Open living-donor nephrectomy
Open nephrectomy can be performed through various surgical approaches (median or subcostal laparotomy, lumbotomy) and may be transperitoneal or extraperitoneal. The most commonly used technique is extraperitoneal lumbotomy and, as mentioned above, this is the reference technique with which new surgical procedures are compared.
Mini-incision living-donor nephrectomy
After the introduction of laparoscopic surgery, modifications to open surgery were developed in an attempt to compete with laparoscopic surgery. Thus, mini-incision nephrectomy was developed, which consists of performing an anterior, flank or posterior nephrectomy, with an incision of about 7cm in length. This is also considered minimally invasive surgery.
Hand-assisted laparoscopic living-donor nephrectomy
This surgical technique was developed to overcome the steep learning curve involved in pure laparoscopic surgery. The name refers to the insertion of the hand throughout the surgery process to facilitate surgical manoeuvres and provide greater safety by allowing immediate control of bleeding caused by injury to the large vessels. The incision for inserting the hand can be made at different locations, with the optional use of devices that assist in maintaining the pneumoperitoneum, according to surgeon preference.
The hand-assisted organ extraction technique is not included in this section because the incision is made at the end of the intervention and is only used for the extraction of the organ itself.
Retroperitoneoscopic living-donor nephrectomy
This technique was developed to reduce intra-abdominal handling, thus reducing complications in that area. Using this approach, the space is reduced and the anatomical view is different from the transperitoneal, making it somewhat difficult. Possible disadvantages are the risk of pneumomediastinum, pneumothorax, pneumopericardium and gas embolism.
Robot-assisted living-donor nephrectomy
The use of robot-assisted living-donor nephrectomy, pure and hand-assisted, has been reported but experience is minimal. Using the robot’s instruments, finger movements can be performed with greater mobility than with conventional laparoscopy, although at greater cost.
Advantages and disadvantages of living donor kidney transplantation.
Kidneys from living donors have better graft and patient survival rates for the recipient than do kidneys from deceased donors. This is because living donors are physiologically and hemodynamically normal; hence, the graft is not exposed to ischemic alterations associated with brain death or cardiac death in deceased donors. Also, transplantation can be scheduled electively, with both donor and recipient surgeries coordinated at the same facility. This minimizes cold ischemia time for the donated kidney.
In ideal circumstances, kidney transplantation from a living donor is preemptive, so that the recipient with end-stage kidney disease (ESKD) avoids the complications of dialysis altogether. Healthy donors are exposed to some, albeit limited, medical and surgical risks, as well as some degree of postoperative pain.