July 11, 2023/Transplant

Moving Closer Toward Narcotic-Free Kidney Transplantation

Smaller incision may lead to reduced postoperative pain for some patients

23-URL-3973558 CQD 650×450-B

Several years ago, the kidney transplant surgeons at Cleveland Clinic adopted a new, less invasive incision for kidney transplant called the anterior rectus sheath approach (ARS). They now use the approach in almost 90% of kidney transplant cases. And while, anecdotally, the incision offers improved pain outcomes, there was no scientific evidence to corroborate that — until now.


Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

What is the anterior rectus sheath approach?

Dr. Eltemamy and Cleveland Clinic colleagues led a single-center prospective trial that randomized 75 patients into one of two incision cohorts: the smaller, muscle-splitting ARS approach versus the conventional muscle-cutting Gibson approach. Study participants were followed for a minimum of one year following transplantation. The authors published findings from the trial in Clinical Transplantation.

“Previous studies have demonstrated the benefit of ARS in patients with obesity, but ours was the first to implement the approach in a larger cohort, without the exclusion of obesity, and evaluate outcomes alongside the Gibson approach,” says Dr. Eltemamy.

The ARS approach offers a cosmetic advantage over the Gibson approach, although the study was not powered to evaluate aesthetic outcomes. The ARS approach includes a 7 cm to 12 cm oblique skin incision 2 cm to 5 cm above and parallel to the inguinal ligament. It’s typically half or less than half the size of the conventional incision.

The authors note that the technique involves a muscle-splitting approach to the iliopsoas fossa, in contrast to the muscle-cutting Gibson approach. They also provide supplementary video of the technique in their paper as well as step-by-step instructions on performing the ARS, as demonstrated in the below illustrations.

A. Skin incision and anatomic landmarks

B. Division of anterior rectus sheath

C. Ligation of inferior epigastric vessels and incision of transversalis fascia

D. Exposure of iliopsoas fascia after positioning of self-retaining retractor

(E) Mobilization of iliac vasculature

F. Graft positioning in retroperitoneal pocket with vascular anastomosis completed

G. Externalization of graft from retroperitoneal pocket following completion of vascular anastomosis for hemostasis examination

H. Ureteral anastomosis over stent

I. Closure of anterior rectus sheath

Slide 1/9


No significant difference noted in wound-related complications

In addition to pain outcomes, the investigators also evaluated wound-related complications (WRC) associated with each approach, although they did not find a notable difference between the two cohorts (P = .23). Still, Dr. Eltemamy emphasizes the importance of surgeon-led efforts to minimize risk for WRC. This is particularly germane in the context of rising annual rates of kidney transplantation and the increasing comorbidity burden within the patient population.

A modest investment with great returns

The approach does not require specialized technology or expertise in laparoscopic of robotic surgery to perform. What does it require? Dr. Eltemamy says, “A modest investment in small, slim profile retractors to make the incision possible and the initial learning curve. That’s all it takes.” In terms of exclusion criteria, he explains there are two scenarios he would likely avoid the ARS: when patients have severe calcifications of the external artery that require a higher incision or in cases when more complex vascular reconstruction is warranted.

A near-future reality for some patients

Dr. Eltemamy and colleagues have also completed a follow-up analysis examining the ARS in conjunction with transversus abdominis plane (TAP) block, an intraoperative analgesic. While this study is pending final publication, it represents continued efforts from the Cleveland Clinic team to explore improved patient outcomes following kidney transplant.

“Our goal is to get to a point where patients won’t need any narcotics following kidney transplant — and we think that’s a near-future reality,” concludes Dr. Eltemamy.

Related Articles

Masked Medical Appointment
March 21, 2022/Transplant
Pilot Study to Create Automated Referral Process for Kidney Transplants

The process could improve access and equity for patients with end-stage kidney disease

22-URL-2682158 – CQD 650×450
February 3, 2022/Transplant
A Closer Look at Single-Port Robotic Kidney Transplant: Venous and Arterial Anastomosis (Video)

Video offers glimpse into technically challenging portion of the procedure

September 7, 2021/Transplant
Early Successes in Kidney Transplantation From Deceased Donors With COVID-19

Infectious disease and kidney transplant specialists share key insights

September 2, 2021/Transplant
Many High-Priority Patients Not Placed on Kidney Transplant Waitlist

Demographic and social factors found to influence preemptive listing

March 26, 2021/Transplant
Access to Kidney Transplantation Unchanged Over 20 Years

New interventions and policies haven’t increased wait-listing

November 5, 2019/Transplant
First Kidney Transplant Performed in the World Using Single-Port Robot

Cleveland Clinic surgeons use single-incision robotic surgery to perform kidney transplant

December 7, 2018/Transplant
Pushing the Limits of Organ Transplant

Transplant Center makes more organs available to more patients