Bansal, Devanshu,*; Mittal, Sanjay; Mathur, Piyush1
Department of Urology, Renal Transplant Unit, Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India
1Department of Nephrology, Renal Transplant Unit, Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India
Address for correspondence: Dr. Devanshu Bansal, Department of Urology, Santokba Durlabhji Memorial Hospital, Jaipur - 302 015, Rajasthan, India. E-mail: [email protected]
Received November 26, 2021
Received in revised form June 07, 2022
Accepted September 05, 2022
Dear Editor,
The stage is set. The cast is ready. The audience waits with bated breath. The protagonists enter and the show commences. The current operation suites were originally called “operation theaters,” where interested scholars and students could watch live surgery.[1] We started the laparoscopic donor nephrectomy (LDN) program at our center on September 18, 2021. We were regularly performing open donor nephrectomy (ODN) before this. The surgery went successfully. Performing the actual procedure was a lot like being in a theater, with many people watching and expecting a good performance. A lot of learnings are to be gained from starting a new surgical program, as below:
- Select your scripts wisely. Starting the LDN program is a huge responsibility because the donor is not really a patient. Case selection in the initial weeks is crucial, as a clean case is least likely to get complicated. This helps in building up the confidence of the transplant team and operation theater (OT) staff. This also ensures an initial high success rate
- Make sure you have all the props and costumes in place. A surgery without proper instrumentation is a disaster waiting to happen. It is important that you check all the instruments with the staff beforehand; any instrument missing should be added to the armamentarium; any technical fault should be corrected at least a day before. Technical glitches happening during the procedure create undue mental stress and pose risk to the patient
- The backstage team is as important as the on-stage cast. Make sure your OT team is well versed with the procedure. This includes the anesthetist (good patient perfusion and pre-clipping iv mannitol[2]), OT attendants (items required for patient positioning) and OT nurses (a great nurse studies the procedure beforehand, knows your steps, and replaces your instruments without asking)
- Do your rehearsals. Do the procedure under your mentor's guidance during your training. This will make you and your team confident in your abilities and make your staff used to your surgical preferences. Before the procedure, run the surgical steps through with your team so that everybody knows what to expect
- Focus on your performance. When you do your first new surgery, expect all eyes on you. Keep calm, remember your training and make use of common sense. If you lose your way, reorient; if you encounter a bleeder, compress first clip later; if you start to lose confidence midway, seek support from your teammates; if you reach an impasse during laparoscopy, convert (it is not a failure! The patient is the priority!)
- Give a vote of thanks. After the surgery, thank your team, your nurses, your anesthetist; you could not have done it without them. Inform your teachers, and they will be happy to know of your progress. You owe your surgical skills to them.
On why should you switch from ODN to LDN, considering the latter is an advanced nonablative laparoscopic surgical procedure done in a normal individual, the following points need to be considered:
- LDN is currently the primary method of living donor nephrectomy, with equivalent graft outcomes as ODN and all the benefits of minimally invasive surgery, including early recovery and better cosmesis[3]
- LDN entails minimal direct handling of the kidney, and in our personal experience, has led to minimal vasospasm in the renal artery during dissection
- The learning curve for LDN is 20–30 cases, which can be successfully achieved with adequate guidance in a high-volume transplant center already performing ODN.[4] Prior experience with ablative laparoscopic procedures (as discussed above) helps in further reducing the learning curve
- LDN is a valuable teaching tool for residents, considering the donor anatomy is normal, and residents can get a better understanding of surgical planes and steps for laparoscopic nephrectomy during this procedure.
The performance goes without a hitch. The audience enjoys it thoroughly, as do you. The after-party awaits. But it is not the end. There will be more scripts. The show must go on.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Brown MSchlich T. Surgery and emotion: The era before anaesthesia The Palgrave Handbook of the History of Surgery. 2018 UK Palgrave Macmillan:327–48
2. Nasrallah G, Souki FG. Perianesthetic management of laparoscopic kidney surgery Curr Urol Rep. 2018;19:1
3. Wang L, Zhu L, Xie X, Wang H, Yin H, Fang C, et al Long-term outcomes of laparoscopic versus open donor nephrectomy for kidney transplantation: A meta-analysis Am J Transl Res. 2020;12:5993–6002
4. Bansal D, Bansal VK, Krishna A, Misra MC, Rajeshwari S, Singh S, et al Quality improvement in laparoscopic donor nephrectomy by self-imposed proctored preceptorship model Indian J Surg. 2020;82:163–8
