title: Altering the Approach: Open Minimally Invasive Renal Transplant in Obese Patients Through the Anterior Rectus Sheath.
abstract: OBJECTIVE
  To retrospectively analyze the wound issues for obese renal transplant patients, as well as post-transplant outcomes including graft and patient survival, hypothesizing improvement over the standard approach. As the obese population has expanded, minimally invasive renal transplant techniques have attempted to improve the issues of complications related to wounds and hernias. The anterior rectus sheath approach, which facilitates a minimal incision, has been adopted at our center for all renal transplants, including obese patients.
  
  
  METHODS
  Between January 1, 2011 and December 31, 2014, 166 renal transplants were performed at the Charleston Area Medical Center with the new approach adopted in November 2012. Of the extraperitoneal transplants, 71 adult patients were classified as morbid/severe (≥35) or obese (30-34.9) by body mass index. Demographics, perioperative results, and outcomes were retrospectively collected for the conventional (CON) and anterior rectus sheath (ARS) approaches until August 21, 2015.
  
  
  RESULTS
  The ARS and CON groups comprised 40 of 71 (56%) and 31 of 71 (44%) patients, respectively. The majority of demographics and perioperative data indicated no significant statistical differences between procedures (P < .05). Wound complications, incision length, operative time, and glomerular filtration rate at 6 and 12 months were significantly different. Multivariate calculations indicated procedure as the only variable expected to affect wound healing in obese patients.
  
  
  CONCLUSIONS
  For obese patients, the ARS approach was shown to be an effective option that reduced wound complications and operative times. This easily adopted approach provides the obese and morbidly obese with comparable overall graft outcomes and significant improvement on wound complications.
authors.affiliation: Urologic Surgery, Charleston Area Medical Center, Charleston, WV.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Phillips
authors.affiliation: Health Education and Research Institute, Charleston Area Medical Center, Charleston, WV.
authors.forename: Sharon K
authors.initials: SK
authors.lastname: Hill
authors.affiliation: Renal Transplant Center, Charleston Area Medical Center, Charleston, WV.
authors.forename: Lorie D
authors.initials: LD
authors.lastname: Lipscomb
authors.affiliation: Renal Transplant Center, Charleston Area Medical Center, Charleston, WV; Glickman Institute, Cleveland Clinic, Cleveland, OH. Electronic address: Joseph.africa@camc.org.
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Africa
mesh_terms: D005260:Female; D006085:Graft Survival; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D017568:Rectus Abdominis / Q000601:surgery*; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome