Spokane surgeon Dr. Robert Golden has begun performing a minimally invasive, laparoscopic kidney-removal procedure here that allows living kidney donors to recover in much less time than typically has been required after conventional surgery.


Golden has performed the procedure here eight times since May and is scheduled to perform it four more times during the next four weeks. He says he expects that the laparoscopic procedure eventually will become the standard in Spokane for removing kidneys from living donors, which medically is called a nephrectomy.


I foresee all but one or two nephrectomies a year being done laparoscopically, says Golden, director of Sacred Heart Medical Centers kidney transplant program here.


The program, which is the only one between Seattle and Salt Lake City, performs an average of 40 kidney transplants a year. In the last two years, about half of the kidneys it has transplanted have come from living donors, while the rest have come from deceased donors (also known as cadaveric donors). Just five years ago, only about one-fourth of the kidneys transplanted here came from living donors, says Liz Pearce, manager of the 18-year-old Spokane kidney transplant program.


Removal of a kidney from a living donor usually is possible because most people are born with two kidneys, but are able to survive with only one. Assuming a person has two healthy kidneys, he or she can donate one to a relative or close friend who is suffering from kidney disease, as long as the donor and recipient have compatible blood types and tissue types.


The kidneys are located deep in the lower abdomenone on each side of the spineand are embedded in fatty tissue, which protects the organs.


As part of a conventional, open nephrectomy, a 12-inch to 14-inch incision is made below a donors ribs from near the belly button around to the donors back. The large incision typically takes from four weeks to six weeks to heal, and about 10 percent of patients experience chronic discomfort, such as sporadic twinges of pain caused by a weakened abdominal wall.


By comparison, a laparoscopic nephrectomy requires only a crescent-shaped incision about 3 inches long made next to the patients navel and two or three incisions less then 1 inch long on the front and side of the patients body.


A nephrectomy really is a unique surgery, Golden says. Typically, when you perform surgery its because somebody has something wrong with them, but in this case, there is nothing wrong with these patients. In fact, theyre usually very healthy people who have jobs and children. So, we hope for only minimal interruption to their lives.


Laparoscopic nephrectomy has been able to cut a patients hospital stay in half to about three days, reduce the amount of painkillers needed by about 10 percent, and slice recovery time to between two and three weeks from the four to six weeks following a conventional open nephrectomy, Golden says. Patients energy levels return more quickly after the laparoscopic procedure; they can eat solid foods the morning following the surgery rather than having to wait as many as three or four days following an open nephrectomy; and bodily functions, such as urination and bowel movements, return to normal about two days after the surgery rather than seven days, he says.


So far this year, a total of 28 kidney transplants have been performed in Spokane. Twelve of the kidneys implanted in those procedures have come from cadaveric donors, while the remaining 16 have come from living donors, Golden says. Of the 16 living-donor kidney removals, half have been performed laparoscopically.


The procedure


Laparoscopic nephrectomies first were performed in the U.S. in 1993 at both the University of Maryland and at Johns Hopkins University. So far, about 400 of the laparoscopic procedures have been performed at the University of Maryland alone, and at least 1,000 have been performed nationally, Golden says.


Golden began performing lap-aroscopic nephrectomies here in May, but preferred not to speak about it publicly until now so he could have time to evaluate outcomes. He received training for the procedure at the University of Washington. Then, as required by Sacred Heart, he was overseen by a certified laparoscopic surgeon during the first five laparoscopic nephrectomies he performed here.


The procedure is performed with the use of a laparoscope, which is a slender, tubular scope equipped with a camera lens that allows surgeons to view the inside of the abdominal cavity on TV monitors above the operating table.


In a laparoscopic nephrectomy, the laparoscope is placed through one of the patients small incisions. A working instrument, which is a combination cutting and cauterizing device, is placed through another incision. In some cases, a third incision is made so a suction device can be inserted into the body cavity.


When a kidney is removed, a surgeon must preserve not only the kidney, but also a portion of the kidney vein, the kidney artery, and the ureter, which is the duct that carries urine from the kidney to the bladder. They will be reconnected inside the kidney recipient during the transplant procedure.


As part of the laparoscopic nephrectomy, the donor is placed on the operating table on his or her right sidejust as in an open nephrectomy. Those who can donate their left kidney and who havent had extensive abdominal surgeries are candidates for the procedure. Golden says that surgeons currently only take left kidneys laparoscopically because the vein leading from the kidney is longer on the left side since it has a greater distance to travel to the heart than the vein from the right kidney. In an open nephrectomy, either the left or right kidney can be removed, but the left kidney still is the most likely to be removed, he says.


In the laparoscopic nephrectomy, the incision thats made next to the navel allows the surgeon to place his hand into the patients body cavity. The kidney eventually is removed through that same incision. The procedure takes as long as four hours to perform, Golden says.


What makes this laparoscopic procedure different from others is that youre able to have your hand inside. Thats actually the real beauty of this type of surgery, he says. He explains that for him to be able to place his hand inside a persons abdominal cavity is helpful because hes able to feel, as well as see, whats being done.


As part of the procedure, air is pumped into the abdominal cavity through one of the patients small incisions. The surgeon slides his arm into an airtight sleeve, called an Pneumosleeve, before extending his hand into the abdominal cavity. Thanks to the sleeve, air doesnt escape from the body cavity, which would cause the abdominal cavity to collapse and obstruct the view of the lens at the end of the laparoscope.


If a donor suffers excessive bleeding during the surgery, the main incision must be lengthened, Golden says. He says that of the eight laparoscopic nephrectomies he has performed here so far, just one donor had to have the main incision lengthened to control excessive bleeding.


Kidney demand increases


The number of patients in the U.S. on the national waiting list to receive a kidney transplant has risen to 55,000 from 25,000 in the last 11 years, and that figure now far exceeds the number of kidneys harvested each year from cadaveric donors.


There will never be enough cadaveric donors to supply those on the waiting list, Golden told an audience at a kidney patient workshop at Sacred Heart earlier this month. In an interview later, Golden said that people have an average wait of two years to receive a kidney from a cadaveric donor once theyre placed on a waiting list. During that two-year wait, a patients state of health deteriorates.


The local waiting list currently includes about 80 people, while the statewide waiting list numbers about 800, he says. Both the local list and the statewide list are pulled from a national list that is maintained by the United Network of Organ Sharing, a national body that oversees all organ transplants.


Due to the relatively flat number of cadaveric donors each year, people who need a kidney are relying more on living donors, Golden says.


While the laparoscopic procedure makes donating a kidney a little less painful and improves recovery time, Golden doesnt want the procedure to be used as a wrench to coerce relatives to donate a kidney.


Ninety-nine percent of the time, a living donor would give a kidney anywayregardless of whether laparoscopic nephrectomy was available. The decision to donate a kidney is a big emotional commitment and not one that we would want to force on anyone.