Laparoscopic cholecystectomy performed simultaneously with retroperitoneoscopic live donor nephrectomy

Abstract

Aim: To evaluate safety of simultaneous Laparoscopic cholecystectomy (LC) and Retroperitoneoscopic live donor nephrectomy (RPLDN). Materials and Methods: We have retrospectively reviewed 400 patients who have undergone RPLDN. Ten patients underwent a combination of RPLDN and LC. Ten patients underwent a combination of RPLDN and LC. Results: Mean operative time was 141.1 ± 27.47 min (range 95-170 min), with a mean estimated blood loss (EBL) of 61.1 ± 18.33 mL (range 30-80 mL). No blood transfusions were required. No short- or long-term complications were found. Mean hospital stay was 2.6 ± 0.84 days (range 2-4 days). Mean follow-up period was 1.8 ± 0.71 years (range 1-3 years). Conclusion: From our results, we conclude that simultaneous RPLDN and LC are safe.

Keywords: Laparoscopic cholecystectomy (LC), live donor nephrectomy

How to cite this article:
Sutariya VK, Modi PR. Laparoscopic cholecystectomy performed simultaneously with retroperitoneoscopic live donor nephrectomy. Ann Trop Med Public Health 2016;9:102-4

 

How to cite this URL:
Sutariya VK, Modi PR. Laparoscopic cholecystectomy performed simultaneously with retroperitoneoscopic live donor nephrectomy. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Aug 10];9:102-4. Available from: https://www.atmph.org/text.asp?2016/9/2/102/177377

 

Introduction

Live donor nephrectomy, via an open flank approach, was first performed in 1954. It made clinical solid organ transplantation a reality. [1] Open live donor nephrectomy is considered to be an extremely safe operation with an estimated mortality rate of 0.03%. [2] Minimally invasive techniques have been introduced so as to make kidney donation easier and relatively more feasible for donors. First laparoscopic live donor nephrectomy was performed in 1995. [3] First retroperitoneoscopic live donor nephrectomy (RPLDN) was performed in 2000. [4]

Routine preoperative evaluation of probable kidney donors many a times identifies patients with recurrent biliary colic and multiple mobile gallstones. Patients with such minor medical problems can be considered for live donation if the overall short- and long-term risk remains acceptably small. The increasing disparity between organ supply and demand has forced many centers to liberalize their criteria for organ donation. Thus, probable kidney donors with multiple gallstones can be subjected to a combination of RPLDN and laparoscopic cholecystectomy (LC). As two procedures have never been performed together, the precise level of additional risk(s) entailed in such a combined approach, as compared to either cholecystectomy alone or RPLDN alone, is not known. Below we describe our experience of 10 cases of cholecystectomy performed laparoscopically simultaneously with RPLDN.

Materials and Methods

A retrospective review of 400 consecutive patients who underwent RPLDN at our institute from January 2009 to December 2011 was performed. All the patients underwent a thorough evaluation by both a nephrologist and a surgeon as outlined in guidelines of the American Society Of Transplant Physician before being considered as kidney donors. [2] Ultrasonography of the abdomen and spiral computed tomography (CT) angiography were performed on all the prospective donors. All the patients were offered open nephrectomy as an alternative to retroperitoneoscopic procedure. Added benefits and risks incurred by cholecystectomy being performed simultaneously with RPLDN had been explained to them. RPLDN was performed with a similar technique as described previously. [5] LC was performed after RPLDN in all the cases. The patient’s position was changed from lateral to supine after ports for RPLDN were closed. LC was performed using standard four trocars with minimal use of electrocautery during dissection of Calot’s triangle.

Results

A total of 10 patients underwent LC after RPLDN. Among them, 9 were females and 1 was male. The indication for cholecystectomy in all patients was recurrent biliary colic with multiple mobile gallstones. Mean age of all live donors was 47.5 ± 10.2 years (range 63-34 years). Mean body mass index (BMI) of all the patients was 22.9 ± 4.85 (range 16.9-31.2). Left kidney was harvested in six patients while right kidney was harvested in the remaining four patients. Decision to take right kidney was based on the policy of selecting the kidney with lowest risk of technical failure, but most importantly, leaving the donor with better kidney. Mean warm ischemia time was 157 ± 46 s (range 114-236). Mean operative time was 141.11 ± 27.47 min (range 95-170). Mean estimated blood loss (EBL) was 61.1 ± 18.3 mL (range 30-80). No blood transfusions were required. Mean hospital stay was 2.6 ± 0.84 days (range 2-4). No short- or long-term complications have been found. The mean follow-up period was 1.8 ± 0.71 years (range 1-3 years).

Discussion

Beginning with first live donor in 1954, critics as well as supporters of live donation have raised concerns about whether it is ethical for surgeons to subject donors to potential harm and risk by operating them not for their own good but in order to benefit another person in the need of kidney transplantation. [6] Dr. Francis Moore, who has performed the first live donor kidney transplantation successfully, mentioned that living donor tissue transplantation is a unique field of surgery. It flaunts the ancient principles of surgery upon which medical and surgical care is based: “Do no harm and help the patient to help himself.” The welfare of a healthy person, which is never sacrificed in human medicine, in now jeopardized in healthy donor(s). [7] Even after such concerns, living donor kidney transplantation has grown markedly because of the continuing shortage of kidneys.

Donor nephrectomy via an open approach and usually flank incision is relatively safe. However, some morbidity is always associated with open donor nephrectomy that may deter many potential donors from kidney donation. Minimally invasive surgery has the potential for decreasing postoperative pain, decreasing incision related morbidity and hospitalization, hastening the return to normal activity, and improving cosmesis. [8] Retroperitoneoscopic nephrectomy, when compared to laparoscopic transperitoneal nephrectomy, offers a significant advantage in that it is extraperitoneal with a potentially lower risk for intra-abdominal organ injuries and for early and late postoperative adhesions and bowel obstruction. This is a relevant consideration as early and late bowel-related complications remain a leading cause of reoperations and readmissions of transperitoneal laparoscopic live kidney donors. [9] RPLDN has a favorable impact on postoperative pain and pulmonary function. Even then, RPLDN technique is applied on a larger scale by relatively few centers. This approach provides quick access to renal vessels, there is no need for mobilizing ascending or descending colon that saves operative time. Main drawback of retroperitoneoscopic approach is limited working space, making the procedure more demanding as compared to transperitoneal approach. At our institute, the setting for RPLDN is well-established.

By coupling LC with RPLDN, we can increase the donor pool. The sequence, in which both the procedures are performed, is very important. Both the donor’s and the recipient’s safety should be taken into account before considering the order of the procedure. In all our patients, we have performed LC after RPLDN. So, there is no risk of any deleterious effects on renal allograft and ultimately no difference in recipient outcome. The addition of simultaneous surgery along with RPLDN does not have any untoward effect on the donor. Testa et al. have proposed a model for live kidney donation where elective cholecystectomy patients were invited to become unrelated living kidney donors. [10] Imaging modalities may identify many probable kidney donors with minor medical problems. Rather than excluding such probable donors, we can rectify such problems concomitantly by virtue of RPLDN. By combining elective operation with live donor nephrectomy, we can minimize postoperative pain, length of hospital stay, recuperative time, and financial losses associated with time out of work. [11]

In a previously published literature on live donor nephrectomy, [12],[13],[14] operative time, EBL, and length of hospital stay for laparoscopic approach were 175-256 min, 122-266 mL, and 2.2-3 days, respectively. While operative time, EBL, and length of hospital stay for open approach were 183-213 min, 192-408 mL, and 3.8-5.7 days, respectively. In one study, mean operative time, mean EBL, and mean hospital stay for RPLDN were 146 ± 44 min, 159 ± 108 mL, and 6.8 days, respectively. [15] In our series, where LC has been performed along with RPLDN, mean operative time, mean EBL, and length of hospital stay were 141.1 min, 61.1 mL, and 3 days, respectively. No short- or long-term complications were found.

To our knowledge, no one has previously reported performing RPLDN and LC as an elective minimally invasive procedure. So, additional risk entailed by combining these two procedures is not known exactly.

Conclusion

In conclusion, we believe that the combination of RPLDN and LC is safe but a larger series is required before applying such an approach on wider basis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

References

 

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Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.177377

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