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Lewandowski, Pierre-Marie; Leslie, Scott; Gill, Inderbir; Desai, Mihir M.
LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
Archivos Españoles de Urología, vol. 65, núm. 3, abril, 2012, pp. 318-328
Editorial Iniestares S.A.
Madrid, España
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MONOGRAPHIC ISSUE ON LESS & NOTES IN UROLOGY
Arch. Esp. Urol. 2012; 65 (3): 318-328
LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES
AND OUTCOMES
Pierre-Marie Lewandowski, Scott Leslie, Inderbir Gill, and Mihir M. Desai.
Section of Laparoscopic and Robotic Surgery. USC Institute of Urology. University of Southern California. USA.
Summary.- OBJECTIVES: Living donor nephrectomy
is a unique surgical procedure in urological practice
and must optimize the trifecta of: patient safety, minimal
morbidity and successful graft function. The laparoscopic
technique has become the gold standard over the last
decade for harvesting the kidney from a living donor.
Laparo-endoscopic single-site (LESS) surgery is an
attempt to further enhance cosmetic benefits and reduce
the morbidity for potential kidney donors. We have
summarized and reviewed the literature of LESS-DN and
described the techniques and outcomes.
METHODS: Using the National Library of Medicine
database, the English language literature was reviewed
from 2006 to 2011. Keyword searches included LESS,
Donor, Nephrectomy, Living, Single-site, e-NOTES,
Mini-invasive, Laparoscopic, Single-port. Within the
bibliography of selected references, additional sources
were retrieved.
RESULTS: After Gill’s description of the first four patients
to undergo LESS-DN, we found five series published
describing the surgical techniques of LESS-DN as well
as the outcomes. We have outlined in detail the various
techniques of the trans-umbilical LESS-DN and compared
the outcomes with conventional LDN. We also briefly
discuss new innovative techniques of LESS-DN.
CONCLUSIONS: LESS-DN is a safe albeit technically
challenging alternative to LDN. LESS-DN appears
to have comparable results to LDN in terms of graft
function, patient morbidity, and cosmesis. Further long
term results and the development in parallel with other
LESS procedures is required before LESS-DN is to be
considered a standard of care.
Keywords: LESS. Donor. Living. Nephrectomy.
@
CORRESPONDENCE
Mihir Desai, MD
USC Institute of Urology
1441 Eastlake Ave
NOR7416
Los Angeles, CA 90033 (USA)
mihir.desai@usc.edu
Resumen.- OBJETIVO: La nefrectomía del donante
vivo (NDV) es una operación quirúrgica única en la
práctica urológica y debe optimizarse la triada perfecta
de: seguridad del paciente, morbilidad mínima y función
del injerto con éxito. La técnica laparoscópica se
ha convertido durante la última década en el patrón oro
para obtener el riñón de un donante vivo. La cirugía
laparoscópica por puerto único (LESS) es un intento de
mejorar más aún los resultados cosméticos y de reducir
la morbilidad para los potenciales donantes de riñón.
Hemos revisado y resumido la literatura en lengua inglesa
sobre NDV LESS desde 2006 a 2011. La búsqueda
de palabras clave incluía LESS, nefrectomía del
donante, vivo, puerto único, e-NOTES, mínimamente

LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
319
invasiva, laparoscópica, sitio único. Dentro de la bibliografía
de las referencias seleccionadas se consiguieron
fuentes adicionales.
RESULTADOS: Tras la descripción de los primeros cuatro
pacientes sometidos a NDV LESS por Gill, encontramos
cinco series publicadas describiendo las técnicas quirúrgicas
de NDV LESS así cómo los resultados. Hemos
resumido en detalle las diferentes técnicas de NDV LESS
transumbilical y comparado los resultados con la NDV
laparoscópica convencional. También discutimos brevemente
nuevas técnicas innovadoras de NDV LESS.
CONCLUSIONES: La NDV LESS es una alternativa segura
a la NDV laparoscópica aunque técnicamente desafiante.
La NDV LESS parece tener resultados comparables
con la NDV laparoscópica en términos de función
del injerto, morbilidad del paciente y cosmética. Son
necesarios resultados más a largo plazo y el desarrollo
en paralelo con otros procedimientos LESS antes de que
la NDV LESS se considere un procedimiento estándar.
Palabras clave: LESS. Donante vivo. Nefrectomía.
INTRODUCTION
Surgery is in constant progress, and over
the last two decades we have witnessed an everincreasing
adoption of minimally invasive techniques.
This has been particularly true in the field of urology
where laparoscopic procedures have all but replaced
open techniques for many urological operations.
The benefits of minimally invasive surgery; less postoperative
pain, improved cosmesis, shorter hospital
stay, faster return to normal activities, are the reasons
that these techniques have gained widespread
popularity. Laparo-endoscopic single-site (LESS)
surgery is perhaps the next step in the evolution of
minimally invasive techniques, with the potential for
further reduction in morbidity and improvement in
cosmesis compared to conventional laparoscopic
surgery. In this article we discuss the role of LESS
surgery for living donor nephrectomy. We compare
the various techniques described in the literature and
review the outcomes that have been published by
academic centers utilizing this new technology.
The first laparoscopic living donor
nephrectomy (LDN) was performed in 1995 (1). It
has since replaced open donor nephrectomy (ODN)
as the technique of choice for living renal allograft
retrieval in most major transplant centers. Indeed,
many studies have demonstrated not only the expected
benefits of minimally invasive technique (less pain,
shorter hospital stay, rapid convalescence) but also
equivalent outcomes in terms of graft function when
compared to ODN (2-4).
LESS donor nephrectomy (LESS-DN) was
first described by Gill in 2008 (5) and is for many
the next step in donor surgery after conventional
laparoscopy. End stage renal failure patients whom
are dialysis dependent face ever-increasing waiting
times before they receive a kidney due to the small
number of donors available. If LESS-DN can provide
benefits over LDN in terms of minimizing morbidity
to donors, then this may encourage expansion of the
living donor pool.
METHODS
We performed a literature search between
2006 and 2011, using the PubMed Database and the
keywords: LESS, Donor, Nephrectomy, Living, Singlesite,
e-NOTES, Mini-invasive, Laparoscopic, Singleport.
After Gill’s description of the first four patients to
undergo LESS-DN (5), five series have been published
describing the surgical techniques of LESS-DN as well
as the outcomes (6-10).
• Canes & Gill (6) from the Cleveland clinic,
described 17 consecutive patients undergoing LESS-
DN, comparing them to a contemporary matched-pair
cohort of 17 patients undergoing standard LDN.
• Ganpule & Desai et al (7) from Muljibhai Patel
Urological Institute reported their experience with the
first 13 patients undergoing LESS-DN.
• Gimenez & Del Pizzo (8) from Cornell Medical
College presented their initial experience in 40
patients undergoing LESS-DN.
• Kurien & Desai (9) from Muljibhai Patel Urological
Institute reported the first randomized trial comparing
LESS-DN and LDN.
• Lunsford & Vikraman (10) from Duke University
medical center compared 10 patients undergoing
LESS-DN with a matched-pair cohort undergoing
standard LDN.
LESS Donor nephrectomy: Surgical
technique
Donor selection
In all institutions a multi-disciplinary team
screens potential donors to ensure they meet

320
P. M. Lewandowski, S. Leslie, I. S. Gill, and M. M. Desai.
criteria suitable for donation. Donors are generally
young, healthy patients with favorable anatomy for
surgery. Pre-operative imaging includes a computed
tomography scan with vascular reconstructions to
identify renal vessel anomalies, as well as delayed
images to demonstrate the collecting system. The preoperative
workup for LESS-DN is the same as for LDN,
however it is paramount to identify any anatomical
variations (such as two or more renal arteries) as
this may make the challenging dissection already
associated with LESS-DN even more difficult. In the
randomized trial by Kurien (9), patients with multiple
renal arteries, or venous anomalies were excluded
from the study.
Anesthesia and Patient Positioning
As with standard LDN patients receive a
general anesthetic, an indwelling catheter is placed,
and calf compressors are utilized throughout the
procedure and in the early post-operative period.
Positioning of the patient is typically in a modified
45-degree flank position with the operating table
flexed and pressure areas addressed. The patient’s
hydration status is well maintained throughout the
case with generous amounts of intravenous fluids.
Pneumoperitoneum is achieved either with the use
of a 2 mm Veress needle, or using an open Hassan
technique.
Single Site Ports
In the published literature, there are two
types of ports described for use in LESS-DN: R-Port
(Advanced surgical concepts, Dublin, Ireland);
GelPoint (Applied Medical, Rancho Santa Margarita,
California, USA) .
• R-Port: There are two types of R-ports used
for LESS-DN in the literature. Gill (5,6) describes the
use of the Triport (Figure 1) which is a unique single
access port with three inlet channels (1 of 12 mm
and 2 of 5 mm). A 2 cm completely intra-umbilical
vertical skin incision is made followed by a 2 to 3
cm midline fasciotomy to enter the peritoneal cavity.
The port is then inserted and secured in position
by 2 plastic rings (1 within the peritoneum and the
other remaining outside the skin), both connected
by a sliding plastic sleeve. Pulling up on the sleeve
removes its slack, thereby tightly approximating the
2 rings against each other and creating an airtight
seal for pneumoperitoneum. The fasciotomy between
the 2 rings is effectively tented open by the taut waist
of the intervening plastic sleeve. Various standard 5,
10 and 12 mm laparoscopic instruments, as well as
novel curved instruments, can be inserted through this
port.
The Quadport (Figure 2) differs from the
Triport with respect to a wider inner plastic ring (3 vs.
1.5 inches). With an extra inlet channel, thus allowing
the simultaneous use of two 12 mm laparoscopic
instruments if required it became the preferred port
for Gill and Desai for LESS DN on its availability in
the United States (7,9). The technique of inserting the
Quadport is similar to that described for the Triport
above.
• GelPoint: This was the port of choice for Del
Pizzo (8) and Vikraman (10) in their published LESS-
DN series. A 5 cm vertical periumbilical incision is
FIGURE 1. Triport.
FIGURE 2. Quadport.

LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
321
made in the skin (therefore a longer incision than with
the R-port). This is followed by a midline fasciotomy
to enter the abdomen. The GelPoint (Figure 3), with
three trocars already in place, is then inserted into
the abdomen and pneumoperitoneum established.
Initially, two 5 mm and one 15 mm trocar is used in
the GelPoint with the laparoscope introduced through
the 15 mm trocar. However, towards the end of the
dissection, a 12 mm trocar can replace one of the
5 mm trocars to allow for the introduction of larger
devices such as the EndoGIA® vascular stapler or
Hem-o-lock® clip applier.
Laparoscope
Both the teams of Gill and Desai used a
5mm 30° digital laparoscope (EndoEYE, Olympus
Orangeburg, New York) which was introduced
through one of the 5mm channels of the R-port. In a
small number of cases a 5mm Deflectable-Tip EndoEYE
laparoscope was used (Figure 4).
The team of Gimenez preferred a bariatric
10mm laparoscope via the GelPoint. In addition to
its extra length a right angle attachment was used for
the light cord, both of which minimized clashing with
the graspers.
Instruments
In most cases standard rigid laparoscopic
instruments were used for the LESS-DN. However, on
occasion articulating (Figure 5) or curved instruments
specifically designed for LESS surgery were used. The
design of these graspers is aimed at reducing the
clashing between instruments and to allow a greater
freedom of movement. However, given the unfamiliar
ergonomics of the graspers, they were not routinely
utilized by all the surgical teams.
Mobilization of the Kidney and Hilar Dissection
Once the single-site port access has been
inserted and pneumoperitoneum achieved, the LESS-
DN surgical technique duplicates conventional LDN.
In the case of a left sided donor nephrectomy (which
is by far the most common side given the extra length
of renal vein that can be harvested), the descending
colon, spleen, and tail of the pancreas are mobilized
generously, such that they retract medially without the
need for constant retraction. At the level of the lower
pole of the kidney, the ureter and gonadal vein packet
are elevated off the psoas muscle. The gonadal vein
is maintained intact and traced cephalad to the renal
vein.
The renal vein is skeletonized, the adrenal
vein is divided between titanium clips, and the
adrenal gland is released from the upper pole. Akin to
standard LDN, the renal vein is dissected completely
up to the interaortocaval region, and the renal artery
is dissected to its aortic origin, taking care not to
induce arterial spasm.
Kidney Extraction
Once the kidney has been completely
mobilized, the ureter divided at the pelvic brim and
the renal artery and vein adequately skeletonized, the
kidney is ready for extraction. In the case of standard
LDN a separate Pfannenstiel incision is made through
which the kidney is removed after division of the
vessels. However, in the case of LESS-DN, kidney
FIGURE 3. GelPoint.
FIGURE 4. Deflectable-Tip EndoEYE Laparoscope.

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.

LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
323
TABLE I. DEMOGRAPHIC DATA OF THE FIVE PUBLISHED STUDIES.
Canes (6)
Ganpule (7)
Gimenez (8)
Kurien (9)
Lunsford (10)
Number of Patients
17
13
40
25
10
105
Mean Age
38
46.6
43.7
44.4
47
43.6
Male / Female
5/12
5/8
18/22
7/18
5/5
40/65
Mean BMI (kg/m2)
26
22.2
26.1
22.3
24
24.5
Left Kidney
17
12
39
25
10
103
Anatomic complexity†
5
1
8
-
0
14
† Denotes more than one renal artery
of LESS-DN that should be considered and compared
with conventional LDN:
- Donor Safety: Kidney donors are unique in
that they are undergoing major surgery without having
any pathology. Their actions are completely altruistic
and it is of utmost importance that complications are
avoided and the safety of the donor is placed before
all else.
- Graft Outcome: Standard LDN has
demonstrated equivalent graft function (both longterm
and short-term) when compared to ODN (11).
It is important that LESS-DN does not compromise
graft function and demonstrates comparable results to
standard LDN.
- Morbidity: The proponents of LESS surgery
argue that the primary advantages over standard
laparoscopy are decreased post-operative pain,
improved cosmesis (as there is only a single incision,
commonly hidden within the umbilicus) and a shorter
convalescence. There is some evidence in the literature
suggesting superiority of LESS surgery over standard
laparoscopy in these domains (12,13) and we assess
these outcomes in the LESS-DN series.
The demographic data for the five published
series is outlined in Table I.
Donor Safety. There were no documented
deaths among the donors in any of the five series.
Complications ranged from 0% to 16%. In the
series of Gimenez (8) there was one documented
complication of a wound infection which was treated
with antibiotics. In the randomized trial of Kurien
(9) with 25 patients in each group, there were four
complications in the LESS-DN group (16%) and five
complications in the standard LDN group (20%). The
four complications in the LESS-DN group included two
post-op febrile patients managed conservatively and
two wound infections treated with antibiotics. There
was a corneal abrasion in the study by Canes (6)
that appears unrelated to the LESS-DN procedure
itself. There were no documented complications in
the series of Ganpule (7) or Lunsford (10). This data
TABLE II. INTRAOPERATIVE OUTCOMES.
Canes (6)
Ganpule (7)
Gimenez (8)
Kurien (9)
Lunsford (10)
(mean)
Operative Time (min)
269
177
167
172
179
187
Estimated Blood Loss (mL)
108
158
107
84
50
102
Warm Ischemia Time (min)
6.1
6.8
3.96
7.2
-
5.6
Incision Length (cm)
4.1
5.2
5.1
5.2
-
4.95

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P. M. Lewandowski, S. Leslie, I. S. Gill, and M. M. Desai.
TABLE III. WARM ISCHEMIA TIME AND GRAFT OUTCOMES.
Canes (6) Kurien (9) Lunsford (10)
LESS-DN
LDN
LESS-DN
LDN
LESS-DN
LDN
WIT (min)
6.1
3.0
7.15
5.11
-
-
1 month
Cr† 1.5
Cr 1.3
eGFR‡ 94.6
eGFR 86.5
Cr 1.4
Cr 1.4
3 months
Cr 1.5
Cr 1.3
eGFR 88.9
eGFR 86.1
12 months
eGFR 81.5
eGFR 80.9
† Creatinine (mg/dL)
‡ estimated Glomerular filtration rate (ml/min)
demonstrates safety for the donor undergoing LESS-
DN with only a small number of complications, and
no complication considered Clavien (14) grade III or
higher.
Graft Outcome. The mean warm ischemia
time (WIT) for each of the five series is outlined in
Table II. WIT is defined as the time from when the renal
artery is clipped to when the kidney is re-perfused by
the transplant surgeon on the back table. The average
WIT for the five series is 5.6 minutes (3.96 – 7.2).
Table III looks at the WIT and graft function in the series
which directly compared LESS-DN to standard LDN.
In the series by Canes6 the WIT for LESS-DN is twice
that of standard LDN (6.1 v. 3.0). The reason for the
increased WIT in the LESS-DN procedure is primarily
due to the time taken to remove the R-port, extend the
fasciotomy and skin incision to allow safe extraction
of the kidney. In the case of standard LDN, where
the kidney is removed via a pfannenstiel incision,
this delay is not encountered. However, despite the
longer WIT, this does not seem to impact on graft
function, with the 1 month and 3 month recipient
creatinine levels not significantly different between the
two groups (1.5 mg/dL v 1.3 mg/dL). In the study by
Lunsford10, although the WIT was not reported, the
recipient creatinine level on discharge was equal in
both the LESS-DN and the standard LDN groups (1.4
mg/dL). In the randomized study by Kurien (9), there
is again a significant difference in WIT between the
LESS-DN and the LDN (7.15 v 5.11). But once again,
this did not translate into inferior graft outcomes in the
recipient. Long term follow up of eGFR in the recipient
did not demonstrate any difference between the LESS-
DN group and the standard LDN group. This data
suggests that a slightly increased WIT does not have
any detrimental impact on graft function either in the
short or long term. It is also important to appreciate
that these studies included the very first LESS-DN
procedures, and it would be expected that with time,
refinement of the technique will allow for shorter WIT
in the future.
Morbidity. The average hospital length of stay
(LOS) in the published series is 2.5 days (Table IV).
In the studies comparing LESS-DN and standard LDN
(Table V), there is minimal difference in LOS between
the two groups.
The mean visual analogue pain score (VAS)
on discharge is 1.9 for the five series, and in the
studies of Canes (6) and Lunsford10, there was no
difference in the VAS pain scores between the LESS-
DN group and the LDN. The randomized study of
TABLE IV. POSTOPERATIVE OUTCOMES.
Canes (6)
Ganpule (7)
Gimenez (8)
Kurien (9)
Lunsford (10)
(mean)
Length of Stay (days)
3
-
1.8
3.9
1.3
2.5
Visual Analogue Pain Scale
2.7
2.9
1.4
1.2
2.5
1.9

LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
325
Kurien (9) demonstrated that in the first 48 hours
after the procedure there was no difference in pain
between the two groups. However, after 48 hours
there is divergence of VAS scores with significantly
less pain observed in the LESS-DN group. The VAS
pain score on discharge between the LESS-DN group
and the LDN group were 1.2 and 2.1 respectively.
In the study by Canes6, although there was no
difference in the VAS score it did demonstrate that the
number of days patients were using oral analgesia
and the number of days until patients returned to
work were significantly shorter in the LESS-DN group
(Table V).
In terms of the cosmetic satisfaction, Kurien
(9) did not demonstrate any difference in body image
or cosmetic satisfaction between the two groups.
This is in contrast to the study of Canes (6) where the
patients were asked to report their “scar satisfaction”
on a scale of 1 to 10. A significant difference was
noted with the LESS-DN group more satisfied with
their scar compared to the standard LDN group (9.7
v. 7.7) (Figure 7).
In these studies, the morbidity following LESS-
DN in terms of post-operative pain and perceived
cosmetic results are at least equivalent and in some
cases superior to conventional LDN. The extent to
which a psychological bias plays a role in these
outcomes is difficult to determine. Patients in the LESS-
DN group are aware that they have undergone an
innovative, less-invasive procedure, and the better
results may be related to a confirmation bias where
their preconceptions of the procedure may affect how
they rate the outcome.
DISCUSSION
Donor nephrectomy is a unique surgical
procedure as it is the only one performed on a
healthy patient in urological practice. Donor kidneys
are in critical shortage. The renal transplant waiting
list in the United States is increasing annually, and
has more than doubled in the last 15 years from
35,939 patients listed in 1997 to 89,442 in 2011
(15). This is despite an increase of more than 85%
TABLE V. COMPARISON OF LESS-DN TO STANDARD LDN.
LESS-DN
Standard LDN
Canes (6)
Kurien (9)
Lunsford (10)
Canes (6)
Kurien (9)
Lunsford (10)
Total no
17
25
10
17
25
20
Mean age
38
44.4
47
39
47.2
46.5
Intraoperative Outcomes
OT (minutes)
269
172
179
239
176
187
EBL (mL)
108
84
50
141
92
75
WIT (minutes)
6.1
7.15
-
3
5.11
-
Postoperative Outcomes
Length Stay (days)
3
3.9
1.3
3.5
4.6
1.1
VAS on discharge
2.7
1.2
2.5
1.4
2.1
2
Days back to Work
18
-
-
46
-
-
Days 100% recovery
29
-
-
83
-
-
Days oral pain pills
6
-
-
20
-
-

326
P. M. Lewandowski, S. Leslie, I. S. Gill, and M. M. Desai.
in the number of living donors between 1995 and
2010 largely due to the adoption of LDN (15,16).
It is evident that the supply of donor kidneys still
does not match the demand. The advent of LESS-DN
affords hope that a procedure with less pain, superior
cosmesis and shorter convalescence may further
remove barriers for donation. However, as with
any innovative procedure, it must be judged on its
results and of paramount importance in LESS-DN are
harvesting a quality kidney with excellent long-term
graft outcomes, whilst maintaining donor safety and
minimizing morbidity.
From ODN to LDN to LESS-DN
The initial transition from ODN to LDN
was associated with increased complications and
longer warm ischemia time. However, these issues
have since been overcome, and with the reduced
morbidity, shorter hospital stay and equivalent
graft outcomes (3,17-19) LDN has become the
gold standard in most major transplant centers
(20,21). LESS-DN will have to prove equivalent, if
not superior when compared to standard LDN if
it is to gain wider acceptance amongst transplant
donor surgeons. In the series of LESS-DN that have
been published, WIT was found to be significantly
longer than standard LDN. However there were
no differences seen in terms of graft function or
graft loss between the two groups. Although the
preliminary outcomes for LESS-DN are promising,
this mode of surgery is technically challenging and
requires further prospective studies to determine its
true role in donor surgery.
LESS-DN – Technical Challenges
Surgical techniques have evolved dramatically
over the last two decades and have moved towards
the ideal of scar-less surgery. LESS surgery is at the
forefront of this movement and since the initial reports
in 2007, LESS has been utilized to undertake a wide
breadth of urological procedures (22). However,
as we have moved toward single port surgery, new
challenges have presented themselves. LESS-DN
faces the same technical challenges as with all LESS
procedures and include:
Lack of triangulation – One of the principles
of conventional multi-port laparoscopy is to space
the ports far enough apart to allow for optimal
triangulation. In so doing, clashing of the instruments
is avoided and adequate counter traction can be
provided to the tissues to allow ease of dissection. In
the series of LESS-DN described above, a number of
strategies are employed to overcome the restrictions
of a single port:
- Gimenez (8) makes use of a bariatric
laparoscope with a right angle attachment for the
light cord. This serves to take the laparoscope away
from the surgeon’s graspers to minimize any clashing
that may occur.
- Gill (5) describes the use of curved graspers
(Novare Surgical Systems, Cupertino, California)
or a 2 mm needlescopic grasper inserted in the left
hypochondrium in order to provide counter-traction.
- Desai (7) also describes the use of an extra
3 or 5 mm port placed to assist with retraction in 11
of their first 13 cases.
- For the most part, standard laparoscopic
instruments were used to facilitate dissection. However,
when clashing of the instruments became a problem,
curved or articulating graspers were occasionally used.
- The GelPoint device itself, used in the
series of Gimenez (8) and Lunsford (10), has the
advantage of a larger diameter, allowing the inlet
ports to be spaced further apart thus providing better
triangulation.
- The Quadport, with an extra channel
compared to the Triport, has the obvious advantage
of allowing an additional instrument to provide
retraction during the procedure. Additionally, with
the Quadport, the surgeon can make upto a 5-6 cm
incison which allows greater freedom of movement of
the instruments and easier graft extraction.
Vision – As the laparoscope is placed via
the umbilicus in LESS-DN (lower than in conventional
LDN) this provides an unfamiliar view of the anatomy.
In particular, visualization of the upper pole and
posterior aspect of the renal pedicle may be
suboptimal even with the use of a 30-degree camera.
Desai (7) describes the use of a 5 mm Deflectable-Tip
EndoEYE laparoscope to facilitate a better view of
these structures.
Learning Curve – As LESS-DN is a challenging
procedure, adoption of the technique should ideally
be guided by a mentor and undertaken in major
transplant units. In addition, the surgeon should master
other LESS procedures (such as simple or radical
nephrectomy) before moving to LESS-DN where there
are time-critical factors and a higher scrutiny of patient
outcomes.
Novel Techniques of LESS-DN
In the literature the most common approach
to LESS-DN has been via a trans-umbilical port as

LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES
327
described above. However there have been recent
reports of alternative sites of access, which may have
benefits in terms of cosmetic outcomes.
Kavoussi (23) describes the use of a
Pfannenstiel incision to perform LESS-DN in six
patients. After making a 5cm Pfannenstiel skin
incision, three ports are positioned in a triangular
manner underneath the skin flaps. This differs
from the previously described techniques in that a
dedicated single-access device is not used to perform
the procedure. The median operating time was 142
minutes and the median WIT was 5 minutes. They
argue that a scar which can be concealed with
undergarments offers a superior cosmetic result when
compared to trans-umbilical LESS-DN.
Van der Merwe (24) describes the use of
a GelPoint placed in a 6 cm groin incision (below
the “bikini line”) to perform a retroperitoneal LESS-
DN. There were only 2 patients in this initial series
and apart from a long operating time (median 270
minutes) the outcomes in terms of WIT (3.8 minutes)
and post-operative pain were promising. Once again,
the authors argue that an incision that can be hidden
by undergarments offers a better cosmetic result.
In both theses studies, the number of patients
is small, and further prospective trials are required
to determine if these techniques offer equivalent or
superior results to trans-umbilical LESS-DN.
A recent study from Dubey (25) described a
trans-umbilical LESS-DN without the use of a single port
access device. Instead three standard laparoscopic
ports were placed under the skin flaps of a single
trans-umbilical incision Although the cohort was small
(six patients) the results were encouraging with a mean
WIT of three minutes, a mean operating time of 153
minutes and an average length of stay of three days.
This study showed the feasibility of a trans-umbilical
LESS-DN technique, without the need of a single port
access device.
Right LESS-DN
The left side is the predominant side for
donor nephrectomy given that a longer length of
renal vein and artery can be harvested facilitating an
easier anastomosis in the recipient. However in a few
situations, such as a smaller right kidney (measured
by scintigraphy) or multiple left renal arteries or
veins, the right kidney may be the preferred side for
donation. However, many proponents of LESS-DN
have avoided the right side on the basis that it is a
more difficult procedure than the left.
This has been challenged by Afaneh (26) who
reported six cases of right sided LESS-DN compared
to a matched cohort of left sided LESS-DN. Although
more technically challenging, they found that the graft
outcomes were equivalent between the two groups.
They concluded that right side LESS-DN is safe and
feasible, and can be an alternative when the right
kidney is the preferred side for donation.
CONCLUSIONS
Transplant donor surgery continues to
evolve. Over the last 15 years conventional LDN has
decreased disincentives for individuals to undergo
kidney donation. Although this has resulted in an
increase in the kidney donor pool there is still an
ever-widening gap between available kidneys and
the patients that need them. Initial data suggest that
LESS-DN may offer further improvements over LDN
in terms of quicker recovery and superior cosmetic
results. These are important considerations in young,
healthy, and physically active people who may be
considering donation.
The published literature on LESS-DN has
demonstrated that it is safe, has good graft outcomes
and improved patient morbidity. However, these
preliminary results need further support from larger
prospective studies to assess if the incremental
benefits in patient morbidity outweigh the added
intraoperative technical challenge of the procedure.
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