the first kidney allotransplantation in the world between living patients was performed in 1952 in paris , although the kidney failed 3 weeks later . since its inception , living - donor kidney transplantation has shown superiority over deceased - donor transplantation , with shorter cold ischemia time , the use of perfect kidneys from perfectly healthy donors , and reduced waiting time for the recipient . these advantages have increased the use of living - donor kidneys . because people volunteering for a surgery that will not provide any personal physical health benefits are in particular need of a safe operation , the benefits for recipient and society must be balanced against the potential harm to the donor . thus , surgeons performing living - donor kidney transplantation have focused on the quality of life and safety of the donor , as well as on graft function , leading to the development of minimally invasive donor nephrectomy techniques . the first pure laparoscopic donor nephrectomy ( pldn ) was reported by ratner et al . in 1995 . several subsequent studies found that laparoscopic donor nephrectomy ( ldn ) , whether hand - assisted or not , was superior to open donor nephrectomy in terms of the donor 's recovery , with less pain , reduced estimated blood loss , and shorter hospital stay . although ldn has several disadvantages when compared to open donor nephrectomy , including longer operative and warm ischemia times , it does not increase intraoperative and postoperative donor complications or compromise graft function . the subsequent development of hand - assisted laparoscopy for harvesting the donor kidney has resulted in a wider acceptance of minimally invasive surgery . the organ procurement and transplantation network / scientific registry of transplant recipients estimated that , in 2012 , 95% of kidneys were harvested from donors by laparoscopic nephrectomy , whether hand - assisted or not . although about 60% of living donor nephrectomies have been performed by hand - assisted procedures , the proportion harvested without hand assistance is continuously increasing . fewer studies , however , have compared these 2 laparoscopic techniques , and these studies have demonstrated conflicting results . in the present study , we sought to determine the feasibility of technical transition from haldn to pldn by comparing perioperative donor outcomes and early graft function of hand - assisted laparoscopic donor nephrectomy ( haldn ) and pldn performed by a single surgeon . the study protocol was approved by the institutional review board of the asan medical center ( no . 2014 - 0852 ) . a prospectively collected database of 60 donor nephrectomies performed by a single surgeon ( dy ) from october 1 , 2012 , through june 30 , 2014 , was reviewed . the surgeon had less than 2 y of actual experience after completion of a 2-y urology fellowship . the first 30 donor nephrectomies were performed by haldn and the last 30 by pldn . before surgery , the renal vascular anatomy and relative renal function of both kidneys were examined by computed tomography angiography and diethylene triamine penta - acetic acid scintigraphy . the kidney to be extracted was determined on the basis of relative renal function and number of arteries . if the difference in relative renal function was 5% , and both kidneys had a single artery , the left kidney was preferred . baseline data included patient age , sex , relationship to recipient , body mass index , medical and surgical histories , american society of anesthesiologists ( asa ) score , laterality , number of arteries and veins , hemoglobin concentration , and glomerular filtration rate ( gfr ) . gfr was estimated from serum creatinine concentration with a variation of the modification of diet in renal disease equation . donor patients undergoing right - sided haldn were placed in a 45 oblique position with the left side down while under general anesthesia . a 9-cm incision was made below the level of the umbilicus along the lateral border of the right rectus muscle for insertion of the gelport laparoscopic system ( applied medical , rancho santa margarita , california ) . a 12-mm trocar was placed above the umbilicus , a second 12-mm trocar was placed below the costal margin in the right midclavicular line , and a 5-mm trocar was placed approximately 2 cm from the tip of the right 12th rib for retraction . while under general anesthesia , donors undergoing left - sided haldn were placed in a 45 oblique position with the right side down . a 9-cm incision was made between the level of the xiphoid process and the umbilicus for insertion of the gelport laparoscopic system ( applied medical ) . a 12-mm trocar was placed below the level of the umbilicus in the left midclavicular line , a second 12-mm trocar was placed more caudally in the left anterior axillary line , and a 5-mm trocar was placed approximately 2 cm from the tip of the left 12th rib for retraction . pldn was performed as previously described , with minor modifications , using the umbilical incision as the kidney extraction site . for right ( left)-sided pldn , patients were placed in a 45 oblique position with the left ( right ) side down , while under general anesthesia . a 6-cm omega - shaped incision was made around the umbilicus for insertion of the lapdisc ( hakko medical , tokyo , japan ) or dextrus ( ethicon endo - surgery , inc . , a 12-mm trocar was placed in the center of the hand port and used to establish pneumoperitoneum and for camera placement . a second 12-mm trocar was placed below the right ( left ) costal margin in the right ( left ) midclavicular line and a third 12-mm trocar was placed below the level of the umbilicus in the right ( left ) anterior axillary line . finally , a 5-mm trocar was placed approximately 2 cm from the tip of the right ( left ) 12th rib for retraction . after the white line of toldt was incised and the colon reflected medially , gerota 's fascia was entered near the renal hilum . the renal artery and vein were completely freed of lymphatic and other perivascular tissue , avoiding any injuries to the vessels . the gonadal , lumbar , and adrenal branches were tied and divided from the renal vein . the ureter was dissected caudally to the level of the internal iliac vessels , leaving sufficient margins to ensure an adequate blood supply around it . an extra - large hem - o - lok clip ( teleflex medical , research triangle park , north carolina ) was applied at the caudal end of the dissected ureter , and the ureter was divided cephalad to the clip without electrocautery . the renal artery was clamped with 1 ( for left - sided ) or 2 ( for right - sided ) extra - large hem - o - lok clips ( teleflex medical ) and 2 titanium clips ( autosuture endo clip l ; covidien surgical , norwalk , connecticut ) . an endopath ets - flex articulating endoscopic linear stapler ( ethicon endo - surgery , inc . ) was applied to transect the renal vein . the kidney was removed through the hand port ( for haldn ) or umbilical incision ( for pldn ) in an endocatch bag ( covidien surgical ) , placed immediately in sterile ice slush , and delivered to the recipient team for grafting . after the abdomen was carefully inspected at a reduced intraperitoneal pressure , bleeding was controlled , and a jackson - pratt drain was inserted . after the hand port and trocars were removed and the pneumoperitoneum was evacuated , the wounds were closed in the usual method . operative time was defined as the time between skin incision for placement of the first trocar and skin closure of the trocar wounds . warm ischemia time was defined as the time from renal artery occlusion to immersion of the kidney in ice slush . postoperative pain was assessed with a patient - reported visual analogue scale ( vas ) . delayed graft function was defined as the need for renal replacement therapy within the first week after surgery . nondialyzed patients were divided into those with slow and excellent graft function , based on whether serum creatinine concentration on postoperative day 7 was higher or lower than 2.5 mg / dl , respectively . all complications within 90 days of surgery were graded according to the clavien - dindo classification . continuous variables were analyzed with student 's t test , and categorical variables were analyzed with pearson 's  test or fisher 's exact test . binary logistic regression analysis was used to estimate the association of baseline characteristics with intra- or postoperative complications . correlations between outcomes and assessed variables are expressed as the odds ratio ( or ) with a 95% confidence interval ( ci ) . the study protocol was approved by the institutional review board of the asan medical center ( no . 2014 - 0852 ) . a prospectively collected database of 60 donor nephrectomies performed by a single surgeon ( dy ) from october 1 , 2012 , through june 30 , 2014 , was reviewed . the surgeon had less than 2 y of actual experience after completion of a 2-y urology fellowship . the first 30 donor nephrectomies were performed by haldn and the last 30 by pldn . before surgery , the renal vascular anatomy and relative renal function of both kidneys were examined by computed tomography angiography and diethylene triamine penta - acetic acid scintigraphy . the kidney to be extracted was determined on the basis of relative renal function and number of arteries . if the difference in relative renal function was 5% , and both kidneys had a single artery , the left kidney was preferred . baseline data included patient age , sex , relationship to recipient , body mass index , medical and surgical histories , american society of anesthesiologists ( asa ) score , laterality , number of arteries and veins , hemoglobin concentration , and glomerular filtration rate ( gfr ) . gfr was estimated from serum creatinine concentration with a variation of the modification of diet in renal disease equation . donor patients undergoing right - sided haldn were placed in a 45 oblique position with the left side down while under general anesthesia . a 9-cm incision was made below the level of the umbilicus along the lateral border of the right rectus muscle for insertion of the gelport laparoscopic system ( applied medical , rancho santa margarita , california ) . a 12-mm trocar was placed above the umbilicus , a second 12-mm trocar was placed below the costal margin in the right midclavicular line , and a 5-mm trocar was placed approximately 2 cm from the tip of the right 12th rib for retraction . while under general anesthesia , donors undergoing left - sided haldn were placed in a 45 oblique position with the right side down . a 9-cm incision was made between the level of the xiphoid process and the umbilicus for insertion of the gelport laparoscopic system ( applied medical ) . a 12-mm trocar was placed below the level of the umbilicus in the left midclavicular line , a second 12-mm trocar was placed more caudally in the left anterior axillary line , and a 5-mm trocar was placed approximately 2 cm from the tip of the left 12th rib for retraction . pldn was performed as previously described , with minor modifications , using the umbilical incision as the kidney extraction site . for right ( left)-sided pldn , patients were placed in a 45 oblique position with the left ( right ) side down , while under general anesthesia . a 6-cm omega - shaped incision was made around the umbilicus for insertion of the lapdisc ( hakko medical , tokyo , japan ) or dextrus ( ethicon endo - surgery , inc . , a 12-mm trocar was placed in the center of the hand port and used to establish pneumoperitoneum and for camera placement . a second 12-mm trocar was placed below the right ( left ) costal margin in the right ( left ) midclavicular line and a third 12-mm trocar was placed below the level of the umbilicus in the right ( left ) anterior axillary line . finally , a 5-mm trocar was placed approximately 2 cm from the tip of the right ( left ) 12th rib for retraction . after the white line of toldt was incised and the colon reflected medially , gerota 's fascia was entered near the renal hilum . the renal artery and vein were completely freed of lymphatic and other perivascular tissue , avoiding any injuries to the vessels . the gonadal , lumbar , and adrenal branches were tied and divided from the renal vein . the ureter was dissected caudally to the level of the internal iliac vessels , leaving sufficient margins to ensure an adequate blood supply around it . an extra - large hem - o - lok clip ( teleflex medical , research triangle park , north carolina ) was applied at the caudal end of the dissected ureter , and the ureter was divided cephalad to the clip without electrocautery . the renal artery was clamped with 1 ( for left - sided ) or 2 ( for right - sided ) extra - large hem - o - lok clips ( teleflex medical ) and 2 titanium clips ( autosuture endo clip l ; covidien surgical , norwalk , connecticut ) . an endopath ets - flex articulating endoscopic linear stapler ( ethicon endo - surgery , inc . ) was applied to transect the renal vein . the kidney was removed through the hand port ( for haldn ) or umbilical incision ( for pldn ) in an endocatch bag ( covidien surgical ) , placed immediately in sterile ice slush , and delivered to the recipient team for grafting . after the abdomen was carefully inspected at a reduced intraperitoneal pressure , bleeding was controlled , and a jackson - pratt drain was inserted . after the hand port and trocars were removed and the pneumoperitoneum was evacuated , the wounds were closed in the usual method . operative time was defined as the time between skin incision for placement of the first trocar and skin closure of the trocar wounds . warm ischemia time was defined as the time from renal artery occlusion to immersion of the kidney in ice slush . postoperative pain was assessed with a patient - reported visual analogue scale ( vas ) . delayed graft function was defined as the need for renal replacement therapy within the first week after surgery . nondialyzed patients were divided into those with slow and excellent graft function , based on whether serum creatinine concentration on postoperative day 7 was higher or lower than 2.5 mg / dl , respectively . all complications within 90 days of surgery were graded according to the clavien - dindo classification . continuous variables were analyzed with student 's t test , and categorical variables were analyzed with pearson 's  test or fisher 's exact test . binary logistic regression analysis was used to estimate the association of baseline characteristics with intra- or postoperative complications . correlations between outcomes and assessed variables are expressed as the odds ratio ( or ) with a 95% confidence interval ( ci ) . table 1 shows the baseline characteristics of the 60 donors . there were no significant differences between the haldn and pldn groups , except that asa score ii was significantly more frequently assigned in the latter group ( 10.0% vs 43.3% , p = .007 ) . there were no significant between - group differences in total operation time , warm ischemia time , estimated blood loss , vas pain scores on postoperative day 1 and at discharge , interval to removal of the drain , interval to return to a regular diet , and overall hospital stay . baseline characteristics of donors operative and convalescence parameters of donors and graft outcomes intra- and postoperative complications are outlined in table 3 . the rates of overall intraoperative complications were similar in the 2 groups ( p = .598 ) . thirteen patients ( 43.3% ) in the haldn group experienced a total of 17 intraoperative errors , and 11 ( 36.7% ) in the pldn group experienced a total of 14 intraoperative errors . the most common intraoperative complication was adrenal gland injury ( two intra - adrenal hematomas and 10 adrenal gland injuries , including 7 that required repair ) . the overall postoperative complication rate was similar in the 2 groups ( p = .209 ) . twenty - six patients ( 86.7% ) in the haldn group experienced a total of 47 postoperative complications , and 21 ( 70.0% ) in the pldn group experienced a total of 28 postoperative complications . ileus and aspartate aminotransferase / alanine aminotransferase elevation were commonly reported in the haldn group . one patient in the haldn group had prolonged chyle leakage from a jackson - pratt drain ; this patient was treated with long - term drainage ( 14 days ) and a low - fat diet . one patient in the pldn group underwent wound revision under local anesthesia for wound dehiscence . a second patient in the pldn group had a blood transfusion for postoperative bleeding . however , this bleeding originated mainly from a concomitantly performed ovarian cystectomy site and menstruation . intra- and postoperative complications none of the baseline characteristics assessed was significantly associated with intraoperative complications . univariate and multivariate analyses of the associations between baseline characteristics and postoperative complications showed that sex ( or : 0.183 , 95% ci : 0.0400.840 , p = .029 ) and learning curve ( or : 0.602 , 95% ci : 0.3750.966 , p = .036 ) were significant determinants ( table 4 ) . kidney transplantation is the treatment of choice for most patients with end - stage renal disease because of cost effectiveness , better quality of life , and longer survival compared with dialysis . the gap between the demand for kidney transplants and the supply of donor kidneys is continuously increasing . this discrepancy and the inadequate supply of deceased donor kidneys have resulted in greater demand for living - donor kidney transplantation . the increased use of living donors has made attention to donor well - being a priority , leading to the widespread adoption of minimally invasive donor nephrectomy techniques . despite the increased use of ldn , few studies have compared pldn with haldn directly , and those studies have yielded conflicting results . moreover , most of those studies have evaluated a small number of patients ( 22100 ) , have had a selection bias ( ie , a tendency to procure more left kidneys ) , and were retrospective in design . this study , therefore , compared perioperative donor outcomes and early graft function after haldn and pldn performed by a single surgeon lacking experience with laparoscopic renal surgery . the 2 types of surgery performed by this surgeon yielded similar operative and convalescence outcomes . most meta - analyses comparing pldn with haldn have reported shorter operative and warm ischemia times with haldn than with pldn , and lower estimated blood loss with haldn than with pldn . although we also observed that estimated blood loss was slightly greater in the pldn group , the difference was not statistically significant . the differences between the previous studies and this report may be because of the sequence in which the procedures were learned by our surgeon , who attempted pldn only after surmounting the learning curve for haldn . a recent meta - analysis reported that overall hospital stay is shorter with pldn than with haldn . we found that drain removal and return to a regular diet tended to take place earlier in the pldn group , but early recovery did not bring about a reduction in overall hospital stay . this apparent contradiction may have been related to the lack of between - group differences in pain on postoperative day 1 and at discharge . moreover , many of these patients had been transferred from other areas and may have required longer hospitalization because of difficulties in returning for early follow - up . the warm ischemia times reported were somewhat longer than previously reported , both in the haldn ( our study , 6.4 ; prior reports , 1.64.4 minutes ) and pldn ( our study , 6.6 ; prior reports 2.65.4 minutes ) groups . however , the ranges of warm ischemia times observed in our patients ( 1.315.3 minutes ) did not adversely affect graft outcomes in lnd . one patient with slow graft function in our study had a short warm ischemia time ( 2.9 minutes ) , but showed good late graft function after 15 months ( serum creatinine , 0.89 mg / dl ) . therefore , efforts to decrease warm ischemia time , by more rapid ligation and division of the renal vessels and kidney extraction , are not warranted at the expense of potential traumatic injury to the donor or the graft . the most important findings of our study included a lack of significant difference in overall intraoperative complications between the 2 groups , a finding consistent with previous reports . the intraoperative complication rate in our series was higher than previously reported , both in patients undergoing haldn ( our study , 43.3% ; prior reports , 4%28% ) and pldn ( our study , 36.7% ; prior reports , 2.8%25% ) . the postoperative complication rate was also higher than reported previously , both for haldn ( our study , 86.7% ; prior reports , 0%15% ) and pldn ( our study , 70.0% ; prior reports , 0%43% ) . the higher complication rates may be due to prospective recording by systematic classification methods , including minor complications that may have been underreported in previous studies . most intra- and postoperative complications were grade i , and such complications could reflect the degree of completion of surgical skill or quality of postoperative management . after adjustment for confounding factors , we confirmed that the type of surgery did not affect intra- or postoperative complications . women were at 82% lower risk of postoperative complications than were men , which may be caused by the higher rate of genitourinary complications in men , including urinary retention and orchalgia . in addition , assessments of learning curves showed that the risk of postoperative complication was reduced by 40% for every 10 patients . this finding may be due to more frequent ileus in the initial patients , resulting from the need for bowel manipulation by hand and a relatively longer operation time . in addition , aspartate aminotransferase / alanine aminotransferase may have been elevated more frequently in the initial donors . right kidneys tended to be procured earlier , and these patients may have needed a longer liver - retraction time , with possible risk of liver injury . the main limitation of this study was its retrospective nonrandomized design , which caused bias . the most serious bias was that our surgeon began performing pldn after surmounting the learning curve for haldn . therefore , the learning curve was included as a confounding factor in logistic regression analysis of the association of baseline characteristics with patient complications . our study may be underpowered to detect any potential differences between the 2 types of surgery . one drawback was the use of a hem - o - lok clip ( teleflex medical ) on the renal artery , despite the u.s . food and drug administration ( fda ) warning in 2006 . in 2008 , however , a survey of u.s . transplant surgeons showed that 28% of them still preferred hem - o - lok clips for ldn . furthermore , a review of the fda manufacturer and user facility device experience database revealed a higher rate of device failure associated with staplers than with hem - o - lok clips ( 3.0% vs 1.7% ) . in conclusion , the technical transition from haldn to pldn does not have a steep learning curve for surgeons who lack experience with laparoscopic renal surgery , maintaining similar perioperative donor and graft outcomes . the occurrence of postoperative complications may be associated with the donor 's sex and surgical experience .
background and objectives : we compared perioperative donor outcomes and early graft function of hand - assisted laparoscopic donor nephrectomy ( haldn ) and pure laparoscopic donor nephrectomy ( pldn ) performed by a single surgeon , to define the feasibility of technical transition from haldn to pldn.methods:from october 1 , 2012 , through june 30 , 2014 , 60 donor nephrectomies were performed by a single surgeon who lacked experience with laparoscopic renal surgery : the first 30 by haldn and the last 30 by pldn . 
 operative and convalescence parameters were compared , as were intra- and postoperative complications within 90 days according to the satava and clavien - dindo classifications , respectively . 
 binary logistic regression analysis was used to estimate the association of baseline characteristics with complications.results:baseline characteristics were similar in the 2 groups , except for american society of anesthesiologists score ii ( 10.0% vs 43.3% ; p = .007 ) . 
 all procedures were completed as planned . 
 all operative and convalescence parameters of donors and graft outcomes were similar in the 2 groups , as were overall rates of intraoperative ( 43.3% vs 36.7% , p = .598 ) and postoperative ( 86.7% vs 70.0% ; p 
 = .209 ) complications . 
 no factor was significantly predictive of intraoperative complications , whereas sex ( female vs male , odds ratio , 0.183 ; p = .029 ) and learning curve ( odds ratio , 0.602 ; p = .036 ) were significant determinants of postoperative complication.conclusion:the technical transition from haldn to pldn does not involve a steep learning curve for surgeons less experienced with laparoscopic renal surgery and maintains similar perioperative donor and graft outcomes .