Preoperative Preparation and Planning
Renal transplantation is currently the best long-term treatment option for patients with end-stage renal disease. Laparoscopic live donor nephrectomy is considerably more appealing to potential donors than the traditional open approach in that it provides decreased postoperative pain, improved cosmesis, and a shorter convalescent period. Furthermore, laparoscopic kidney procurement has been shown to have equivalent graft function compared with open excision. As such, laparoscopic live donor nephrectomy had gained popularity and is the standard for renal transplantation at many high-volume medical centers. Furthermore, the traditional laparoscopic technique has been further advanced with the introduction of laparoendoscopic single-site (LESS) surgery and robot-assisted laparoscopy, which have both been described, and have been shown to be viable surgical techniques for live donor nephrectomy.
Clinical history and physical examination are important when evaluating prospective kidney donors. Multiplicity of renal vessels, or anomalous renal vasculature, are not contraindications. The surgeon must thoughtfully assess each individual’s vascular anatomy to determine whether successful ex vivo reconstruction is feasible. Dual-phase helical computed tomography angiography with three-dimensional reconstruction is extremely useful for radiographic imaging of renal anatomy and vasculature. Renal function measurements may be determined by nuclear renal imaging studies.
Informed consent with explanation of all pertinent risks is obtained prior to the procedure. Patients are instructed to maintain a clear liquid diet for 12–24 hours before surgery and to administer a bowel preparation consisting of 300 mL of magnesium citrate on the prior day. Sequential compression devices are placed on the lower extremities. A single dose of prophylactic intravenous antibiotics is administered 60 minutes before surgical incision. Patients are aggressively hydrated on induction of general anesthesia and throughout the operative procedure to maintain adequate diuresis.
Operating Room Preparation and Instrumentation
Operating room preparation, as well as necessary instrumentation required, is similar to that required for laparoscopic radical nephrectomy.
Patient Positioning, Surgical Incision, and Operative Technique
Conventional Laparoscopic Donor Nephrectomy
Left Laparoscopic Donor Nephrectomy
Patient: Before positioning the patient, a marking pen is used to mark a 5–7 cm Pfannenstiel incision approximately 2–3 fingerbreadths above the pubic symphysis. This incision will be used as the eventual extraction site of the kidney, and the site should be marked before rotating the patient to ensure symmetry. The patient is placed in a modified right lateral decubitus position (45–60 degrees) with the flank situated over the kidney rest. The table may be flexed to increase the area between the iliac crest and costal margin as necessary. A bean bag or large gel rolls are used to support the patient in this position. Pillows or foam cushions are placed between the legs, and the right leg is flexed at the knee whereas the left leg is placed straight. The arms are placed parallel onto well-padded arm boards. The ankles, knees, dependent hip, shoulders, and brachial plexus are adequately padded. After verifying that all areas prone to pressure injury are well padded, the patient is secured to the operating table using 3″ cloth tape across the left shoulder and arm as well as across the hip. Fig. 23.1 demonstrates proper patient positioning for left-sided laparoscopic donor nephrectomy.
Trocar: The peritoneal cavity is insufflated to 15 mm Hg using a Veress needle or Hassan technique. Fig. 23.2 illustrates the trocar placement for conventional laparoscopic donor nephrectomy (left and right), robot-assisted laparoscopic donor nephrectomy (left and right), and hand-assisted laparoscopic donor nephrectomy (left and right). A 5- or 10-mm trocar is inserted under direct vision at the umbilicus. The primary camera trocar (5 or 10 mm) is placed slightly left of midline, approximately 2 cm below the xiphoid process. The primary working trocar (12 mm) is placed along the midclavicular line, 2 cm below the level of the umbilicus. An accessory trocar (5 mm) may be placed along the anterior axillary line approximately 2 cm below the costal margin. A 0- or 30-degree laparoscope is used throughout the procedure.
The descending colon is mobilized along the white line of Toldt using ultrasonic shears or an alternate monopolar or bipolar thermal energy device. The superficial peritoneal attachments between the colon and lateral sidewall should be released initially. Lateral renal attachments to the sidewall should not be released at this point, as this maneuver would result in medial mobilization of the kidney and interfere with hilar dissection. The colon is further dissected medially using a blunt dissector or suction-irrigator device, exposing the proper plane between the colonic mesentery and Gerota fascia, shown in Fig. 23.3 . Recognition of this plane is important, in that inadvertent entry into the mesentery can lead to bleeding as well as mesenteric defects with potential for internal herniation. Premature entry into Gerota fascia can create bleeding and limit visualization of the renal hilum. The dissection is carried cephalad toward the upper pole of the kidney. Extensive splenic mobilization is required to provide adequate exposure of the upper pole of the kidney. Fig. 23.4 shows the division of the splenorenal ligaments using ultrasonic shears.
The psoas muscle is exposed below the lower pole of the kidney. This muscle functions as an important landmark for locating the ureter. The ureter and gonadal vein are identified along the medial border of the psoas muscle. Care should be taken to avoid entering the psoas muscle fascia, which may lead to unnecessary bleeding or damage to the genitofemoral nerve. The ureter is dissected to the level of the iliac artery bifurcation. Meticulous care is taken to avoid ureteral devascularization. Following distal ureteral transection, the remaining blood supply to the ureter arises proximally from the renal artery, and therefore excessive dissection of the periureteral tissue is avoided. The ureter is not divided at this time. By gently elevating the ureter and lower pole of the kidney with an instrument, the medial border of the kidney is dissected in a cephalad direction to the level of the renal hilum. The correct plane of dissection lies medial to the gonadal vein. Fig. 23.5 shows the ureter and lower pole being elevated, allowing the gonadal vein to be traced toward the renal hilum. Fig. 23.6 shows the initial exposure of the renal vein, adrenal vein, gonadal vein, and lumbar branch after the colon has been fully mobilized medially.
Alternative: When both lateral traction of the kidney and medial traction of spleen are needed, placement of an accessory trocar (as discussed) may be beneficial.
Dissection of renal vein branches
The gonadal vein is dissected at its insertion into the renal vein using a Maryland dissector or right angle dissector. The gonadal vein can be ligated and divided with titanium or polymer clips, as seen in Fig. 23.7 . Alternatively, the vein can be divided with a bipolar vessel sealing device. The stump of the gonadal vein may serve as a handle for superior traction of the renal vein to help identify the lumbar vein and renal artery posteriorly. An alternative technique is to divide the gonadal vein at the level of the iliac artery bifurcation.
The adrenal vein is dissected at its insertion into the renal vein. The adrenal vein is ligated and divided with clips or a bipolar vessel sealing device, as shown in Fig. 23.8 . An advantage of the vessel sealing device is that it eliminates the presence of clips that may interfere with stapling devices. The lumbar vein, when present, enters the renal vein posteriorly, as seen in Fig. 23.9 . This vein must be ligated and divided in order to identify the renal artery, which lies immediately posterior to the lumbar vein.
Dissection of renal vein and artery
The renal vein is dissected from all surrounding perivascular tissues to a point medial to the adrenal vein stump. This maneuver provides maximal venous length for the vascular anastomosis.
The renal artery is identified posterior to the renal vein and is dissected from the surrounding tissues using a Maryland dissector, right angle clamp, and suction-irrigator device.
The Gerota fascia is entered along the anterior aspect of the upper pole, exposing the renal capsule, as shown in Fig. 23.10 . With gentle displacement of the adrenal gland medially, meticulous dissection between the adrenal gland and the upper pole of the kidney is carried out. The use of clips, ultrasonic shears, or a bipolar vessel sealing device is beneficial in this area because of the highly vascular nature of the adrenal gland. If bleeding is encountered in this area, the application of gentle pressure is usually effective in obtaining hemostasis. In addition, renal artery branches to the upper pole of the kidney are not uncommonly encountered during this portion of the dissection, and one should be careful about inadvertent vascular injury.