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The Gift

At this stage, you've passed the donor evaluation, and it's time to donate. A date for the surgery is scheduled. Note that the date will depend in part on the health of the recipient since he or she must be able to withstand surgery, too. You will be put on eating and drinking restrictions and may be instructed to take a laxative the day before.

Here are some tips for preparing for and recovering from surgery in the hospital: Surgery Tips. And here are suggested questions a prospective living organ donor might ask of medical professionals: Questions.

You and the recipient will be admitted to the hospital the day before or the morning of the surgery. On the day of the surgery, you'll be "prepped," which may involve inserting an IV, dressing in a hospital gown, even taking a mild sedative. You'll be wheeled into the operating room. The surgeon greets you and the nurses get you situated for the surgery. The anesthetist starts the anesthesia through the IV, you count backwards, and "away we go."

While you're unconscious, the surgeon will follow one of two procedures:

• Open nephrectomy. This procedure, which is the older form of surgery, involves making an incision of several inches—as long as 10 inches—from the left side (assuming the left kidney is taken) along the bottom of the lower rib to the midriff.

  There is an alternative open nephrectomy procedure that begins the incision further on the back along the side to the front (a flank incision), but a portion of the rib may have to be removed. You may be offered a choice between these alternatives.

  Regardless of the alternative, the incision requires cutting through three layers of muscle. Once access to the kidney is gained, the arteries and ureter are clamped off. The kidney is removed, flushed, and placed in a cold preservative solution. You may receive a blood transfusion during the operation, but such transfusions are rare.

• Laparoscopic nephrectomy. This procedure uses a laparoscope—a device inserted into the abdomen allowing the surgeon to see and operate. This technique involves making several small (a couple of inches each) incisions in your abdomen, called "ports," to allow insertion of a laparoscope and other instruments. The camera and instruments are used to cut the kidney away from surrounding tissue after clamping off the arteries and ureter. The kidney is removed through an incision below your belly button. Then you're closed up.
  
  Note that donation of the right kidney is more complicated because the liver is in the way, therefore an incision may be made in a different area of your abdomen.

Medical studies have compared the effect of open and laparoscopic procedures on donors and have generally found that the laparoscopic procedure results in less pain, shorter hospital stays, and faster recovery and return to normal activities. Here are the results of a study (Waller, at al., 2002) comparing the recovery times for 20 "laparoscopic" donors to 34 "open" donors in the United Kingdom:

Results favoring the laparoscopic procedure were also found in a Johns Hopkins study (Ratner, et al., 1999) comparing 25 laparoscopic donors to 37 open donors:

This study also found no significant differences in the results for the recipient. Surgical complications, rejection rates, need for dialysis, and hospital stays where comparable for an organ donated by the open or laparoscopic method.

There are data showing a slightly higher incidence of complications to donors arising from laparoscopy, but the difference is very small. (See the summary of medical studies below.)

Laparoscopic nephrectomy is now the more common form of surgical procedure. There are also variations, such as "hand-assisted laparoscopic" and "mini-open" nephrectomy that incorporate features of both laparoscopic and open nephrectomy. In a very limited number of situations, the surgical team will shift from a laparoscopic procedure to open nephrectomy if complications arise during the laparoscopic procedure. The incidence of switching from the laparoscopic to open procedure was 2.1% in a study of 381 procedures at Johns Hopkins over a six-year period from 1995 to 2001 (Su, et al., 2004).

Surgery takes about three to four hours. (Surgery under the laparoscopic method may be at the high end of that range.) After surgery, you are moved to a recovery room for several hours. Once you regain consciousness, you will be wheeled into your hospital room. Your ability to go home is a function of your ability to deal with the pain and your recovery from the anesthesia.

You are helped in dealing with the pain with medication, such as a morphine drip. (Don't worry about addiction; the dosages are tightly controlled.) The other "pain" you'll deal with is those nicely nagging nurses who will aid with your recovery. They'll insert and maintain an IV for nourishment since your gastrointestinal tract is "sleepy" from the anesthesia. A catheter is inserted to remove fluid from your bladder. (The output is measured to ensure your remaining kidney is functioning adequately.) Special socks will be put on your legs to aid circulation and prevent clotting. And you'll be asked to inhale deeply using a special device to reduce the risk of pneumonia. You'll be encouraged to get up and walk as soon as you're able. 

Once your gastrointestinal tract is operational (you can defecate and urinate on your own), you are mobile, and you can manage any pain, you can go home. Generally, recovery—from the time of surgery to the time of your discharge—is three to four days. You will likely be unable to perform any work, especially heavy lifting, for about six weeks.

Medical Risks of Living Donation Surgery

There are risks to the donor during and after the surgery. Unlike most other surgeries, you--the patient--are actually in excellent health when undergoing surgery. Therefore, the risks are attributable primarily to the surgery itself and the removal of a kidney. These risks are small and manageable, but in the interest of full disclosure, here are some of the possible complications and consequences:

• Pain. This is a certainty, and it is one aspect of donation that donors tend to underestimate. Fortunately, pain is managed through medication after surgery.

• Complications. About 10% to 30% of donors report some form of complication following surgery. The complications include infection of the incision, minor bleeding, urinary tract infection, and pneumonia.
  
  One special complication of laparoscopic nephrectomy reported on LDO is feeling bloated. This happens because the abdomen is inflated with gas during the surgery to give the surgeon more room to manipulate the laparoscope and surgical tools. It takes a while after the surgery for the body to eliminate the gas, so the donor can feel uncomfortable for a while. LDO donors report that walking and being active helps to speed the elimination of the gas.

• Reoperation.Some complications may be significant enough that you need to go back into surgery. Research shows reoperation occurs in 2% or less of donations. Examples of the kinds of major complications that require reoperatoin include hernia, bleeding, bowel obstruction, and bowel injury.

• Readmission. You may have problems after you leave the hospital that require you to return to the hospital.  About 2% of donors return to the hospital because of ailments like nausea, vomiting, bleeding, constipation, diarrhea, and infection.

• Death. It happens. Fortunately, it is exceedingly rare. The generally accepted rate of mortality risk is 0.03% (that's three deaths for every 10,000 procedures.)
  

What the research tells us is that the majority of donation surgeries go well. However, there are a few situations where the donors suffer complications from the surgery. If you'd like to learn more about the potential complications, you can read a comprehensive digest of medical research on living donor surgery on LivingDonor101.

Psychosocial Consequences of Donation

There is limited research on the psychosocial impact of donation immediately following donation surgery. However, LDO participants who have donated report these kinds of psychosocial and relationship changes:

• An increase in self-esteem for having done something extraordinary for someone else.

• Positive feelings after seeing the improved health of the recipient.

• A mild depression, perhaps because attention and concern tends to shift to the recipient after the donation and because of a lower level of anticipation and excitement than the level that preceded the surgery.

• A change--sometimes positive and sometimes negative--in the relationship with the recipient, family members, and others close to the donor and recipient.

About the Recipient

Of course, the living donor is not the only one who undergoes surgery during a successful transplant operation. The recipient also undergoes major surgery. The obvious benefit of the surgery to the recipient is getting a functioning kidney that cleans the blood and produces urine. The change in the recipient's health immediately following donation can be dramatic. Longer term, the recipient benefits from a better lifestyle free from dialysis and with prospects for a longer life expectancy.

The recipient can also face risks from the surgery. Infection, bleeding, and complications just like the donor surgery are possible. It's not unusual for the recipient to have a "rejection episode" where their body fights the newly donated organ despite receiving anti-rejections drugs. There is a risk that the recipient will lose the organ. UNOS statistics show that about 95% of living donor organs survive after a year. That means 5% of them are rejected. Recipients can also struggle with the side effects of the anti-rejection drugs. They may experience tremors, hair growth, headaches, high blood pressure, fluid retention, and increased susceptibility to infection. Some of these side effects can be addressed by changing the level of medication. Over the long run, the donated kidney may be lost due to a return of kidney disease or cancer and other complications from taking anti-rejection drugs.

Despite these risks and the side effects of the anti-rejection drugs, recipients report that the results of living donation are far superior to dialysis.

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