'open' approach, should suffer no additional morbidity due to the technique itself and harvested kidneys must have, at least, the same survival and function quality of those obtained with the standard extraperitoneal flank approach. In our experience, laparoscopic renal donation offers several advantages over the traditional approach in the postoperative period: lower analgesic requirements, faster resumption of food intake, shorter hospitalization, quicker return to work and a better postoperative cosmetic appearance (particularly attractive for younger donors). A very important aspect of laparoscopic renal donation is possible alteration in the graft's function because of intra-abdominal hypertension from the pneumoperitoneum [4]. It has been suggested that the critical intra-abdominal pressure necessary to promote renal dysfunction is 15 mmHg [5]; however, this also represents the standard abdominal insufflation pressure usually reached during laparoscopic procedures. In this setting, although fluid administration in excess to the physiological need was reported as 'protective' [6], relative oliguria was observed soon after transplantation of laparoscopic donor kidneys independently from an aggressive intraoperative fluid loading [7] probably because renal dysfunction due to intra-abdominal hypertension is related to a number of different factors [5]; thus, volume loading alone may not be effective. To avoid renal damage, a multidisciplinary approach is common practice at our centre, which is based on three key points: to keep laparoscopic donors with a positive fluid balance before and during the procedure; to obtain an urinary output of at least 100 mL h−1 from the start of the procedure; and to inflate the donor's abdomen with an pressure not exceeding 12 mmHg. The current discrepancy between potential recipients and kidney availability has led transplant physicians to search for new ways to provide more transplants; today, the most interesting option is living donation. Laparoscopic nephrectomy offers donors better postoperative comfort, faster recovery and better cosmetic results when compared with the traditional flank incision technique with the same graft's survival without higher or dedicated anaesthetic cost. G. Biancofiore G. Amorese D. Lugli L. Bindi N. Fossati Azienda Ospedaliera Pisana, Department No. 1; Anaesthesia and Intensive Care; Ospedale di Cisanello; Pisa, Italy Ugo Boggi A. Pietrabissa F. Mosca General and Transplantation Surgery; University School of Medicine; Ospedale di Cisanello; Pisa, Italy" @default.
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• W4254710220 date "2004-01-01" @default.
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• W4254710220 title "Laparoscopic live donor nephrectomy: the anaesthesiologist's perspective" @default.
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