**5. Postoperative care**

The early postoperative period after laparoscopic donor nephrectomy is a particular moment in the management of kidney donors. Extubation is done after

**35**

**6. Complications**

*Laparoscopic Live Donor Nephrectomy: Techniques and Results*

normothermic state. Orogastric tube is removed prior to extubation. Hemoglobin measurement is realized every 6 h postsurgery, and if normal, it will be repeated the next morning with serum creatinine and electrolytes. Urine output is monitored. Shoulder tip discomfort and pain is a major complaint after LLDN perhaps from residual pneumoperitoneum. Epidural analgesia is ineffective for shoulder pain. There has been collective belief to aggressively minimize pain postoperatively in this special category of patients who are usually narcotics naïve. IV "patient-controlled analgesia" (PCA; fentanyl or morphine less commonly) was considered to be the modality of choice to achieve that. If PCA is not available, pain control is achieved with IV paracetamol and if needed ketoprofen or ketorolac over the first 24 h [57]. To reduce the risk of nephrotoxicity, the patient should be kept well hydrated. Opiates also have an effective role for breakthrough pain when opiate-sparing strategies have not been effective. Clear liquids are started on the day of surgery with increase of diet later. The emergence of enhanced recovery after surgery (ERAS) brought major changes to the traditional standard of care. Many centers across the USA have adopted the enhanced recovery programs that include intraoperative fluid restriction to 3 ml/ kg/h preventing excessive third spacing and bowel edema, urine output of 0.5 ml/ kg/h, use of local subfascial bupivacaine or other anesthetics as well as a postoperative narcotic-free pain control regimen, i.e., acetaminophen, ketorolac, etc. [58]. Novelties in this management were associated with reduced length of hospital stay, better pain control, and increased patient satisfaction. It has become evident that ERAS would potentially enhance the benefits of laparoscopic surgery for kidney donors [59]. Foley catheter is removed on the morning of day 1 and ambulation started as soon as possible either during the evening of day 0 or the next morning. Living kidney donors are classified as "medium risk" patients for deep venous thrombosis (DVT) and pulmonary embolism [4]. All living donors must have intra- and postoperative compression stockings and should receive adequate thromboprophylaxis with low-molecular weight-heparin and continuing for at least 1 week. Patient is discharged most frequently on day 2 and seen back 10 days later with a follow-up at 6 months, 1 year, and 2 years after donation. Donors must resume a normal lifestyle as soon as possible with regular surveillance of their blood pressure and their

weight. They should be warned about avoiding nephrotoxic medications.

LLDN appears to be a safe procedure or at least as safe as the open one. But serious complications including death may occur. Overall mortality rate is approximately 0.03% [34] although some large series reported no mortality [60–63]. Most of these deaths occurred in the postoperative period and were due to hemorrhage [47], CO2 gas embolism [64], and pulmonary embolism [34]. The risk of a major intraoperative hemorrhage during LLDN is between 0.6 and 1.6% [60, 63]. Conversion to open surgery has been reported to occur in 0 to 13% of cases, but in most large series, conversion rates of 1–2% are reported [4, 60–63]. Other intraoperative complications are splenic or liver laceration, ureteral and intestinal injury, and pleural laceration. The total incidence of surgical complications is 5.46% [61]. All major complications occurred in the first 100 cases [62]. This raises the question of the learning curve and how many laparoscopic nephrectomies should be done before performing the first LLDN? There is no precise answer but a number between 50 and 100 seems to be convincing for this type of surgery to be learned. Postoperative complications of LLDN are hematomas, fever, urinary tract infection, pneumonia, pulmonary embolism, wound infection, incisional hernias, prolonged ileus, chylous ascites, and left testicular pain perhaps due to gonadal vein

*DOI: http://dx.doi.org/10.5772/intechopen.80880*
