Laparoscopic live donor nephrectomy: the anaesthesiologist's perspective

摘要

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 si