Living-donor nephrectomy is usually an altruistic act. The surgery is different from other destructive surgeries in that it involves a healthy individual being exposed to the risks of the procedure. The symptoms and discomfort that patients encounter should be minimized in clinical practice. Compared to open donor nephrectomy, laparoscopic donor nephrectomy showed superior donor postoperative recovery and convalescence[14, 15], and also equivalent safety and post-nephrectomy outcome in the donor[16].
LESS is a revolutionary laparoscopy because of the advantage of less bleeding, less wound pain, less risk of incisional hernia, and better cosmesis[17]. At our institution, our surgeons experience single-port laparoscopic surgery technique, such as LESS adrenalectomy, herniorrhaphy, partial nephrectomy, and robotic single-port radical prostatectomy in daily practice[18–20]. LESS-DN has become the standard procedure for living-donor kidney transplantation since December 2017 in our institution.
This article is a comparison of transperitoneal and retroperitoneal LESS-DN. Based on previous studies, although the transperitoneal approach of laparoscopy provides a broader view and clear anatomic landmarks to gain direct access without bowel manipulation, the retroperitoneal approach of laparoscopy can reduce the violation of abdominal organs and bypass the intraperitoneal adhesion[21, 22]. This may contribute to the reduced operation time and even the shortened recovery periods post-surgery in our analysis. In our study, the faster operation time in the retroperitoneal approach group did not lead to more blood loss or a longer warm ischemia time during the surgery compared to the transperitoneal group. The LOS was significantly shorter in the retroperitoneal group. Minimal interference of the abdominal organs during the retroperitoneal approach supposedly shortens the duration of bowel recovery and hospital stay. In our study, the wound of the transperitoneal approach was created on the umbilicus. During wound healing, the wound retracted to the inner-side of the umbilicus and the healing scar was less visible in the transperitoneal approach group, as mentioned in other literatures[23]. Thus, the wound size was smaller than in the retroperitoneal approach, although the original incision was the same size. Based on Choi et al.’s study, poor renal function recovery and chronic kidney disease were predicted by unstable renal function at one month postoperatively. Such patients should be followed for more than one year to confirm their final renal outcomes[24]. After donor nephrectomy, all patients were followed for one year to evaluate the postoperative renal function. There was no significant difference between the transperitoneal group and the retroperitoneal group, which indicates that the safety of LESS-DN was identical regardless of the approach method.
The present evidence demonstrates that the retroperitoneal LESS-DN may be a faster surgery without compromising safety under the expertise of an experienced surgeon. There are limitations to this study. First, there is a small number of patients in our study. Further studies should include more patients to provide more robust evidence. Second, all patients underwent surgeries under the same team. The bias about the surgeon’s learning curve could therefore not be neglected in this study.