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Laparoscopic Nephrectomy - (full conference transcript)

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Professor Michael Nicholson

Consultant Surgeon and Professor of Transplant Surgery, University of Leicester. Member of the Council of the Association of Surgeons of Great Britain and Ireland and Chairman of the Clinical Trials Committee of the British Transplantation Society.

There are around 5000 people awaiting a transplant as we speak, and this is in the face of a contraction in the number of organ donors, and therefore a reduction in the amount of transplants being performed.

The amount of cavaderic donors is difficult to maintain because of advances of blood pressure control and there are not as many patients dying of strokes, and fewer dying on the roads. This is the reason for the increase in the interest in living related donors as a potential alternative source for kidney transplantation.

Kidney transplantation itself is an incredibly successful treatment, arguably one of the most successful treatments developed in the last century. Patients who have a kidney transplant don't have to dialyse. Because their bloods are purified better by kidney than by dialysis they feel better, and so these two things together give an improved quality of life compared to dialysis. There is also increasing evidence that transplantation increases the quantity of life slightly better than dialysis. Of course it is very cost effective. After the first year a kidney transplant only cost £5,000 a year in comparison with dialysis, which is in the region of £25,000 a year.

I think live kidney transplants are probably the best type of transplantation. These are kidneys which are in pristine condition when transplanted. They are perfect kidneys and they work well to start with, and therefore give you the best graft patient's survival figures, because the procedure can be planned, and both the donor and the recipient can be put into an optimum condition. There is no waiting list and the results are very good.

Survival rates in the first five years are very good, with cadaver transplants at 70%, but in living related transplants it was even better at 85%. The average years of a transplanted cadaver kidney is around eight compared with a living related kidney, which is around 15 years.

Living related transplants are now slowly on the increase. In the 1990s living related transplants accounted for five to 10 % of transplants compared to the last few years, when they have increased to 20%. But we are still a long way behind other countries. Norway is the world champion at living related transplants - they perform 45% to 50% of all their kidney transplants from live donors. In America it's about 35%. The down side of live donation is that it is a massive operation to remove a kidney. Kidneys are one of the most difficult bits of the body to remove. Your kidneys are about the size of your clenched fist, and it is deeply embedded in the back. It's not like the appendix or your tonsils, which are relatively easy to remove and which take half an hour. The other thing is when you do an operation to remove a kidney; it's very interesting and difficult surgery. If you remove somebody's gall bladder, because it is diseased, you have to do it carefully, but you do not have to worry about the state of the bladder when it is removed. You are going to throw it away. When you do a kidney removal it has to come out in perfect condition without being damaged, and because of this it is relatively challenging surgery. The traditional way to do it is to make a big incision in the loin, so that you have a big cut making it easy to remove the kidney without damaging it. You can imagine with a cut like that there is a concern about postoperative pain and prolonged recovery from the operation.

(A slide was shown of a young girl who has donated a kidney and shows a large scar around her side (see photograph to the left). He then showed another photograph of an operation in progress showing the process of removal (see photograph to the right)).

Laparoscopic surgery is very different, it is performed through keyholes.

(A slide of laparoscopic surgery showed three keyhole incisions about a centimetre and a half in size, with three metal cannulas placed through the incisions, and then long instruments shaped like knitting needles are put down the ports to perform surgery. On the ends of these instruments are various cutting devices and staple tools for sealing off blood vessels (see photograph to the left)).

His assistant holds a camera into one of the holes or ports made and this gives us a picture of what is going on inside on a television screen. So you can see we do not look at the patient, we look at the television screen, so it is rather like playing a computer game (See photograph below/left half)! And I have two ports through which I can put various instruments to perform the operation.

(He shows a picture from the camera from inside the patient showing how he needs to move the spleen to one side to perform the removal of the kidney (see photograph to the left/right half).

Once you have divided all the tissue around the kidney and separated it so it is free inside, you have to remove it. You do this by placing it in a plastic bag. This plastic bag is folded up inside a metal frame, which is rather like a tennis racket frame (see photograph to the left/left half), the kidney is scooped up, and a drawstring device is tightened around the kidney (see photograph to the left/right half). The kidney is then ready to remove.

(He showed again by way of a slide that an incision is made below the bikini line, to which the kidney is lowered down to be removed easily (see photograph to the right - the left photo shows the 4 cuts through which the Laparoscopic instruments are inserted, whilst the photo on the right shows the incision made below the bikini line, from where the kidney is removed).

(A photo was then shown of the patient after the operation showing very little scarring to the patient afterwards at 4 days (see photograph to the left) and 6 weeks (see photograph to the right) after the operation. After full recovery very little evidence was left to see.)

Laparoscopic surgery was first performed in the USA by surgeons called Lloyd Rapner and Louis Kavousi. My colleague Mr Veitch and myself visited the surgeons in 1998 to see what they were doing and then imported their technique back into the UK performing the first operation in Leicester.

(Professor Nicholson showed a graph comparing laparoscopic surgery to conventional open surgery (not shown here). One line on the graph showed blue for normal surgery and another line in orange showing laparoscopic surgery. It showed slightly more women than men have had the operation by the new technique, but on the whole there showed to be no discrimination between the two sexes. Most of the kidneys removed are the left ones due to longer blood vessels and easier to transplant, although there are some right sided one also removed.)

Keyhole surgery does take longer. It is probably surprising to many people that it takes two hours to remove a kidney using the open operation. But keyhole surgery is very challenging, indeed it is probably the hardest keyhole operation you can do. And so it takes an extra hour on average, although we have noticed that with time our operating time is actually decreasing as we get more experienced.

After open surgery patients stay on average around six days in hospital, but with keyhole surgery they are in hospital around four days. However they have had patients discharged after two days with the laparoscopic operation. They only do this operation on a Thursday and most have gone home on the Saturday if they live close to the hospital.

If you look at the longer term recovery getting back to normal activities, after the open surgery it is quite a prolonged recovery (see diagram above). Three weeks or so to go shopping, four weeks to start driving the car, ten weeks back to normal exercise, and twelve weeks back to normal full time employment. So quite a long prolonged recovery period.

After the keyhole operation shopping and driving in about two weeks, exercising after about four weeks and only six weeks to get back to normal activities, which really is quite remarkable after this large operation. That is similar to other keyhole operation such as gall bladder removal, so it is halving the recovery time effectively. Postoperative pain is a very important aspect of this. As I mentioned earlier, with the large incision open surgery can very painful. We use a morphine infusion system in all patients to treat them after the operation. After the open operation patients need on average 180mg of morphine, and the system is in place for about 60 or 70 hours, so for about three days. After the keyhole operation the morphine requirement is reduced to only a third, and the system can be taken down after a day or two - about 35 hours on average. So it is a less painful operation.

All operations have their complications, but the complication rate for this surgery is relatively low. There are some complications that seem to occur in both groups. About 10% of patients have a chest infection or a wound infection after the operation but is no different between the two procedures. Deep vein thrombosis is a serious potential problem. This is the economy class syndrome, where you get a blood clot in the leg. That can be potentially very serious, but fortunately we have not seen any of that in either of the two operations. There are some complications which are peculiar to the open operation such as a collapsed lung because the operation is done near to the end of the lung base. Two patients have complained of long term wound pains, so they have been referred to a pain clinic. We have seen neither of those after the keyhole surgery.

The keyhole surgery is done through the abdominal cavity, and can cause raw surfaces and getting things stuck together inside. You can get these adhesions formed, and we have had two patients re-operated using the keyhole technique to take down these adhesions that were causing trouble. Of course you cannot always guarantee that you can do the operation with keyhole surgery. Sometimes you have to open the patient up, but fortunately we have only done these once in 60 cases. Now the cosmetic appearance of these operations can very good indeed

So if you ask people to grade the cosmetic results after their surgery out of a 100, then the average value is about 55 after the open operation, but 90 after the laparoscopic procedure. The recipient kidney transplant operation is done in exactly the same way no matter how the kidneys are removed. A kidney is a very sophisticated small blood filter that needs blood supply and a drainage system. Doing the operation is rather like plugging in a washing machine (see diagram to the left). It needs a blood supply so the arteries are joined to a branch of the patient's artery, the veins drained into the vein that runs down the leg and the pipe for the urine is plugged into the bladder. So it is three joins, it's like a washing machine, but it has to be done very carefully.

There is no difference in that surgery. I have explained the advantages of keyhole surgery, but it would not be any good if it actually damaged the kidney in removing it, and the results in the recipient were not as good, so we have to look at the results in the recipient. If you look at the problems the recipient has had after the open operation we have unfortunately had one episode of the kidney clotting, but none in the laparoscopic removal. Ureic complications are difficulties with the kidney drainage systems, either becoming narrowing, or leaking, and we have had two episodes of that in the key hole series, but these were in the first 15 cases and we have not had any in the last 55 or so. On average you would expect these complications to occur up to five % of the time anyway.

Delayed graph function means the kidney not working immediately; we have had one of those in the open group but none in the keyhole group. Importantly there is no difference in rejection rates; these are treatable rejections, which are in the region of 30% with both operations. If you look at the way the kidney functions immediately after the transplant, a graph of the level of creatinine after a living related transplant shows a massive drop in level, and after three days it is back to normal levels. After keyhole it is back to normal after four to six days, so there is no real difference between the two. The good thing is that after a living related transplant blood levels return to normal fairly quickly. In Leicester in the early 90's around five to 10% of transplants were living related compared to the late 1998, when 30% were living related. Then in the last two years 50% were carried out. In the last six months 60% were related donors.

To summarise, I think that the laparascopic operations has removed some of the disincentives to donating a kidney. Patients stay in hospital for a shorter period of time, it's less painful, they can get back to normal activities more quickly, the cosmetic results are undoubtedly better particularly for ladies. Overall we have found the technique has increased the live donations by about five-fold in our own centre. Of the future, well you can now do these operations using robots.

(The picture to the right shows a surgeon away from the patient using a computer to operate the robot by remote control. The robot is called the Da Vinci Robot.)

So you could theoretically carry out the operation from anywhere in the country by this means. These can be purchased for £1 million each so they are not cheap. There is some debate as how best to remove kidneys. As well as removing kidneys through large open incisions, it is also possible to remove them through relatively small open incisions, so called minimal incision open operation, and actually in Leicester we are looking at this to see if this compares favourably with the keyhole technique which does take a long time and is a very difficult thing to do.

(He ends his talk with a picture or two ladies who have undergone surgery, one is the recipient, the other the donor. Both look happy, fit and look very well. (see photograph below)).

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