by George Taniwaki

Because of a scheduling conflict, my case has been transferred to another surgeon at University of Washington Medical Center. I’ve been asked to come in today to meet with the new surgeon, Ramasamy Bakthavatsalam. This will be my seventh appointment at the hospital since starting my evaluation.

I’ve been reading up on medical articles on live donor nephrectomy. For instance, I already know that all things being equal, left donor nephrectomy is the preferred option because the left kidney usually has less branching of the renal artery that feeds it. Having a longer straight sections makes it easier to cut the artery farther from the aorta, leaving more behind when clamping off the donor’s blood vessels after extraction. The additional length of artery on the extracted kidney also makes it easier to connect the vessels to the recipient’s blood supply. The left kidney is also easier to extract; removing the right kidney requires an extra retractor to hold the liver out of the way.

However, left donor nephrectomy is contraindicated (is not recommended) in cases where the donor’s left kidney branches into three or more arteries (which increases the chance of bleeding), or when the right kidney has cysts (the rule is to always remove the less desirable kidney and leave the better one behind), or when the right kidney is smaller than the left one (same logic as previously stated, you want to leave the bigger kidney with the donor).

In my case, the CT scan showed that my left kidney was larger than my right, which would recommend taking the right one. But my right renal artery branches very close to the aorta which would make it difficult to transplant. So which kidney should be removed?

The surgeon, whom everyone calls Dr.  Baktha, is quite certain which kidney should be removed, my right one. I asked him about the preference many surgeons have for the left kidney and the extra arteries that may require attaching if he removes my right kidney. His response was, “They (the surgical team that will transplant the kidney into the recipient) will make it work. A kidney from a live donor is a special gift and they will be happy to get it.”

I also asked him whether he will use an open, laparoscopic, or hand-assisted laparoscopic method for my surgery.

First, some background. One of the biggest advances in donor nephrectomy is the switch from open surgery (where an incision is made large enough for the surgeon to insert his/her hand) to laparoscopic surgery (where three small incisions called ports are made and robotic instruments are inserted into the patient). One port contains a retractor that holds the liver out of the way. Another port contains the cauterizing scalpel. The third holds a video camera; the surgeon views the operation using a video monitor. All of the ports are glued shut and the patient’s abdomen is inflated with carbon dioxide to allow the surgeon to easily view and access the kidney and manipulate the instruments. At the end of the surgery, a final 8cm (3inch) incision is made to remove the kidney and release the gas. The technique was pioneered at Johns Hopkins Medical Center in 1995. Laparoscopic surgery leads to less post-operative pain, smaller scars, and reduced recovery time.

There is one side effect of laparoscopic surgery. Some carbon dioxide gas can remain in the abdomen after surgery and push the diaphragm into the phrenic nerve which can cause pain while breathing. The pain can extend into the shoulder. The pain is temporary and will stop once all the gas is absorbed by the blood.

Left side laparoscopic donor nephrectomy. Video from ORLive

Originally, all of the laparoscopic instruments for donor nephrectomy were designed for left side use only. It wasn’t until a few years ago that instruments designed for right nephrectomy became available, as the video below describes.

Since right nephrectomy requires special instruments and are not performed frequently, some surgeons don’t get a lot of practice using them. Further, one of the limitations of the current generation of robots is that they don’t provide haptic feedback. That is, surgeons have difficulty sensing how much pressure they are applying to the instrument and how much resistance or tension the tissue is providing.

Conducting surgery completely by robot is a skill that takes practice. To reduce the incidence of complications during laparoscopic surgery, some surgeons recommend having a hand inside the patient to assist during right nephrectomy. As reported in J. Transpl. Jan 2010, a meta-analysis covering 9,000 patients (that included both left and right nephrectomies) shows that hand-assisted laparoscopic method provides superior results to robot-only surgery.

My surgeon says that using hand-assist is a personal preference and that he expects to use the robot-only technique in my case. I trust his judgment in this since he is one of the coauthors of a brief case article on hand-assisted right donor nephrectomy in Transpl. Nov 2003.

Right side laparoscopic donor nephrectomy. Video from UAB Health

A story in the The New York Times Feb 2010 points out that despite the many advantages of laparoscopic surgery, there isn’t much evidence that it provides better outcomes than open surgery. However, patients like it, so surgeons often promote robotic surgery. The availability of laparoscopic surgery may even encourage more people to become kidney donors says an article in Am. Surgery Oct 2004.

For more information on becoming a kidney donor, see my Kidney donor guide.

[Update1: Intuitive Surgical is the sole producer of surgical robots and markets them under the da Vinci name. Its monopoly may be hindering innovations in the surgical robot market according to Tech. Rev. Mar 2010. The story contains with a very nice video showing a repair of a blocked kidney.]

[Update2: The Wall St. J. May 2010 discusses the case of a small hospital in New Hampshire that purchased a da Vinci robot to remain competitive, but may not be performing enough operations to get surgeon proficient at using it.]

LaparoscopicWSJ

da Vinci robotic surgical instruments. Video still from Wall St. J.

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