Pfannenstiel incision is the most widely accepted site of extraction. The incision is widely used in obstetric and gynaecological procedures. The advantages include that the incision is non-muscle cutting and theoretically has less pain. This has potential to reduce wound complications and has superior cosmesis. It may not be safe to extract the kidney through this incision without a hand-assist device, as there is a possibility of misplacing the kidney inside the abdomen with intervening organs like bowel coming in way. In order to avoid this, the surgeon on opening the peritoneum should insert his hand and feel for the grasper holding the kidney. In this way the chance of losing the kidney is minimised. Alternatively, a hand-assist device like Gelport may be used which in turn mandates a slightly larger incision. Comparative studies have proven that Pfannenstiel incision has superior outcome compared to other incisions [7–10].

Midline periumbilical incision is cosmetic; as most of the incision is concealed under the umbilicus, the incision is typically used in single-port approach. Alternatively, an incision skirting the umbilical skin crease can be taken. The incision offers a more direct approach to the renal fossa. The downside however includes challenges involved in graft retrieval. In case of life-threatening bleeding from the renal fossa after extraction, this incision could be converted to a hand-port access. Incidence of wound infection and wound breakdown is more likely because of the tenuous blood supply in the periumbilical area. In obese patients, thick subcutaneous fat and sagging abdomen while in lateral position make it more challenging [7].

This is the incision of choice when employing the single-port approach (Fig. 11.3). The incision is placed at the outset. The single-port device is inserted through the same incision. The graft can be retrieved through the same incision. This step can be made easier by using a Gelpoint™ device.

The kidney can be easily extracted through the incision as there are no intervening structures like the colon. This is the preferred method of extraction in retroperitoneoscopic donor nephrectomy. The muscle-cutting incision is expected to be more painful and prone to wound complications as shown in some studies [7, 8]. This is the incision of choice in obese individuals.

This incision has a direct access to the renal hilum and hence offers a theoretical possibility of fast graft retrieval.

The alternative methods for extraction is using custom made Endobag bag (Ethicon endosurgery, OH, USA), Gelport device (Applied Medical, Rancho Santa Margarita, CA, USA) and manual extraction without any hand assit devices [11]. The retrieval bags offer the advantage of smaller incisions and a possibility of controlled extraction. The drawback of this technique is that the retrieval bags are expensive and cost 500$. With this technique, pneumoperitoneum is not maintained after extraction, and any emergent situation cannot be tackled until the abdomen is closed.

Recently few studies have demonstrated the advantage of transvaginal extraction in female donors [12–14]. During a transvaginal extraction, a vaginal swab culture is taken 2 weeks before surgery. The donors are advised to use vaginal pessaries 3 days prior to surgery. The donor nephrectomy is performed with routine steps. The studies have shown that with transvaginal extraction cosmetic outcome and pain score are superior to other methods of extraction [12–14]. Drawback of transvaginal extraction includes alteration in position of the patient and can be performed only in patients with capacious vagina. The authors in one of the series used a modified extractor which helped in maintaining the pneumoperitoneum just prior to extraction. The authors placed the extractor in the posterior fornix; this facilitated the extraction. The authors state that this helped in reducing the warm ischaemia time [14]. Theoretical concern of infection has been the deterring factor in embarking on such a procedure. But till now any of these studies have not demonstrated increased rate infection. [13, 15]. Canes and associates note that this approach was particularly difficult in obese patients. The reasons cited were inability to obtain adequate exposure, poor manoeuvrability of instruments and inability to retract the colon. In addition, difficulty was encountered in placing the patient in modified position. Patients with large fibroids pose challenge as the access through the posterior fornix is precluded.