Laparoscopic live-donor nephrectomy: modifications for developing nations

OBJECTIVE To describe modifications to laparoscopic live-donor nephrectomy (LLDN) to make it more cost-effective for developing countries; LLDN was developed as a better alternative to conventional donor nephrectomy, with advantages of an earlier return to normal activities and smaller scars, but is not popular in developing countries because of high cost of disposable items. PATIENTS AND METHODS From January 2000 to January 2002, 148 LLDNs were performed, of which two used a hand-assisted technique, 17 the standard technique, 79 a modified laparoscopically assisted cost-saving approach and 50 by the modified technique. In the latter approach the kidney was delivered through a 6-8 cm anterior subcostal flank incision. In last 50 patients we further modified the technique, clipping the hilum using endoclips and delivering the kidney by holding the lateral pararenal fat through a 5 cm iliac fossa incision. RESULTS ischaemia time, blood loss, analgesic requirements, pain score and hospital stay were comparable among the various techniques used. Re-exploration was required in four patients (bleeding in two, trocar-induced bowel injury in two). Immediate complications after surgery occurred in 20% of patients. Using endoclips, the cost was considerably reduced, from $400 to $290. The iliac fossa incision was aesthetically pleasing and more acceptable to patients. CONCLUSION These modifications are relevant in the context of a developing nation, as they provide all the benefits of LLDN at reduced cost and with better cosmetic results.