American Journal of Transplantation 2005; 5: 1966–1970 Copyright C Blackwell Munksgaard 2005 Blackwell Munksgaard doi: 10.1111/j.1600-6143.2005.00950.x

Laparoscopic Donor Distal for Living Donor and Pancreas–

Miguel Tan, Raja Kandaswamy, David ER high panel-reactive antibody (PRA) who is unlikely to re- ∗ Sutherland and Rainer WG Gruessner ceive a cadaver organ. Before 1994, our institution only of- fered an LD pancreas transplant as a pancreas transplant Department of Surgery, Division of Transplantation, alone (PTA) or as a pancreas after kidney (PAK) transplant, University of Minnesota, MN because of the fear that multiorgan retrieval from an LD ∗ Corresponding author: Rainer WG Gruessner, entailed too much morbidity (4). With that approach, how- [email protected] ever, diabetic uremic patients had to endure two separate procedures, which many patients were loath to undergo. With the proliferation and expanding applications of Even today, patients will sometimes pass up a single organ laparoscopic techniques, we determined the applica- in order to undergo a simultaneous pancreas–kidney (SPK) bility of the laparoscopic approach to living pancreas transplant despite its prolonged waiting time. donation. We performed the first laparoscopic donor distal pancreatectomy in 1999. We herein present our It has also been demonstrated that diabetic patients on initial experience with five hand-assisted laparoscopic dialysis have increased morbidity and mortality, as com- donor . Three donors underwent dis- pared with nondiabetic patients on dialysis. Diabetic pa- tal pancreatectomy alone; two underwent a simultane- tients undergoing a kidney transplant alone (KTA) have a ± ous left nephrectomy. The mean donor age was 48.4 higher mortality rate as compared with those undergoing 8.7 years with a body mass index of 23.7 kg/m2. The an SPK transplant (5,6). donor and recipient survival rate was 100% at up to 3 years of follow-up. There were no episodes of pan- creatitis, leaks, or pseudocysts. All donors returned to Consequently, we now perform LD SPK transplants in se- their preoperative state of health and to work. None lected patients to alleviate prolonged waiting time and to of the donors have required oral anti-diabetic medica- decrease the morbidity and mortality of diabetics awaiting tions or insulin. We conclude that laparoscopic donor a transplant. distal pancreatectomy is a safe and efficient procedure; hand-assisted laparoscopic distal pancreatectomy ap- Although the donor operation can be done safely, it is as- pears to be preferable, because of the added margin of sociated with postoperative morbidity related, in part, to safety from increased tactile feedback and ease of pan- the bilateral subcostal incision. The advent of laparoscopic creatic dissection. The procedure can be accomplished technology has offered an alternative to the open approach. with a single 6-cm periumbilical incision and only two 12-mm ports, resulting in excellent cosmesis and high Its viability has been demonstrated by laparoscopic donor donor satisfaction. nephrectomy, which has rapidly become the procedure of choice for kidney donation because of reduced hospital Key words: Laparoscopic pancreatectomy, living don- stay, decreased pain and more rapid convalescence (7,8). or, pancreas transplantation Cosmetically, laparoscopic donor nephrectomy is more ap- pealing to potential donors, as compared with the tradi- Received 28 October 2004, revised and accepted for tional flank incision required for open nephrectomy. It is publication 14 March 2005 equivalent to the open procedure in terms of donor safety and allograft quality (8).

Introduction Laparoscopic techniques have rapidly been applied to other organ systems, including the pancreas. Laparoscopic dis- The pancreas was the first extrarenal organ to be success- tal pancreatectomies have been described for treatment fully used from living donors (LDs) (1). Yet, of the more of a variety of pathologic states. They appear to be safe, than 20 000 pancreas transplants performed since 1966, with the additional benefit of reduced hospital costs and fewer than 1% have come from LDs (2,3). Underuse of this accelerated postoperative recovery (9,10). resource can be attributed to concerns about the potential morbidity of an open distal pancreatectomy in an otherwise In an effort to decrease the morbidity associated with healthy donor. In selected cases, however, an LD pancreas open pancreas donation and to assess the applicability of transplant is an appropriate option, such as a recipient with this technology, we performed the first laparoscopic donor

1966 Laparoscopic Donor Pancreatectomy distal pancreatectomy in 1999. We herein present our ini- shears, laparoscopic scissors and other instruments. The surgeon and assis- tial experience with this procedure. tant stood on the donor’s left side. Mobilization of the left colon, the ureter and the left gonadal vein, as well as dissection of the kidney, is described elsewhere (12). Before ligation of the renal vessels, the donor was given Methods 70 units/kg of intravenous heparin, the effect of which was reversed with protamine sulfate (10 mg/1000 units heparin) after the vessels were ligated. Preoperative donor evaluation The renal artery was ligated with two Hem-o-lok clips (Weck Closure Sys- From March 1999 through August 2003, we performed five hand-assisted tems, Research Triangle Park, NC), then divided with laparoscopic scissors. laparoscopic donor pancreatectomies at the University of Minnesota. All The renal vein was ligated with a 35-mm vascular stapler (ETS Flex Enco- donors underwent an extensive multidisciplinary workup involving endocri- scopic Articulating Linear Cutter, Ethicon Endosurgery, Cincinnati, OH). The nologists, nephrologists, cardiologists, social service personnel, psychia- kidney was extracted by hand through the midline incision and passed off trists and transplant surgeons. Potential pancreas donors were only con- to the recipient surgical team. sidered if they fit the following criteria: body mass index (BMI) <27 kg/m2, insulin response to glucose or arginine >300% of basal insulin, HgbA1c The donor was then rotated to a supine position with reverse Trendelenburg <6%, basal insulin fasting levels <20 umol/L, plasma glucose <150 mg/L positioning. The inferior margin of the pancreas was completely mobilized during a 75-g oral glucose tolerance test and a glucose disposal rate >1% by using ultrasonic shears and electrocautery. The inferior mesenteric vein during an intravenous glucose tolerance test. In genetically related donors, (IMV) was identified, ligated with staples, and divided near its insertion into no other family members other than the recipient could be diabetic. A ge- the splenic vein. The tail of the pancreas was encircled with a finger: a hole netically related donor had to be at least 10 years older than the recipient was made in the avascular plane along the superior margin of the pancreatic was at the time of onset of in the recipient. Other contraindications tail and then a finger was passed along the underside of the pancreas. The to donation included a history of gestational diabetes and previous pancre- tail was encircled with a blue vessel loop, in order to facilitate atraumatic atic surgery or disorders. All potential donors during this time period that anterior retraction of the pancreas. The posterior surface of the pancreas met the aforementioned criteria were eligible for laparoscopic donation. No was freed from its retroperitoneal attachments by using electrocautery. The open procedures were performed. splenic artery and vein were identified in the hilum of the spleen and indi- vidually ligated and divided using a 35-mm vascular stapler. Care was taken Radiologic evaluation not to disturb the short gastric and right gastroepiploic vessels, because We evaluated each potential donor’s vascular anatomy to determine suit- they constituted the major remaining blood supply to the spleen. ability for pancreas donation. At our center, magnetic resonance angiogra- phy (MRA) is the modality of choice because of its noninvasive nature and With the pancreas mobilized medially, the splenic artery was mobilized just its ability to discern parenchymal details and to provide details of venous as it bifurcated off the celiac axis; likewise, the splenic vein was mobilized anatomy (11). Of interest is the anatomy of the splenic vessels, specifically circumferentially near its junction with the SMV (Figure 1). Before ligation the takeoff of the splenic artery and the location of the confluence of the of the vessels, heparin (30 units/kg) was administered. Protamine was ad- splenic vein and superior mesenteric vein (SMV). MRA also allows evalu- ministered after the vessels were divided. Two clips were applied to the ation of the location and number of renal vessels, in case a simultaneous splenic artery just distal to the celiac axis (Figure 2), then divided with la- nephrectomy is to be done. The decision to procure the left or right kidney paroscopic scissors. Two staples were applied to the splenic vein at the is made on a case-by-case basis according to the number and location of level of its junction with the SMV, and then divided. A 45-mm ETS Flex Lin- accessory renal vessels. Our preference, however, is to procure the left ear Articulating Stapler (Ethicon Endosurgery, Cincinnati, OH) was used to kidney, because of the longer renal vein and subsequent ease of dissection transect the pancreatic parenchyma. The pancreatic segment was then ex- of the inferior margin of the pancreas once the upper pole of the left kidney tracted by hand through the midline incision and passed off to the recipient is dissected. team. The staple line of the pancreatic remnant was oversewn in a running

In this series, we procured only left kidneys in SPK donors (i.e. a segmental pancreas and kidney). In the future, we would not, however, exclude an SPK donor if the right kidney had to be procured.

Operative technique After induction of general anesthesia, the donor was placed in a modified right lateral decubitus position to allow rotation from a left-side-up position (for the nephrectomy) to a supine position (for the distal pancreatectomy). Donors undergoing a distal pancreatectomy alone were left in a supine position.

◦ For a left nephrectomy, the operative table was flexed to 45 ,inorder to open up the left subcostal space to facilitate dissection of the kidney. A 6-cm midline incision was made either supra- or periumbilically, depending on the donor’s body habitus. A Gelport (Applied Medical, Rancho Santa Margarita, CA) was placed in the midline incision to allow for hand assistance. Using standard laparoscopic equipment, a 12-mm port was placed at the level of the umbilicus along the lateral edge of the left rectus for insertion of a 30o camera. A pneumoperitoneum was established (13 mmHg).

Asecond 12-mm ’working’ port was inserted in the left midabdomen in the Figure 1: Laparoscopic view of donor pancreas retracted me- plane of the anterior axillary line. Doing so allowed insertion of ultrasonic dially. A = pancreas, B = splenic vein and C = splenic artery.

American Journal of Transplantation 2005; 5: 1966–1970 1967 Tan et al.

Figure 3: Port sites and midline incision 3 weeks after laparo- scopic distal pancreatectomy and left nephrectomy. A = mid- line incision for Gelport placement, B = 12-mm camera port and C = 12-mm operative port.

Figure 2: Laparoscopic view of ligated splenic artery. A = two staples on splenic artery. follow-up laboratory tests. All five donors returned to their preoperative state of health and are back to work as de- fashion with 4-0 polypropylene sutures, in order to achieve hemostasis and termined by a follow-up telephone survey. All donors were prevent leakage of the pancreatic duct. After irrigation, the port sites were satisfied with their decision to donate, with the exception closed under direct vision using 0- polyglactin sutures on a suture passer. of one donor who noted a strained relationship with the The midline fascia was closed with 0- looped polypropylene sutures. recipient.

The operative technique for the recipient pancreas transplant using a seg- Because the donor operation could be performed through mental pancreas (21) and for an LD kidney transplant is described elsewhere a relatively small midline incision and only two trocar sites, (13). The pancreatic exocrine secretions were managed by either bladder or enteric drainage. The duct was anastomosed to either the bladder or small donor satisfaction was high in terms of cosmetic result bowel mucosa using 7-0 polypropylene sutures. (Figure 3).

The recipient, pancreas and kidney graft survival rates Results were 100% at 3 years posttransplant.

The mean donor age was 48.4 ± 8.7 years; the mean BMI, 23.7 kg/m2. The mean length of surgery for PTA donors Discussion was 4.5 ± 0.13 h; for SPK donors, 7.9 ±0.38 h. The mean blood loss was 330 ± 228 mL. The number of available deceased donor cur- rently exceeds the number of pancreas transplants per- The actual operative time, however, was probably shorter formed annually (14). Yet, the waiting list for diabetics than suggested by the mean length of surgery. For two awaiting a pancreas transplant is growing by more than of the five cases, the donor surgeons had to wait about 15% annually (6); the limiting factor is the quality of avail- 1.5 to 2 h for the recipient team to prepare to receive the able pancreases. In the subset of patients awaiting both a organs, resulting in a considerable amount of intraoperative pancreas and a kidney transplant, the waiting time contin- waiting time on the part of the donor team. One splenec- ues to be lengthy. In fact, about 6% of these patients die tomy had to be performed at the time of the initial donor while waiting for an SPK transplant (15). Evidence suggests surgery for a nonviable spleen. None of the cases required that uremic diabetics on dialysis have a higher mortality conversion to an open pancreatectomy. rate than nondiabetics on dialysis. For uremic diabetics on dialysis, the mortality rate 2 years after starting dialysis is There were no postoperative pancreatic leaks or pancre- 17%; after 3 years, 27% as compared with nondiabetics atitis. The mean length of hospital stay was 8 ± 2 days. on dialysis who have a 2 year mortality rate of 7% to 8% On discharge, the mean serum glucose level was 112 ± and a 3 year mortality rate of 11% to 14% (5). 11.7 mg/dL. The mean creatinine level in kidney donors was 1.1 ± 0.3 mg/dL. None of the five donors have re- Patients who undergo an SPK transplant may have better quired oral anti-diabetic medications or insulin. Their mean survival than diabetics who undergo a kidney transplant postoperative hemoglobin A1c (HgbA1c) was 5.7 ± 0.2% at alone (5,16,17). The rationale, therefore, of LD pancreas up to 3 years of follow-up. One donor, who had normal fast- transplantation is to decrease the morbidity and mortality of ing glucose levels, however, declined to undergo extensive diabetics on the waiting list, as well as to provide a source

1968 American Journal of Transplantation 2005; 5: 1966–1970 Laparoscopic Donor Pancreatectomy of organs for high PRA patients who are unlikely to receive pancreatectomy data (6). Three donors out of 67 patients a deceased donor pancreas. who were followed long-term became insulin-dependent. One of these patients had a history of gestational diabetes In the past, the morbidity and prolonged postoperative re- and the other two had high BMIs. All these cases occurred covery on the part of a potential open pancreas donor prior to 1996 before our current selection criteria were en- have been a hindrance to wider acceptance of LD pan- forced. Since 1996, none of the living pancreas donors have creas transplants. But, application of laparoscopic tech- required anti-diabetic medication. niques may make this procedure more appealing. A few technical points merit discussion. Since our first re- The viability of LD pancreas and SPK transplants have been port of laparoscopic LD SPK transplantation (12), the tech- demonstrated previously (6). From 1994 through 2000, 32 nique has been modified such that only two laparoscopic open LD SPK transplants were performed at the Univer- ports are now used (instead of three). Even with the re- sity of Minnesota (6). Results have been excellent, with moval of the additional retraction port, the combination of 1-year recipient and kidney graft survival rates of 100%. the hand port and single working port allowed for excel- Pancreas graft survival was 87%. These rates compare lent exposure. An advantage of the laparoscopic approach favorably with recent cadaver SPK transplant data demon- is that, once the left kidney is removed, the inferior border strating a 1-year pancreas graft survival rate of 84% and of the pancreatic tail is already partially dissected. Further- a kidney graft survival of 90% (18). In our 1994–2000 se- more, with this inferior approach, we avoid dividing the ries, the median operative time for open nephrectomy and gastrocolic ligament: leaving the right gastroepiploic artery segmental pancreatectomy was 6 h and 55 min, with a as well as the short gastric vessels intact. Doing so is impor- postoperative stay of 8 (range: 6–24) days (6). tant for sustaining the spleen, which is devoid of its main blood supply after the splenic hilum is divided. In general, For our laparoscopic donations, the donor and recipient sur- we try to preserve the spleen in order to prevent poten- vival was 100%, with 100% pancreas and kidney graft sur- tial immunologic sequelae associated with splenectomy. vival at 3 years of follow-up. These favorable outcomes At the current stage of the evolution of this technique, are related to the strict selection criteria ensuring good we prefer the hand-assisted approach, because having tac- quality pancreases, as well as minimal ischemia time, both tile feedback greatly facilitates safe dissection and partially of which are not always possible to control in deceased overcomes the lack of three-dimensional visualization in- donors. With the laparoscopic technique, the mean time herent in . Furthermore, extraction time of the was 7.9 h ± 0.4 for SPK procurement and 4.5 h ± 0.1 organ is rapid when it is retrieved by hand through the for segmental pancreatectomy alone. However, once the Gelport. learning curve has been overcome, the laparoscopic ap- proach may actually have shorter operative times, because With further experience, this approach will likely prove to less dissection is required as compared with the open tech- be technically advantageous compared with the open pro- nique. Postoperative stay for the laparoscopic donors was cedure because of the decreased operative incision size 6.5 days ± 0.7 for PTA donors; 9.0 days ± 2.6 for SPK and correspondingly improved postoperative pain and ac- donors. In laparoscopic nephrectomies, the advantages of celerated recovery. At the present time, however, laparo- reduced hospital stays and earlier postoperative recovery scopic donor distal pancreatectomy is likely beyond the have been demonstrated in large series (19,20). More data grasp of most institutions without an established living pan- are required to make the same conclusions in our current creas donor program and surgeons trained in advanced la- series. However, in the donors who underwent laparo- paroscopy. scopic pancreatectomy, all five were out of bed and am- bulating on the first postoperative day. In our last two such Summary donations, both donors were tolerating normal oral intake by postoperative day 3. Furthermore, all the laparoscopic Per our initial experience, laparoscopic donor distal pan- donors report that they are back to their preoperative state createctomy is a safe procedure with excellent donor out- of health and working. Donor satisfaction was high from a come. It could provide a good source of organs for patients cosmetic perspective. awaiting an SPK transplant and for those who are highly sensitized and unlikely to receive a cadaver pancreas. At Potential complications include , leak, pseudo- this point, hand-assisted (vs. fully) laparoscopic distal pan- cyst formation or splenic infarction. As mentioned previ- createctomy seems preferable, because of the added mar- ously, the only perioperative complication in our series was gin of safety as a result of increased tactile feedback, the a splenectomy at the time of the initial distal pancreatec- ease of pancreatic dissection, and the relatively quick graft tomy secondary to an infarcted spleen. A more devastating extraction time. Furthermore, the procedure can be accom- long-term complication is the development of diabetes in plished with a small (6 cm) midline incision and two 12-mm the donor. At 3 years of follow-up our laparoscopic donors ports, resulting in excellent cosmesis and high donor sat- have maintained normal HgbA1c levels (<6%). This com- isfaction. At up to 3 years of follow-up, graft and recipient plication, however, has been described in the open donor survival rates were 100%.

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1970 American Journal of Transplantation 2005; 5: 1966–1970