1154_1163 의학강좌_김성환

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1 J KMA Continuing Education Column Minimally Invasive Video Assisted Kidney Transplantation Seong Hwan Kim, MD Seong Pyo Mun, MD Department of Surgery, Chosun University College of Medicine E mail : shdkim@chosun.ac.kr spmun@chosun.ac.kr Korean Med Assoc 2006; 49(12): J KorJ Abstract Minimally invasive surgery (MIS) has been applied to nearly all fields of surgery due to its advantages like reduced morbidity, a better cosmetic outcome and early recovery. The recent advances in its technique have allowed us to use modified MIS technique in the field of kidney transplantation. From January 2004 to Mar 2006, minimally invasive kidney transplantation was carried out in 20 patients. Many clinical variables were compared to the conventional method. The operative procedure began with 7~8cm skin incision. A laparoscopic balloon dissector was used to create the retroperitoneal space for the placement of the grafted kidney. Vascular anastomosis and ureteroneocystostomy were performed under direct vision and with video assisted TV monitoring. The average length of the wound was 7.8 cm and it was placed below the belt line. The average operating time was 186 minutes. Less analgesic was given compared to conventional methods. There was one postoperative complication, a mild lymphocele. All patients showed normalized serum creatinine levels within 4 days. All grafted kidneys showed normal findings on the postoperative ultrasound and renal scans. Minimally invasive video assisted kidney transplantation is technically feasible and may offer benefits in terms of better cosmetic outcomes, less pain and quicker recuperation than conventional kidney transplantation. Keywords : Minimally invasive surgery; Kidney transplantation 1154

2 Minimally Invesive Invasive Video Assisted Kidney Transplantation Characteristics of the 20 patients of MIVAKT Clinical Characteristics Mean (Range) Age (years) 36.8 (18 45) Gender (Male/Female) 5/6 Body mass index (kg/m 2 ) 29.7 ( ) Cause of ESRD (Number) Glomerulonephritis 14 Diabetic nephropathy 5 Others 1 Preoperative BUN (mg/dl) 67.1 ( ) Preoperative Cr (mg/dl) 9.6 (6.8~12.4) Method of Dialysis (Numbers) Peritoneal 6 Hemodynamic 14 Duration of dialysis (years) 6.8 ( ) MIVAKT minimally invasive video assisted kidney transplantation, ESRD end stage renal disease, BUN blood urea nitrogen, Cr creatinine 1155

3 Kim SH Mun SP Results of MIVAKT Mean value (range) Characteristic of the patients MIVAKT(n 20) CKT(n 20) P Age (yr) Body mass index (kg/m 2 ) Incision length (cm) Distance between belt line and most upper point of incision (cm) Operative time (min) Narcotic use (mg) Visual Analogue Scale 8 hours postoperatively 16 hours postoperatively 24 hours postoperatively 48 hours postoperatively The length of hospital stay (days) Complications Creatinine at 4th operative days Resuming the normal activity (days) Duration of returning to work (days) Total hospital cost ( 1000 $) 36.8 (18 ~ 45) 29.7 (25.6 ~ 34.1) 7.8 (7 ~ 8) 0.2 ( 0.6 ~ 0.3) 178 (156 ~ 210) 45 (25 ~ 150) 8.5 (8 ~ 10) 8.3 (7 ~ 9) 6.9 (4 ~ 8) 5.3 (3 ~ 7) 21.4 (18 ~ 24) 1 lymphocele 1.1 (1.0 ~ 1.2) 2.2 (2 ~ 5) 41.2 (32 ~ 49) 17.4 (14.2 ~ 19.8) 40.1 (32 ~ 52) 35.5 (26.9~38.2) 21.2 (16 ~ 23) 5.2 (4.2 ~ 5.8) 159 (129 ~ 205) 85 (25 ~ 200) 9.2 (8 ~ 10) 8.9 (8 ~ 10) 8.1 (7 ~ 9) 7.3 (5 ~ 8) 23.6 (19 ~ 37) 1 infection 2 lymphocele 1.0 (1.0 ~ 1.1) 5.7 (4 ~ 13) 59.6 (38 ~ 65) 18.1 (14.1~20.3) MIVKT minimal invasive video assisted kidney transplantation. CKT conventional kidney transplantation A minus means that the most upper point of the incision is located below the belt line and a positive means it is located above the belt line Pethidine hydrochloride was used for analgesic 0: no pain, 10: maximal pain Normal activity includes washing, dressing, brushing of the teeth, making up, using the bathroom, eating, etc. 1156

bladder (thin arrow) were marked preoperatively using ultrasound (B) A 7~8 cm incision

4 Minimally Invasive Video Assisted Kidney Transplantation A B (A) The location and course of the external iliac vessels (thick arrow) and the contour of the urinary bladder (thin arrow) were marked preoperatively using ultrasound (B) A 7~8 cm incision was made from the imaginary line of the external iliac vessels to anterolateral part of bladder 1157

Kim SH Mun SP Peritoneum retroperitoneal dissection by ballooning A B C D (A) Illustration of the making of retroperitoneal space by balloon dissector.

and we investigated whether the space was large enough or if any complications such as bleeding or the perforation of peritoneum existed (C) For the approach to the retroperitoneal area, the

5 Kim SH Mun SP Peritoneum retroperitoneal dissection by ballooning A B C D (A) Illustration of the making of retroperitoneal space by balloon dissector. 20~25 ml of room air was insufflated to the balloon (black arrow head) per each compressing of the pump (thick black arrow) (B) The telescope was inserted through the trocar of the balloon dissector and we investigated whether the space was large enough or if any complications such as bleeding or the perforation of peritoneum existed (C) For the approach to the retroperitoneal area, the aponeurotic confluence of the three abdominal muscles, just lateral to the rectus muscle, was opened about 2cm (D) A laparoscopic balloon dissector was inserted into the retroperitoneal area and 250~ 300ml of room air was insufflated to make a retroperitoneal space for the placement of the grafted kidney 1158

6 Minimally Invasive Video Assisted Kidney Transplantation Illustration of the lifting of the external iliac vessels. Nearly all external iliac vessels were dissected as long as possible within the skin incision and lifted up to the level of skin to facilitate the vascular anastomosis 1159

Kim SH Mun SP TV MONITOR TV MONITOR Surgical retractor A Specially designed blades Laparoscopic videoscope (A) Illustration of the retractor and video assisted TV monitoring (B) The kidney was placed

7 Kim SH Mun SP TV MONITOR TV MONITOR Surgical retractor A Specially designed blades Laparoscopic videoscope (A) Illustration of the retractor and video assisted TV monitoring (B) The kidney was placed just above the skin incision. Surgical retractor made the better operative fields with the help of specially designed blades (thin black arrow). Laparoscope was useful for the visualizing and the illumination of the operative fields that was not exposed well to the assistant surgeon located the opposite side (thin white arrow). In this figure, the left side of venous anastomosis is being performed and assistant surgeon (thick black arrow) is helping the operator (thick white arrow) seeing the TV monitor located at the left side of the patients B 1160

Minimally Invasive Video Assisted Kidney

the retroperitonealspace after the identification

A ureter with good segmental contraction and

8 Minimally Invasive Video Assisted Kidney Transplantation The grafted kidney was placed into the retroperitonealspace after the identification of a sufficient urine output. A ureter with good segmental contraction and urination is seen (black arrow) MIVAKT CKT MIVAKT minimal invasive video assisted kidney transplantation CKT conventional kidney transplantation Comparison of the cosmetic outcomes 1161

9 Kim SH Mun SP 1. Kojima M, Konishi F, Okada M, Nagai H. Laparoscopic colectomy versus open colectomy for colorectal carcinoma: a retrospective analysis of patients followed up for at least 4 years. Surg Today 2004; 34: Patankar SK, Larach SW, Ferrara A, Williamson PR, Gallagher JT, Narayanan S, et al. Prospective comparison of laparoscopic vs. open resections for colorectal adenocarcinoma over a 1162

10 Minimally Invasive Video Assisted Kidney Transplantation ten year period. Dis Colon Rectum 2003; 46: Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Ponzano C, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five year results of a randomized prospective trial. Ann Surg 2005; 241: Marc A. Greenstein,Richard Harkaway Francisco Badosa, Phillip Ginsberg, Shuin Lin Yang. Minimal incision living donor nephrectomy compared to the hand assisted laparoscopic living donor nephrectomy. World J Urol 2003; 20: Marina S. Kurian, Michel Gagner, YasusukeMurakami, Valeriu Andrei, Gregg Jossart, Myron Schwartz. Hand assisted Laparoscopic Donor Hepatectomy for Living Related Transplantation in the Porcine Model. Surg Laparosc Endosc Percutan Tech 2002; 12: G Nanni, V Tondolo, F Citterio, J Romagnoli, M Borgetti, M Castagneto, et al. Comparison of Oblique Versus Hockey Stick Surgical Incision for Kidney Transplantation. Transplantation Proceedings 2005; 37: C Aigner, P Jaksch, G Seebacher, P Neuhauser, G Marta, W Klepetko, et al. Single running suture the new standard technique for bronchial anastomoses in lung transplantation. Eur J Cardiothorac Surg 2003; 23: Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology 2003; 61: Demirci D, Gulmez I, Ekmekcioglu O, Karacagil M. Retroperitoneoscopic ureterolithotomy for the treatment of ureteral calculi. Urol Int 2004; 73: Takada M, Ichihara T, Toyama H, Suzuki Y, Kuroda Y. Retroperitoneoscopic laparoscopic distal pancreatectomy with spleen salvage. Hepatogastroenterology 2004; 51: Francis DM, Walker RG, Becker GJ, Millar RJ, Powell HR, Kincaid Smith PS, et al. Kidney transplantation from living related donors: a 19 year experience. Med J Aust 1993; 158: Matas AJ, GillinghamKJ, Elick BA, Dunn DL, Gruessner RW, Najarian JS, et al. Risk factors for prolonged hospitalization after kidney transplants. Clin Transplant 1997; 11: Peer Reviewer Commentary 1163

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic