Further improvements in laparoscopic donor nephrectomy: decreased pain andaccelerated recovery

Fear of postoperative pain is a disincentive to living donor kidney transpl antation. Laparoscopic donor nephrectomy (LDN) was developed in part to dis pel this disincentive. The dramatic increase in the number of laparoscopic donor nephrectomies performed at our institution has been in part due to th e reduction in postoperative pain as compared to traditional, open donor ne phrectomy. We sought to further diminish the pain associated with this surg ical technique. The purpose of this study was to compare the efficacy of th ree different postoperative pain management regimens after LDN. All living kidney donors performed laparoscopically (n=43) between September 1998 and April 2000 were included for analysis. Primary endpoints included postopera tive narcotic requirements and length of stay. Narcotic usage was converted to morphine equivalents (ME) for comparison purposes. Patients received on e of three pain control regimens (group I: oral and intravenous narcotics; group II: oral and intravenous narcotics and the On-Q (TM) pump delivering a continuous infusion of subfascial bupivicaine 0.5%; and group III: oral a nd intravenous narcotics and subfascial bupivicaine 0.5% injection). Postop erative intravenous and oral narcotic use as measured in morphine equivalen ts was significantly less in group III versus groups I and II (group III: 2 8.7 ME versus group I: 40.2 ME, group III: 44.8 ME; P <0.05). Postoperative length of stay was also shorter for group III (1.8 days) versus group I (2 .5 days) and group II (2.9 days). LDN has been shown to be a viable alterna tive to traditional open donor nephrectomy for living kidney donation. We o bserved that the use of combined oral and intravenous narcotics alone is as sociated with greater postoperative narcotic use and increased length of st ay compared to either a combined oral and intravenous narcotics plus contin uous or single injection subfascial administration of bupivicaine. The prog ressive modification of our analgesic regimen has resulted in decreased pos toperative oral and intravenous narcotic use and a reduction in the length of stay. We recommend subfascial infiltration with bupivicaine to the three laparoscopic sites and the pfannenstiel incision at the conclusion of the procedure to reduce postoperative pain. We believe this improvement in post operative pain management will continue to make LDN even more appealing to the potential living kidney donor.