Robotic living donor nephrectomy is associated with reduced post-operative opioid use compared to hand-assisted laparoscopic approach.

BACKGROUND: Robotic donor nephrectomy (RDN) has emerged as a safe alternative to laparoscopic donor nephrectomy (LDN). Having previously demonstrated comparable efficacy, this study aims to examine postoperative analgesia use (opioid and non-opioid) in the two groups. METHODS: We conducted a retrospective review of 300 living donor nephrectomies performed at our center, comparing 150 RDN's with a contemporary cohort of 150 hand-assisted LDN's. In addition to clinical and demographic information, data on postoperative inpatient opioid and non-opioid analgesia (from patient's arrival to the surgical floor after surgery till the time of discharge) was collected. Opioid dosages were standardized by conversion to morphine milligram equivalents (MME). All patients were managed post-operatively under a standardized ERAS pathway for living donor nephrectomy patients. RESULTS: There were no significant differences in donor age, gender, and BMI between RDN and LDN groups. Total post-operative opioid use (MME's) was significantly lower in RDN patients (RDN 27.1 vs. LDN 46.3; P < 0.0001). Breakdown of opioid use with post-operative (POD) day demonstrated significantly lower use in RDN group on POD1 (RDN 8.6 vs. LDN 17.0; P < 0.05), and POD2 (RDN 3.9 vs LDN 10; P < 0.05). RDN patients had a shorter post-operative length of stay (LOS) (RDN 1.69 days vs. LDN 1.98; P = 0.0003). There were no differences between groups in non-opioid medication use, complications, and readmission rates. CONCLUSION: RDN has comparable safety to hand-assist LDN and offers additional benefits of lower postoperative opioid requirement and a shorter hospital LOS.

Relationship between surgical difficulty and postoperative complications of hand-assisted laparoscopic living donor nephrectomy and establishment of prediction model.

BACKGROUND: Few studies have systematically explored the factors influencing the difficulty of hand-assisted laparoscopic living donor nephrectomy. To investigate the relationship between the difficulty of hand-assisted laparoscopic living donor nephrectomy and postoperative complications of the donor as well as the recipient, and then build a model for predicting the difficulty of surgery. METHODS: In this study, 60 patients who underwent hand-assisted laparoscopic living donor nephrectomy by the same surgeon from September 2022 to March 2024 were included as the modeling group. 20 patients operated on by another surgeon served as the external validation group. The subjective score (1-3 points) of surgical difficulty was used as the quantitative index of surgical difficulty. Pearson and Spearman correlation tests were used to explore the correlation between preoperative data and surgical difficulty scores of kidney donors, and finally built a prediction model through multiple linear regression analysis. RESULTS: With the increase in the difficulty of operation, both donors and recipients' complications were increased. Linear regression analysis showed that only the number of renal arteries, visceral fat thickness and MAP score were independent risk factors for the difficulty of hand-assisted laparoscopic living donor nephrectomy. The prediction equation is as follows: Difficulty score = 0.584*Number of renal arteries + 0.731*MAP score + 0.110*visceral fat thickness. CONCLUSIONS: Donors with higher surgical difficulty are more likely to have serious complications after surgery as well as the recipient. We also established a reliable prediction model for the difficulty of hand-assisted laparoscopic donor nephrectomy.

Usefulness of hand-assisted retroperitoneal laparoscopic radical nephrectomy for extreme obese patients -a case report.

We report a case of retroperitoneal laparoscopic radical nephrectomy (LRN) in which the addition of a hand port was necessary and effective. A 52-year-old man with obesity (BMI 40.6 kg/m2) was diagnosed with a 52-mm left renal cell carcinoma (cT1bN0M0). To avoid thick subcutaneous and visceral fat in the abdomen, we selected LRN using a retroperitoneal approach with four ports in the kidney position. During surgery, a large amount of flank pad and perirenal fat prevented us from securing a sufficient surgical field through traction of the kidney with a retractor. A pure laparoscopic procedure was not feasible;therefore, we added a hand port. Subsequently, we removed the flank pad from the hand port and secured the surgical field by tracing the kidney manually. Finally, hand-assisted LRN was completed without an open conversion. In retroperitoneal LRN, we rarely encounter patients for whom a pure laparoscopic procedure is not feasible because of the large amount of flank pad or perirenal fat. It is important to preoperatively confirm not only the BMI but also the amount of flank pad and perirenal fat on imaging. Hand-assisted LRN via the retroperitoneal approach can be safely performed even in extremely obese patients. J. Med. Invest. 71 : 187-190, February, 2024.

Two-handed assisted laparoscopic surgery: Evaluation in an animal model

Purposes To evaluate in an animal model the feasibility of a novel concept of hand-assisted surgery consisting of inserting two hands into the abdomen instead of one. The chosen procedure was retroperitoneal lymph node dissection (L-RPLND) that was performed in five pigs. Surgical Technique A Pfannestiel and a transverse epigastric incisions were made through which both hands were introduced. The scope was inserted through the umbilicus. The colon was moved medially and the dissection was performed as in open surgery using short conventional surgical instruments. Comments The surgery was fulfilled easily and safely in quite a similar way as in open surgery. Two-handed laparoscopy may be indicated in cases that still today require an open approach as apparently makes the operation easier and significantly shortens the surgery time. However, new opinions and trials are required. .

Hand-assisted laparoscopic radical nephrectomy in the treatment of a renal cell carcinoma with a level ii vena cava thrombus

Excision of renal cell carcinoma (RCC) with corresponding vena cava thrombus is a technical challenge requiring open resection and vascular clamping. A 58 year old male with a right kidney tumor presented with a thrombus extending 1 cm into the vena cava. Using a hand-assisted transperitoneal approach through a 7 cm gel-port, the right kidney was dissected and the multiple vascular collaterals supplying the tumor were identified and isolated. The inferior vena cava was mobilized 4 cm cephalad and 4 cm caudal to the right renal vein. Lateral manual traction was applied to the right kidney allowing the tumor thrombus to be retracted into the renal vein, clear of the vena cava. After laparoscopic ultrasonographic confirmation of the location of the tip of the tumor thrombus, an articulating laparoscopic vascular stapler was used to staple the vena cava at the ostium of the right renal vein. This allowed removal of the tumor thrombus without the need for a Satinsky clamp. The surgery was completed in 243 minutes with no intra-operative complications. The entire kidney and tumor thrombus was removed with negative surgical margins. Estimated blood loss was 300 cc. We present a laparoscopic resection of a renal mass with associated level II thrombus using a hand-assisted approach. In patients with minimal caval involvement, our surgical approach presents an option to the traditional open resection of a renal mass.