June 18, 1998 ANN ARBOR---Surgeons at the University of Michigan Medical Center have removed a kidney from a living organ donor in an unprecedented way.
As a result, kidney donor Lynn Toornman of Toronto returned to normal activities, including driving, within a week of surgery---a recovery that commonly takes three to four weeks. Toornman's kidney was transplanted into her mother, Suzanne Siddall, 65, of Battle Creek, Mich.
The technique used to remove the kidney is a variation on laparoscopy, a form of surgery in which the doctor operates through small incisions with specially designed instruments. For patients, laparoscopy is less invasive, leaves smaller scars, and reduces post-operative pain, pulmonary complications and recovery time. On the other hand, the technique is difficult to master and takes longer to perform than open surgery.
"I liken laparoscopy to operating with chopsticks," says Stuart Wolf, M.D., director of the in the U-M Surgery Department. "It's hard enough for a surgeon just to operate laparoscopically, but the tiny incisions mean we also can't use the greatest surgical instrument ever---the hand."
To remove Toornman's kidney, Wolf and colleagues at the U-M Medical Center used a modified form of laparoscopy in which an incision is made just large enough to accommodate a surgeon's hand (about 2 3/4 inches long). This approach, called "hand-assisted laparoscopy," is easier and quicker to perform than regular laparoscopic surgery but less invasive than open surgery.
The modification allows surgeons without advanced technical training to employ laparoscopic techniques and doctors experienced in laparoscopy to use it on more complicated procedures. "It opens the door for more patients to benefit from laparoscopy," Wolf says.
Surgeons at a few medical centers around the country use traditional laparoscopic techniques to excise kidneys from donors, then make an incision at the conclusion of the procedure to remove the organ. For hand-assisted laparoscopies, however, this incision is made first so the surgeon can use it during the operation. "Current results with standard laparoscopic donor nephrectomy (kidney removal) have been favorable, but the procedure is difficult to perform," Wolf says. "With the hand-assisted technique, more surgeons should be able to safely perform the procedure, so more donors will benefit from minimally invasive surgery."
A major concern for U-M surgeons was whether the quality of the donated kidney would suffer as a result of this novel technique, says Robert Merion, M.D., director of the U-M Transplant Center. Merion assisted Wolf in the laparoscopic kidney removal and also transplanted the organ in the recipient. "In this first pioneering case," he says, "the kidney looked beautiful and functioned perfectly immediately after it was transplanted. We would be hard pressed to make it go any smoother."
The Toornman-Siddall transplant, which was performed April 30, provides anecdotal evidence that hand-assisted laparoscopy is a medically viable alternative to open surgery in some cases. But how does it stack up against standard laparoscopy, in which no incision is made for the surgeon's helping hand?
Wolf and colleagues from the University of Wisconsin address that question in a paper published in the July issue of the Journal of Urology in which they compare hand-assisted and standard laparoscopy for cases---such as kidney cancer---in which it is less critical to extract the kidney in pristine condition.
The researchers concluded the hand-assisted technique was faster and reduced major complications. At the same time, the length of patients' hospital stays, recovery time, and post-operative pain increased only minimally. "The bottom line," Wolf says, "is that hand assistance appears to increase the speed and safety of laparoscopic nephrectomies without sacrificing the benefits of minimally invasive surgery."
Hand-assisted laparoscopy is made possible by a device called a Pneumo Sleeve, a modified surgical glove that allows surgeons to insert their hand through an incision while maintaining the airtight cavity needed to hold injected carbon dioxide that expands the work space and improves visualization.
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