TECHNIQUES AND OUTCOMES - Redalyc

322
P. M. Lewandowski, S. Leslie, I. S. Gill, and M. M. Desai.
fasciotomy is partially closed, the R-port reinserted and
pneumoperitoneum re-established. Once hemostasis
has been confirmed, the R-port is removed and the
fascia and skin closed. Since the Quadport has a 15
mm inlet, the Endocatch bag can be inserted after
hilar dissection.
FIGURE 5. Articulating instruments.
extraction is technically more challenging given that
the umbilical opening, through which the kidney will
be removed, is occupied by the single port access
device.
We outline three techniques by which kidney
extraction is achieved in LESS-DN:
Gill5 describes the use of a 15 mm
EndoCatch® bag to assist with kidney extraction. Prior
to dividing the renal vessels, the EndoCatch® bag is
detached from its metal ring and inserted through the
12 mm inlet of the R-port. The kidney is subsequently
entrapped, with the mouth of the bag loosely tightened
around the renal hilum, taking care not to compromise
perfusion. The renal artery is then clipped with two
Hem-O-Lock® clips and one 11 mm metal clip and
divided. A 12 mm vascular EndoGIA® stapler is used
to divide the renal vein at the interaortocaval location.
The R-port is then removed and the pre-entrapped
kidney is extracted trans-umbilically after adequate
extension of the midline fasciotomy incision and skin
incision to allow for atraumatic graft extraction. Once
the graft has been given to the transplant surgeon, the
Desai (7) describes a technique of graft
extraction without the use of an EndoCatch® bag.
Once the renal artery and vein have been divided
and the graft is ready for retrieval, the graft is brought
near the umbilical extraction site with a grasper
inserted through an extra 3 or 5 mm port. Once the
R-port is removed and the incision extended slightly,
two fingers are inserted to grasp the kidney and then
to gently extract it from the abdomen. The graft is then
handed to the transplant surgeon and the R-port is
reinserted to check for hemostasis.
Del Pizzo (8) describe their technique using
the GelPoint device. The advantage of the GelPoint is
that it has a detachable gel cap to allow extraction of
the graft, without having to remove the whole device.
So once the renal artery and vein are divided, the
graft is entrapped with an EndoCatch® bag and
extracted by removing the gel cap. Once the graft
has been passed to the transplant surgeon, the gel
cap is replaced, pneumoperitoneum re-established
and hemostasis checked.
Outcomes
The surgical steps of LESS-DN in each of the
five studies demonstrate that it is a technically feasible
procedure. However, there are three important aspects
FIGURE 6. Curved Instruments.
FIGURE 7. Postoperative photograph of a LESS donor’s
abdomen at 1 week.