Numerous substitutes for renal vein ligation other than the Endo GIA stapler have been described while developing laparoscopic nephrectomy. Kadirkamanathan described the placement of knots on the renal hilar vessels intracorporeally [13]. Ultrasonic scalpel and bipolar device have been tried on a porcine model successfully [14]. Nevertheless, these techniques were deemed to be unpredictable.

Janetschek et al. described a technique of extracorporeal knots to reduce its diameter prior to the application of Hem-o-lok clips and effectively used this technique for 20 nephrectomies [15]. A knot pusher was used to push the knot down around the renal vein, although this was accomplished with precision to avoid any injury to the vein. On an average, 2 min was needed for placing knots, thus preventing its application during LDN to reduce the warm ischaemia time. Lately, modifications to this technique included manual constriction of the renal vein before the application of Hem-o-lok clip [16].

Numerous variations have been proposed to easily and safely harvest the right kidney via laparoscopic approach. Gill et al. have reported right-sided donor nephrectomy via retroperitoneoscopy. An Endo GIA stapler was used for dividing the renal vessels following which bench dissection was performed to free the hilar vessels, thus gaining additional length for the vascular anastomosis [17]. Lee et al. described a laparoscopic-assisted technique where a horizontal incision of 8 cm was placed in the upper quadrant on the right side which was used to pass a Satinsky clamp over the IVC, and the same was used for vessel control, kidney extraction and repair of cavotomy [18].

A modified Satinsky atraumatic vascular clamp, intended for thoracoscopic procedures, has been used for the purpose of right-sided nephrectomies (Figs. 7.3 and 7.4). A tiny incision is placed to the right side of the anterior superior iliac spine and is used to clamp the IVC and divide the adjacent renal vein with scissors. This modified instrument is longer than the routine clamp and is inserted without trocar into the peritoneum. The IVC is sutured laparoscopically with 3-0 running PDS suture prior to the clamp removal. Also, Scandinavian surgeons sidestep difficult anastomosis due to short renal vein by dividing the internal iliac vein, thus helping them to deliver the external iliac veins to the superficial wound, thus speeding up the anastomosis [4].

Regardless of the method of vascular control employed, the major vessels should be dissected all around, prior to securing them (Fig. 7.5).