后腹腔镜活体供肾切取术手术并发症分析

Complications of Retroperitoneoscopic Living Donor Nephrectomy

目的探讨后腹腔镜下活体亲属供肾切取术供体和供肾相关手术并发症的发生和处理。方法2003年12月～2009年1月行后腹腔镜下活体亲属供肾切取术117例,常规取腰部3个穿刺点入路,在肾脂肪囊内游离肾脏后,输尿管游离至肾脏下极7～8cm处剪断,肾动脉和肾静脉用直线切割器(Endo-cut)切断或用Hem-o-lok(Weck,USA)夹闭后剪断,立即取出肾脏用4℃肾脏保存液灌注肾脏。用直线切割器处理肾血管3例,用Hem-o-lok处理肾血管114例。结果117例供肾切取术均获得成功,无供体死亡,无中转开放手术,无围手术期输血,无移植肾功能延迟恢复。发生供体手术并发症5例(4.3%):术中出血2例,均术中止血;术后腹膜后血肿3例,均经保守治疗后血肿吸收。发生供肾相关并发症8例(6.8%):直线切割器造成供肾动脉额外分支1例,3支肾动脉分支分别与髂外动脉和髂内动脉的2个分支吻合;供肾浅裂伤2例,均用可吸收线缝合;供肾被膜下血肿2例,1例未处理,1例行被膜切开术,均未影响移植肾功能;供肾输尿管并发症3例,肾移植术后10d拔除移植肾输尿管支架管后出现输尿管膀胱吻合口漏尿,再次手术吻合后均获得成功。13例出现供体并发症和供肾相关并发症者,随访15～62个月,平均50个月,供体未发现其他并发症,血尿常规、肝肾功能、血糖及腹部B超正常;供肾B超检查形态正常,肾功能正常。结论后腹腔镜下活体亲属供肾切取术安全可靠,手术并发症发生可能与手术学习曲线有关,不断改进技术可能会减少手术并发症的发生。

Objective To report our initial experience on the complications of retroperitoneoscopic live donor nephrectomy（RPLDN）and their managements in 117 cases.Methods From December 2003 to January 2009,117 cases of RPLDNs were carried out in our hospital.The operation was performed through 3 lumbar ports,after the kidney was liberated fully and the ureter was severed 7-8 cm under the lower pole of the kidney,the renal artery and vein were blocked with Endo-cut or Hem-o-lok and then cut off.Endo-cut was used in 3 patients and Hem-o-lok in 114 donors.Afterwards,the kidney was taken out quickly from the donor and infused with 4℃ kidney preserving fluid（HCA）immediately.We reviewed the intraoperative and postoperative complications in the donors and the grafts and the managements of the cases.Results All the 117 operations were successfully completed.No patients died during the operation or had delayed graft function recovery postoperation.No one was converted to an open surgery or needed blood transfusion during the procedure.Surgery-related complications occurred in 5 donors（4.3%）including intraoperative bleeding in 2（cured by hemostasis during the operation）and retroperitoneal hematoma in 3（cured by conservative management）.Graft-related complications occurred in 8（6.8%）cases;among which extra arteries in the graft owning to endovascular stapler was found in 1 patient（who had a short common stem of the main renal artery,the three branches were anastomosed with the external iliac artery and 2 branches of internal iliac artery respectively）;two graft kidneys were lacerated by laparoscopic instruments superficially and were repaired using absorbable sutures;renal subcapsular hematoma was noted in 2 grafts,capsulotomy was performed in one of them while the other received no treatment,both the cases had normal function of the transplanted kidneys;ureteral complications occurred in 3 grafts,in which vesico-urethral anastomotic leakage was developed in 10 days after withdrawal of the double J stents,they were cured by ureteral re-implantation.All the donors and recipients with complications were followed up for an average of 50 months（range 15-62 months）.No other complications were found in the cases.During the follow-up,blood and urine routine,liver and renal functions,and blood glucose level are all in a normal range,abdominal B-ultrasonography revealed no abnormalities.B-ultrasonography of the implanted kidneys showed normal morphology and renal functions.Conclusions RPLDN is a safe and reliable method.Most of its complications complications may be attributed to the learning curve.Refinements in surgical techniques may decrease the rates of both donor and graft complications.