The Success of Laparoscopic Donor Nephrectomy: Is the Open Approach Justified? A.S. Soin, M.R. Rajasekar, D.V. Rajakumari, A. Mishra, and S. Jasuja L APAROSCOPIC donor nephrectomy (LDN) is fast replacing the open approach due to its advantages of reduced postoperative pain, morbidity, scarring, hospital- isation, and early return to work. 1 Although most centres report graft performance in LDN kidneys 2 as good as in those removed by the open approach, there are some concerns regarding delayed graft function and ureteric complications in laparoscopically retrieved kidneys. We present our experience with the first 80 consecutive cases of India’s first such program. Our goal was to compare donor and recipient postoper- ative outcomes between LDN and open donor nephrectomy (ODN). METHODS A total of 142 living donor kidney transplants were performed at our unit through May 2000. The first 62 were by the open method and, since April 1999, the last 80 by LDN using a transperitoneal approach. Results were compared between the two groups. For LDN, the patient was positioned as for an open nephrectomy. LDN was performed via three 5-mm ports and a 12-mm port inserted in a portion of the preplanned 5-cm retrieval incision in the groin. A fourth 5-mm port was placed in nine cases for retraction of liver, spleen, or bowel. Special care was taken to mobilize the ureter along with the gonadal vein and a generous amount of periureteric tissue. The kidney was eased out of the retrieval incision by gently tugging on the gonadal vein and periureteric tissue without the use a special retrieval bag. All kidneys were successfully dissected laparoscopically, their vessels divided using EndoGIA stapler with 2.5-mm vascular cartridges, removed via a 5-cm groin incision (bar one that required midline laparotomy due to stapler malfunction), and transplanted successfully. The donor and recipient operative and postoperative management protocols were the same for both groups except that 15 patients in the LDN group received myco- phenolate-based immunosuppression as part of an ongoing ran- domised study. The same two surgeons (A.S.S. and M.R.R.) alternately performed all the donor and recipient procedures. RESULTS Seventy-one left and nine right nephrectomies were per- formed laparoscopically. Laparotomy was required in one case (1% conversion rate) at the end of the operation due to stapler malfunction, yet both the donor and recipeint made an uneventful recovery, and the donor was discharged on day 3. Anatomic variations such as multiple arteries (16 cases), venous anomalies (17 cases), and other problems in the donor such as previous laparotomy (7 donors), enlarged spleen (7), and hepatomegaly (2) were successfully dealt with laparoscopically. Donor Parameters Postoperatively, donors in the LDN group had significantly reduced analgesia requirements (33 vs 74 hours; P  .05), reduced incidence of minor wound and chest complications (6% vs 38%; P  .01), no reoperations (0 vs 2%), reduced hospital stay (2.2 vs 7.5 days; P  .05), and early return to work (11 vs 39 days; P  .01) compared with those who donated kidneys via the open approach. The mean operat- ing time for LDN was a little longer (3.1 vs 2.2 hours) than the open operation. Recipient Parameters Laparoscopically removed kidneys worked as well as those removed by the open approach. In the LDN and open groups, there was no significant difference in the incidence of delayed graft function (2 vs 0%), vascular (0% vs 2%) or ureteric complications (4% vs 4%), acute rejection (20% vs 28%), mean serum creatinine at discharge (1.3 vs 1.2 mg/dL), 3-month graft survival (96% vs 96%), or patient survival (98% vs 98%). CONCLUSIONS AND RECOMMENDATIONS Donor nephrectomies can be safely performed by a trans- peritoneal laparoscopic approach. LDN results in less post- operative pain, a decrease in wound and chest complica- tions, early discharge and return to work, and avoidance of painful unaesthetic scars for the donor, without compro- mising the recipient and graft performance. Ureteric complications can be prevented by careful preservation of ureteric blood supply by including generous amounts From the Department of Multiorgan Transplantation, In- draprastha Apollo Hospital, New Delhi, India. Address reprint requests to Dr A.S. Soin, C22, Sector 30, Noida, UP 201301 India. © 2001 by Elsevier Science Inc. 0041-1345/01/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(00)02765-2 Transplantation Proceedings, 33, 1997–1998 (2001) 1997