The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.

BACKGROUND: Adverse events due to energy device use in surgical operating rooms are a daily occurrence. These occur at a rate of approximately 1-2 per 1000 operations. Hundreds of operating room fires occur each year in the United States, some causing severe injury and even mortality. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) therefore created the first comprehensive educational curriculum on the safe use of surgical energy devices, called Fundamental Use of Surgical Energy (FUSE). This paper describes the history, development, and purpose of this important training program for all members of the operating room team. METHODS: The databases of SAGES and the FUSE committee as well as personal photographs and documents of members of the FUSE task force were used to establish a brief history of the FUSE program from its inception to its current status. RESULTS: The authors were able to detail all aspects of the history, development, and national as well as global implementation of the third SAGES Fundamentals Program FUSE. CONCLUSIONS: The written documentation of the making of FUSE is an important contribution to the history and mission of SAGES and allows the reader to understand the idea, concept, realization, and implementation of the only free online educational tool for physicians on energy devices available today. FUSE is the culmination of the SAGES efforts to recognize gaps in patient safety and develop state-of-the-art educational programs to address those gaps. It is the goal of the FUSE task force to ensure that general FUSE implementation becomes multinational, involving as many countries as possible.

Leaders by example: Best practices and advice on establishing a state-of-the art surgical simulation center that optimizes available resources.

BACKGROUND: The role of simulation-based education continues to expand exponentially. To excel in this environment as a surgical simulation leader requires unique knowledge, skills, and abilities that are different from those used in traditional clinically-based education. METHODS: Leaders in surgical simulation were invited to participate as discussants in a pre-conference course offered by the Association for Surgical Education. Highlights from their discussions were recorded. RESULTS: Recommendations were provided on topics such as building a simulation team, preparing for accreditation requirements, what to ask for during early stages of development, identifying tools and resources needed to meet educational goals, expanding surgical simulation programming, and building educational curricula. CONCLUSION: These recommendations provide new leaders in simulation with a unique combination of up-to-date best practices in simulation-based education, as well as valuable advice gained from lessons learned from the personal experiences of national leaders in the field of surgical simulation and education.

Educational implications for surgical telementoring: a current review with recommendations for future practice, policy, and research.

BACKGROUND: Surgical telementoring (ST) was introduced in the sixties, promoting videoconferencing to enhance surgical education across large distances. Widespread use of ST in the surgical community is lacking. Despite numerous surveys assessing ST, there remains a lack of high-level scientific evidence demonstrating its impact on mentorship and surgical education. Despite this, there is an ongoing paradigm shift involving remote presence technologies and their application to skill development and technique dissemination in the international surgical community. Factors facilitating this include improved access to ST technology, including ease of use and data transmission, and affordability. Several international research initiatives have commenced to strengthen the scientific foundation documenting the impact of ST in surgical education and performance. METHODS: International experts on ST were invited to the SAGES Project Six Summit in August 2015. Two experts in surgical education prepared relevant questions for discussion and organized the meeting (JP and HH). The questions were open-ended, and the discussion continued until no new item appeared. The transcripts of interviews were recorded by a secretary from SAGES. RESULTS: In this paper, we present a summary of the work performed by the SAGES Project 6 Education Working Group. We summarize the existing evidence regarding education in ST, identify and detail conceptual educational frameworks that may be used during ST, and present a structured framework for an educational curriculum in ST. CONCLUSIONS: The educational impact and optimal curricular organization of ST programs are largely unexplored. We outline the critical components of a structured ST curriculum, including prerequisites, teaching modalities, and key curricular components. We also detail research strategies critical to its continued evolution as an educational tool, including randomized controlled trials, establishment of a quality registry, qualitative research, learning analytics, and development of a standardized taxonomy.

Fast by nature - how stress patterns define human experience and performance in dexterous tasks.

In the present study we quantify stress by measuring transient perspiratory responses on the perinasal area through thermal imaging. These responses prove to be sympathetically driven and hence, a likely indicator of stress processes in the brain. Armed with the unobtrusive measurement methodology we developed, we were able to monitor stress responses in the context of surgical training, the quintessence of human dexterity. We show that in dexterous tasking under critical conditions, novices attempt to perform a task's step equally fast with experienced individuals. We further show that while fast behavior in experienced individuals is afforded by skill, fast behavior in novices is likely instigated by high stress levels, at the expense of accuracy. Humans avoid adjusting speed to skill and rather grow their skill to a predetermined speed level, likely defined by neurophysiological latency.

Video. Chopstick surgery: a novel technique enables use of the Da Vinci Robot to perform single-incision laparoscopic surgery.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with "wristed" instruments could overcome this limitation but the "arms" collide when working coaxially. This video demonstrates a new technique of "chopstick surgery," which enables use of the robotic arms through a single incision without collision. METHODS: Experiments were conducted utilizing the da Vinci S® robot (Sunnyvale, CA) in a porcine model with three laparoscopic ports (12 mm, 2-5 mm) introduced through a single "incision." Pilot work conducted while performing Fundamentals of Laparoscopic Surgery (FLS) tasks determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, an experienced robotic surgeon performed a cholecystectomy and nephrectomy in a porcine model utilizing the "chopstick" technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This arrangement prevents collision of the external robotic arms. To correct for the change in handedness, the robotic console is instructed to drive the "left" instrument with the right hand effector and the "right" instrument with the left. RESULTS: Both procedures were satisfactorily completed with no external collision of the robotic arms, in acceptable times and with no technical complications. This is consistent with results obtained in the box trainer where the chopstick configuration enabled significantly improved times in all tasks and decreased number of errors and eliminated instrument collisions. CONCLUSION: Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.

Changing attitudes toward endolumenal therapy.

BACKGROUND: As with new laparoscopic techniques, the ability to convince surgeons and gastroenterologists to embrace endolumenal techniques and the additional training required to perform the new procedures will correlate with how rapidly endolumenal therapies are adopted. The authors measured their ability to change attitudes among surgeons, who may or may not perform endoscopy as a part of their practice, toward endolumenal therapies. METHODS: As part of the endoluminal therapy postgraduate course presented at the annual Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting in Ft. Lauderdale, Florida 2005, experts presented current literature and data on new endolumenal techniques. The participants, primarily of surgeons, were polled electronically about a number of case scenarios before and after their presentation. Each scenario was relevant to the topic presented and chosen to reflect potentially controversial disease processes with traditional or endolumenal treatment options. The responses were collected in real time and displayed to course participants. RESULTS: A panel of 10 experts presented data on a range of endolumenal therapies including endolumenal treatment for gastroesophageal reflux disease (GERD), endoscopic stenting, endoscopic treatments in bariatric surgery, intraoperative endoscopy, endoscopic mucosal resection (EMR), transanal endoscopic microsurgery (TEM), mucosal ablation for Barrett's esophagus, intralumenal resection, translumenal endoscopic surgery, and how to educate surgeons in new endolumenal techniques. Demographic data showed that 83.6% of the participants performed endoscopy as part of their practice. A comparison with traditional surgical options showed a statistically significant positive attitude change (p < 0.05) toward adoption of most endolumenal techniques after expert presentation. Only EMR and TEM did not show a statistically significant change in the participants' willingness to adopt these techniques. There was no significant change in the attitudes of how best to train surgeons. After presentation of the training options, 76% of the respondents believed that these techniques should be taught in residency. CONCLUSIONS: The education of surgeons in new endolumenal therapeutic techniques can have a significant impact in terms of changing practice attitudes and may accelerate adoption of new endoscopic techniques.

The role of the surgeon in the evolution of flexible endoscopy.

Several cultures, including the Egyptians, Greeks, Romans, and Arabs, made attempts to view accessible human body cavities using a variety of instruments such as spatulas and specula. The first endoscope was created in 1806 when Phillip Bozzini, a German-born urologist, constructed the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880 Mikulicz made the first gastroscope using a system similar to Nitze's cystoscope. Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Over the ensuing 50 years endoscopy revolutionized many aspects of the surgeon's practice. Endoscopy can now be used to diagnose and often treat gastrointestinal cancer, hemorrhage, obstruction, and inflammatory conditions. This review was initiated by the SAGES Flexible Endoscopy Committee to chronicle the role of the surgeon in the development and introduction of flexible endoscopy into clinical practice, historically and in contemporary surgery. Flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges. There have been many recent technological advances that facilitate endoluminal therapies, and flexible endoscopy is now traversing new ground. Surgeons have been major contributors in the development of all aspects of endoscopy. There is a continually expanding list of therapeutic options available to patients. The difficult questions of which procedure, on which patient, and when can be answered best by the surgeon versed in endoscopic, laparoscopic, and open surgical techniques.

Surgical simulation: a current review.

BACKGROUND: Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

Endoscopic ablation of intestinal metaplasia containing high-grade dysplasia in esophagectomy patients using a balloon-based ablation system.

BACKGROUND: This study aimed to determine the optimal treatment parameters for the ablation of intestinal metaplasia (IM) containing high-grade dysplasia (HGD) using a balloon-based ablation system for patients undergoing esophagectomy. METHODS: Immediately before esophagectomy, patients underwent ablation of circumferential segments of the esophagus containing IM-HGD using the HALO360 system. The treatment settings were randomized to 10, 12, or 14 J/cm2 for two, three, or four applications. After esophagectomy, multiple sections from ablation zones were microscopically evaluated. Histologic end points included maximum ablation depth (histologic layer) and complete ablation of all IM-HGD (yes/no). RESULTS: Eight men with a mean age of 57 years (range, 45-71 years) were treated, and 10 treatment zones were created. There were no device-related adverse events. At resection, there was no evidence of a transmural thermal effect. Grossly, ablation zones were clearly demarcated sections of ablated epithelium. The maximum ablation depth was the lamina propria or muscularis mucosae. The highest energy (14 J/cm2, 4 applications) incurred edema in the superficial submucosa, but no submucosa ablation. Complete ablation of IM and HGD occurred in 9 of 10 ablation zones (90%), defined as complete removal of the epithelium with only small foci of "ghost cells" representing nonviable, ablated IM-HGD and demonstrating loss of nuclei and cytoarchitectural derangement. One focal area of viable IM-HGD remained at the margin of one ablation zone (12 J/cm2, 2 applications) because of incomplete overlap. CONCLUSION: Complete ablation of IM-HGD without ablation of submucosa is possible using the HALO360 system. Ablation depth is dose related and limited to the muscularis mucosae. In one patient, small residual foci of IM-HGD at the edge of the ablation zone were attributable to incomplete overlap, which can be avoided. This study, together with nonesophagectomy IM-HGD trials currently underway, will identify the optimal treatment parameters for IM-HGD patients who would otherwise undergo esophagectomy or photodynamic therapy.

Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass.

BACKGROUND: The use of Roux-en-Y gastric bypass (RYGB) for morbid obesity has raised concern that subsequent endoscopic evaluation of the gastric remnant and duodenum is difficult. By gaining percutaneous access to the gastric remnant, however, both gastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) can be performed easily. This report describes the results of a novel technique for performing "transgastrostomy" gastroduodenoscopy and ERCP. METHODS: Six patients with a RYGB for morbid obesity underwent transgastric remnant endoscopic evaluations. If a gastric remnant tube had not been placed during prior surgery, one was placed percutaneously by an interventional radiologist. The tube tract then was dilated to either 20- or 24-Fr. At the time of endoscopy, the gastrostomy tube was removed and the skin anesthetized. Then either a pediatric duodenoscope (outer diameter, 7.5 mm) or a slim gastroscope (outer diameter, 5.9 mm) was inserted through the gastrostomy tube tract. RESULTS: Percutaneous gastroduodenoscopy was successfully performed for all six patients. The findings included two patients with prepyloric ulcers identified and assessed with a biopsy, one patient with intestinal metaplasia and a benign gastric polyp, and three patients with a normal gastric remnant and duodenum. A nonstrictured enteroenterostomy was noted in one of the three patients with a normal endoscopic evaluation. Percutaneous transgastrostomy ERCP was performed for three of the six patients who underwent gastroduodenoscopy. The findings included one patient who had papillary fibrosis treated with a sphincterotomy, a second patient with a normal biliary tree, and a third patient with a normal pancreatic duct. Selective cannulation of the common bile duct was not successful in the third patient. CONCLUSION: The transgastrostomy endoscopic route ensures access to the excluded stomach and proximal small bowel after RYGB. This route is safe and effective, allowing the use of a duodenoscope to improve the cannulation success rate for ERCPs in this patient population.

Endoluminal and transluminal surgery: current status and future possibilities.

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include "incisionless," "endoluminal," "transluminal," and "natural orifice" transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.

Thin-layer ablation of human esophageal epithelium using a bipolar radiofrequency balloon device.

BACKGROUND: The goal of this study was to determine the optimal treatment parameters for the ablation of human esophageal epithelium using a balloon-based bipolar radiofrequency (RF) energy electrode. METHODS: Immediately prior to esophagectomy, subjects underwent esophagoscopy and ablation of two separate, 3-cm long, circumferential segments of non-tumor-bearing esophageal epithelium using a balloon-based bipolar RF energy electrode (BARRX Medical, Inc., Sunnyvale, CA, USA). Subjects were randomized to one of three energy density groups: 8, 10, or 12 J/cm2. RF energy was applied one time (1x) proximally and two times (2x) distally. Following resection, sections from each ablation zone were evaluated using H&E and diaphorase. Histological endpoints were complete epithelial ablation (yes/no), maximum ablation depth, and residual ablation thickness after tissue slough. Outcomes were compared according to energy density group and 1x vs 2x treatment. RESULTS: Thirteen male subjects (age, 49-85 years) with esophageal adenocarcinoma underwent the ablation procedure followed by total esophagectomy. Complete epithelial removal occurred in the following zones: 10 J/cm2 (2x) and 12 J/cm2 (1x and 2x). The maximum depth of injury was the muscularis mucosae: 10 and 12 J/cm2 (both 2x). A second treatment (2x) did not significantly increase the depth of injury. Maximum thickness of residual ablation after tissue slough was only 35 microm. CONCLUSIONS: Complete removal of the esophageal epithelium without injury to the submucosa or muscularis propria is possible using this balloon-based RF electrode at 10 J/cm2 (2x) or 12 J/cm2 (1x or 2x). A second application (2x) does not significantly increase ablation depth. These data have been used to select the appropriate settings for treating intestinal metaplasia in trials currently under way.

Impact of upper endoscopic survey during percutaneous endoscopic gastrostomy tube placement.

BACKGROUND: No consensus exists concerning the utility of a full diagnostic upper endoscopy during percutaneous endoscopic gastrostomy (PEG) tube placement. We evaluate the effect of a complete survey on identifying and treating unsuspected gastrointestinal pathology. METHODS: During a 10-year period (1990-2000), 1,706 patients underwent attempted PEG tube placement by five different surgical endoscopists at one institution. A complete survey of the esophagus, stomach, and proximal duodenum was attempted in all cases. Endoscopic findings and recommendations were recorded in a computerized log and patient charts. Pathology results were obtained from a computerized pathology database and patient charts. RESULTS: Placement of a PEG tube was successful in 97%, and a full survey was possible in 99% of the cases. Pathologic findings were found in 38% of the surveyed patients (esophagus, 7%; stomach, 24%; duodenum, 7%). One group with gastrointestinal polyps or gastric ulcers (5.7%) was identified as possible candidates for endoscopic intervention. In 30% of this group (1.8% of the total) a biopsy was performed, or bleeding was treated endoscopically. In a second group pathology was identified in the duodenum (6.4%) that would not have been recognized without a full survey. These duodenal findings resulted in a recommendation for treatment change in 38% of this group (2.4% of the total). CONCLUSIONS: Upper endoscopic survey before PEG tube placement showed a significant amount of unsuspected gastrointestinal pathology. Findings requiring biopsy, immediate treatment, or a change in medical treatment occurred in 4.2% of the cases, and these findings did not prevent PEG tube placement in any patient.

Laparoscopic right donor nephrectomy: technique and comparison with left nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) preferentially involves the left kidney to optimize vessel length, but occasionally, right nephrectomy is preferred. Right LDN differs markedly in anatomic relations and the need for a fourth port. This retrospective study compares donor outcomes and graft function of right and left LDN and describes the technique. METHODS: Consecutive patients undergoing right LDN from March 26, 1996 to December 31, 2000 were compared with those undergoing left LDN. Age, height, weight, body mass index, creatinine, creatinine clearance, operative time, warm ischemia time, analgesic requirements, serial postoperative creatinine, time to diet resumption, and hospital stay were compared. A second cohort matched for age, gender, race, and temporal left LDN also were compared with the group undergoing right LDN. RESULTS: No significant differences were found for any of the parameters measured. CONCLUSION: This study demonstrates that despite substantial differences in the procedures, donor outcome and graft survival are similar for right and left LDN.

Short-term endobiliary stenting results in chronic inflammation of the porcine extrahepatic biliary system.

This study reports the histologic changes seen in the biliary ductal system and pancreas as a result of endobiliary stenting. Ten mini pigs underwent endoscopic placement of suprapapillary endobiliary stents. The animals were killed and the liver, biliary tree, and pancreas were resected en bloc and prepared for histologic examination. Endobiliary stenting was found to result in significant chronic inflammation in the biliary system within 4 weeks of stent placement. These changes were present throughout the entire extrahepatic biliary ductal system and persisted throughout the 15-week study period. There was no significant acute inflammation in the biliary tree nor acute or chronic inflammation in the pancreatic duct. Further study is indicated to determine whether these changes will result in fibrosis and stricture.

Simultaneous cadaver pancreas living-donor kidney transplantation: a new approach for the type 1 diabetic uremic patient.

OBJECTIVE: To review the authors' experience with a new approach for type I diabetic uremic patients: simultaneous cadaver-donor pancreas and living-donor kidney transplant (SPLK). SUMMARY BACKGROUND DATA: Simultaneous cadaver kidney and pancreas transplantation (SPK) and living-donor kidney transplantation alone followed by a solitary cadaver-donor pancreas transplant (PAK) have been the transplant options for type I diabetic uremic patients. SPK pancreas graft survival has historically exceeded that of solitary pancreas transplantation. Recent improvement in solitary pancreas transplant survival rates has narrowed the advantage seen with SPK. PAK, however, requires sequential transplant operations. In contrast to PAK and SPK, SPLK is a single operation that offers the potential benefits of living kidney donation: shorter waiting time, expansion of the organ donor pool, and improved short-term and long-term renal graft function. METHODS: Between May 1998 and September 1999, the authors performed 30 SPLK procedures, coordinating the cadaver pancreas transplant with simultaneous transplantation of a laparoscopically removed living-donor kidney. Of the 30 SPLKs, 28 (93%) were portally and enterically drained. During the same period, the authors also performed 19 primary SPK and 17 primary PAK transplants. RESULTS: One-year pancreas, kidney, and patient survival rates were 88%, 95%, and 95% for SPLK recipients. One-year pancreas graft survival rates in SPK and PAK recipients were 84% and 71%. Of 30 SPLK transplants, 29 (97%) had immediate renal graft function, whereas 79% of SPK kidneys had immediate function. Reoperative rates, early readmission to the hospital, and initial length of stay were similar between SPLK and SPK recipients. SPLK recipients had a shorter wait time for transplantation. CONCLUSIONS: Early pancreas, kidney, and patient survival rates after SPLK are similar to those for SPK. Waiting time was significantly shortened. SPLK recipients had lower rates of delayed renal graft function than SPK recipients. Combining cadaver pancreas transplantation with living-donor kidney transplantation does not harm renal graft outcome. Given the advantages of living-donor kidney transplant, SPLK should be considered for all uremic type I diabetic patients with living donors.

Laparoscopic live donor nephrectomy: the University of Maryland 3-year experience.

PURPOSE: We determined whether laparoscopic living donor nephrectomy decreases the morbidity of renal donation for the donor, while providing a renal allograft of a quality comparable to that of open donor nephrectomy. MATERIALS AND METHODS: In a 3-year period laparoscopic donor nephrectomy was performed via the transperitoneal approach. We evaluated donor and recipient medical records for preoperative donor characteristics, intraoperative parameters and complications, and postoperative recovery and complications. RESULTS: Of the 320 laparoscopic donor nephrectomies performed the left kidney was removed in 97.5%. Intraoperative complications, which developed in 10.4% of cases, tended to occur early in the experience and required conversion to open nephrectomy in 5. Average operative time was 31/2 hours and warm ischemia time was 21/2 minutes. As the series progressed, blood loss as well as laparoscopic port size and number decreased but extraction site size remained constant at 7 cm. Urinary retention, prolonged ileus, thigh numbness and incisional hernia were the most common postoperative complications. Postoperative analgesic requirements were low and average hospitalization was 66 hours. CONCLUSIONS: Laparoscopic donor nephrectomy appears to be safe and decreases morbidity in the renal donor. Allograft function is comparable to that in open nephrectomy series. The availability of laparoscopic harvesting may be increasing the living donor volunteer pool.

Laparoscopic nephrectomy in the markedly obese living renal donor.

OBJECTIVES: To determine whether laparoscopic living donor nephrectomy is safe and efficacious in markedly obese renal donors. METHODS: From 1996 to 1999, 431 laparoscopic living donor nephrectomies were performed. The markedly obese group consisted of 41 patients with a body mass index (BMI) greater than 35. Forty-one controls with a BMI less than 30 were matched to the obese donors by sex, age, race, and date of surgery. RESULTS: The markedly obese and control groups were closely matched in sex, race, age, serum creatinine level, creatinine clearance, HLA match to recipient, side of donated kidney, and experience level of the surgeons. The obese patients had a BMI range of 35.2 to 53.9 (mean 39.3), and the control patients had a BMI range of 18.4 to 29.0 (mean 24.3). Donor operations in the markedly obese were significantly longer by an average of 40 minutes. The greater intraoperative blood loss and longer extraction incision length seen in the markedly obese did not reach statistical significance. More and larger laparoscopic ports were used in the markedly obese. Obese donors were more likely to require conversion from laparoscopic nephrectomy to open nephrectomy than ideal-sized donors. The postoperative recovery of the gastrointestinal tract, hospitalization time, analgesic requirements, and total complications were equal in the two groups, although the obese donors' complications tended to be cardiopulmonary problems. The recipient graft function was equivalent between the two groups. CONCLUSIONS: Laparoscopic living donor nephrectomy is more difficult to perform in the markedly obese but is associated with an equivalent donor morbidity and recipient renal outcome.