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Monday, September 5, 2011

Surgeon's Choice

I am pretty sure I can speak for quite a few donors when I say that outside of the obvious health/surgical risks, there is also something else we are concerned with: Where and how big will our scars be? Women probably lead the charge on this worry more so than men, although I am sure there are both genders have people who concern themselves with it, and those who don't. I was moderately curious where my scar would be and what it would look like so I attempted to research it before my surgery. (Note: I don't want to post pictures here in case people are a bit squeamish-if you see a linked word when I am describing an incision or scar, only click on it if you are wanting to see a photo example. I tried to pick well healed ones that weren't too "new").

If you donate your kidney through an open surgery (not laparoscopic) the incisions tend to be bigger and a little more standardized in placement. Most pictures I found online showed a horizontal scar that would start on the front of the body blow the rib cage and wrap around to around the same point on the back. As you can imagine, this surgery is much more invasive than its laparoscopic counterpart and the incision size plays a big role in recovery time being so much longer (2-3 weeks for laparoscopic vs 6-8 weeks for open).

Prior to my donation, I was hopeful (as many donors are) that I would be a good candidate for a laparoscopic procedure. Most of the decision is based on which kidney is healthier/does more work if there is a difference. If they opt to use your left kidney, laparoscopic surgery is much easier and is usually the preferred method assuming to transplant hospital has surgeons who practice that style of surgery. In the US it is very commonplace and in most Canadian transplant hospitals it is as well. Foothills Hospital (here in Calgary AB) for example has been doing it almost exclusively for left side nephrectomies since 2000. However other centres may have only some surgeons who can perform the procedures do depending on who is assigned to your donation, you may not have the option (I have heard for example from another donor that Edmonton has only one doctor on their team who does lap kidney removals).

In doing my research and talking to other donors (before and after my surgery) about their laproscopic kidney removals, I started to realize that there didn't appear to be a standard spot for the larger of the incisions. The smaller incisions or "ports" where the laparoscopic instruments are inserted into the body, vary slightly in location based on the number used (one to sometimes 4). That made sense to me. But what I didn't understand is why some people had larger incisions tucked neatly away, closer to their groin and others (like myself) had scars closer to the navel, much higher in the abdomen.What was different from my surgery to the next person's that would result in so many different incision locations?  I tried to find out more online but wasn't coming to any kind of clear answer. So I asked my friendly neighbourhood transplant surgeon. 

It turns out it is a "surgeons choice" situation. Where the incisions end up and even the number of ports used are dependent on the surgeons preference/style.  He said that there are two distinct kinds of laparoscopic kidney surgeries: hand assisted and not hand assisted. Both types can have a range of "port" holes used as well (the least I've read about is zero, the most is four plus the larger incision). My medial incision (up and down at the navel) was hand assisted meaning that they used the ports for the laparoscopic tools and the larger incision was used to both dissect the kidney (cut it away from the body and close off any attachment points left behind if required). The kidney is then removed from the body by hand. I've read that this type of incision can make the patient more prone to hernia during recovery because of how the abdominal wall and muscles are affected.

When the scar is found lower down, closer to the groin or bikini area, this indicates the surgery was "hands free) and was done entirely using the laparoscopic tools. In this case, the larger incision was an extraction point for the kidney after it was dissected using the tools. This type of scar is normally more horizontal (aka  phanestil/pfannenstiel depending on language preference of your friendly neighbourhood surgeon) and is similar to what is used in a c-section. It is thought that this type of incision is slightly easier to recover from. It also is far less visible than the medial incision by the navel. Bring on the bikinis! However I have noticed a few donors mention that they have had numbness (temporary or semi permanent) as a result of nerves being affected by the incision. For some, the numbness has been localized to the wound area and others have had numbness in the upper leg area. In contrast, I haven't read of any medial incisions having that side effect (and I haven't experienced it either).

The type of larger incision used, their locations and the number of accompanying ports all comes down to the surgeons assessment of the best, safest and least complicated way to remove your kidney based on the particulars of your anatomy, factors like weight and body fat and the surgeon's own level of comfort with laparoscopic tools. Some surgeons might prefer to do the entire surgery with the tools whereas others might prefer to have some "hands on" contact with the surgical area. Both methods are commonplace and acceptable. Depending on the  logistics surrounding your kidney donation, you may not know ahead of time who your surgeon is and what his/her "style is" and you more than likely won't get a say in the matter (although they will advise you ahead of time if an open surgery is required so you can prepare for a longer recovery). If I recall correctly when I had my preoperative meeting with Dr. S, he showed me where I might expect my scars to be but couldn't say for sure-all was "depending on my surgeon and how things went". 

I do find it kind of interesting that there are several surgical routes to take with kidney donation surgery with the same end result. The medical world has always struck me as being very standardized and process based. It hadn't occurred to me that there was any room, particularly in well established, frequently performed surgeries like nephrectomies, for personal style and choice. The nerd in me would like to explore this a bit further and find out what makes the individual surgeons adapt their specific style and when they opt for which type of incision-what make them choose their choice. I'm also curious to see if a transplant team at a hospital like Foothills has a huge variance in style or if they are all similar-if each program has informal standards or best practices they adopt as their "surgeon's choice".




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