Mandal A K, Cohen C, Montgomery R A, Kavoussi L R, Ratner L E
Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287-8611, USA.
Transplantation. 2001 Mar 15;71(5):660-4. doi: 10.1097/00007890-200103150-00015.
The left kidney is preferred for live donation. In open live donor nephrectomy, the right kidney is selected if the left kidney has multiple renal arteries or anomalous venous drainage. With laparoscopic live donor nephrectomy (LLDN), there is reluctance to procure the right kidney because of the more difficult exposure and further shortening of the right renal vein (RRV) after a stapled transection. An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically.
From February 1995 to November 1999, 227 patients underwent live donor renal transplants with allografts procured by LLDN. The results of these transplants were analyzed.
Of the 227 kidneys transplanted, 17 (7.5%) were right kidneys. In the early experience, three (37.5%) of the eight right renal allografts developed venous thrombosis, two of which had duplicated RRV. Based on these initially unacceptable results, donor evaluation and LLDN techniques were modified. Spiral computerized tomography (CT) replaced conventional angiography to define better the venous anatomy. LLDN was modified in one of three ways: (1) changing the stapler port placement such that the RRV was transected in a plane parallel to the inferior vena cava, (2) relocation of the incision for open division of RRV, or (3) lengthening of the donor RRV with a panel graft constructed of recipient greater saphenous vein. Finally, the recipient operation enjoined complete mobilization of the left iliac vein with transposition lateral to the iliac artery. With these modifications, there were no vascular complications with the subsequent nine right renal allografts (P<0.05). Of the left kidneys transplanted, 31 had multiple renal arteries, 14 had retroaortic or circumaortic veins, 4 had both multiple arteries and venous anomalies, and 1 had a duplicated IVC draining the left renal vein. There were no vascular complications with left renal allografts that had multiple arteries or venous anomalies.
LLDN of the left kidney is technically easier. Left kidneys with multiple arteries or anomalous venous drainage are not problematic. The right kidney can be procured with LLDN; however, a rational approach to preoperative angiographic imaging, donor operation, and recipient operation is crucial.
活体供肾时通常优先选择左肾。在开放性活体供肾肾切除术（OLDN）中，如果左肾存在多条肾动脉或异常静脉引流，则选择右肾。对于腹腔镜活体供肾肾切除术（LLDN），由于暴露难度较大且在使用吻合器横断后右肾静脉（RRV）会进一步缩短，所以人们不太愿意获取右肾。本文回顾了LLDN的经验，以确定是否应通过腹腔镜获取右肾。
1995年2月至1999年11月，227例患者接受了LLDN获取供肾的活体肾移植手术。对这些移植手术的结果进行了分析。
在227例移植的肾脏中，17例（7.5%）为右肾。在早期经验中，8例右肾移植中有3例（37.5%）发生静脉血栓形成，其中2例RRV为双支。基于这些最初不可接受的结果，对供体评估和LLDN技术进行了改进。螺旋计算机断层扫描（CT）取代了传统血管造影以更好地明确静脉解剖结构。LLDN从以下三种方式之一进行了改进：（1）改变吻合器端口位置，使RRV在与下腔静脉平行的平面横断；（2）重新定位RRV开放分离的切口；（3）用取自受体大隐静脉构建的补片延长供体RRV。最后，受体手术要求完全游离左髂静脉并将其移位至髂动脉外侧。通过这些改进，随后的9例右肾移植未发生血管并发症（P<0.05）。在移植的左肾中，31例有多发肾动脉，14例有主动脉后或主动脉周围静脉，4例既有多发动脉又有静脉异常，1例有双下腔静脉引流左肾静脉。有多发动脉或静脉异常的左肾移植未发生血管并发症。
左肾的LLDN在技术上更容易。有多发动脉或异常静脉引流的左肾不成问题。右肾可以通过LLDN获取；然而，术前血管造影成像、供体手术和受体手术的合理方法至关重要。
