Laparoscopic Right Donor Nephrectomy (Transperitoneal Approach)

Fig. 6.1

Showing patient positioning

Patients should have an indwelling catheter (IDC) and DVT prophylaxis measures such as pneumatic calf compression device and subcutaneous heparin. Prior to positioning, the site for the Pfannenstiel incision (2–3 cm above pubic symphysis, 5–6 cm length) is marked as this will change once the patient is placed in flank position. This is particularly important in more obese donors. The IDC bag should be placed at the head end of the bed for urine output monitoring by the anesthetist during the case.

Patients are positioned in a 45–60-degree left lateral position with the right side up; a 1 L saline bag is positioned under the axilla to avoid brachial plexus neuropraxia. We do not use the kidney rest routinely. The patient is placed at the edge of the bed and secured with tapes to the bed at the level of iliac crest and mid-thorax. We utilize the 3 in. Leukoplast (BSN medical) as it provides firm grip and does not stretch. Surgeons should ensure that the patient is secure, in case bed rotation is required during the case. Care is taken to protect the nipples as well as the penis from the adhesive tapes. Once the patient is secured to the bed, the arms are placed in their final position. The left arm is extended and rested on an armrest in neutral position, and the right arm is flexed and positioned on an armrest with elbows at same level with angle of the mandible. This positioning of the right arm allows the surgeon’s right arm not to clash with the patient’s right elbow during the procedure which in turn allows for improved access during dissection of the lower pole and the distal ureter. Skin preparation should be extended to include the site for the Pfannenstiel incision as well as the flank should the need for conversion to open surgery arise. We place the camera cord, light source, as well as the insufflation tube cranially and all other tubes and cords caudally. We place two long quivers on the lateral edge of the drape for secure placements of laparoscopic instruments during the case.

6.2.3 The Armamentarium (Fig. 6.2)

1.

Ports:

(a) 2 × 5 mm ports

(b) 3 × 12 mm port

(c) 1 × 15 mm port
2.

10 mm 30-degree telescope
3.

Graspers:

(a) 1× small bowel grasper

(b) 1× bullet nose forceps

(c) 1× short fenestrated forceps

(d) 1× right-angled forceps

(e) 1× laparoscopic Satinsky clamp

(f) 1× laparoscopic 10 mm fan retractor
4.

Energy devices

(a) Dissecting laparoscopic scissors

(b) Monopolar hook diathermy
5.

Hemostasis devices:

(a) Hem-o-lok® (Teleflex Medical, NC, USA) applicator and clips

(b) Titanium clip applicator and clips

(c) Vascular endoscopic stapling device (Endo TA 30 mm)
6.

Open surgical tray

Fig. 6.2

Showing laparoscopic instrumentation required

6.2.4 Port Placements (Fig. 6.3)

The main objective of port placements is optimum vision of the renal hilum. The camera port is a 12 mm port positioned at the lateral edge of the rectus muscle, 2 cm caudal to the transpyloric plane. This should translate intra-abdominally to just below the level of the renal hilum. Surgeons must always correlate this port position with the CT scan and individualize the position accordingly. We utilize the Veress needle technique which has been described in the previous chapter. The next stage is performing a diagnostic laparoscopy and inspection of the abdomen for any injury related to the entry technique as well as the presence of any abdominal pathology. The camera port is the reference port, and the remaining ports position may vary depending on the patient’s body habitus. All ports should be at least 4–5 cm away from each other to avoid instrument clashing. The lower working port (12 mm) is placed between the umbilicus and iliac crest about 2 cm lateral to the midaxillary line. The slight lateral positioning of this port facilitates better retraction of the kidney as well as posterior dissection of the renal hilum. The upper working port (5 mm) is placed along the midaxillary line about 2 cm below the costal margin. A third 5 mm port is placed 4 cm below the xiphisternum and is used to aid in superior retraction of the liver. Occasionally, an additional 5 mm port could be placed which will aid in renal retraction and exposure of the renal hilum so that the surgeon may utilize both arms in performing the dissection. In our experience, the position of this port is optimal at 4 cm lateral to midpoint of the working ports (Image 2). Prior to start of the case, the height of the bed is adjusted to ensure the surgeon’s shoulders are relaxed. This will aid in prevention of fatigue and optimal surgical ergonomics.

Fig. 6.3

Showing port positioning

6.2.5 Exposure (Figs. 6.4 and 6.5)

The first step of the dissection is to provide adequate exposure. Through the xiphisternal port, a ratcheted grasper is deployed underneath the right and left liver lobes as well as the gallbladder to grasp the lateral diaphragmatic muscles for cephalad retraction of the liver for better access and visualization for the upper pole of the kidney. During this step utmost care should be taken to avoid injury of the liver, perforations of the gallbladder, as well as grasping of the intercostal nerves. Occasionally adhesions of the omentum to the gallbladder could be encountered. These adhesions should be divided for optimal view; once again surgeons should be careful of injury to the gallbladder including thermal injury through heat conduction. The right triangular ligaments of the liver should also be divided to allow a better cephalad retraction and slight clockwise rotation of the right liver. Other omental adhesions to the abdominal wall should also be dissected prior to mobilization of the right colon. It is not unusual to encounter adhesions in right lower quadrant, most commonly due to previous appendectomy.

Fig. 6.4

Shows the laparoscopic view of the liver being retracted by Allis forceps

Fig. 6.5

Laparoscopic view on the right side

6.2.6 Medialization of the Colon and Duodenum (Figs. 6.6 and 6.7)

The right colon is medialized by incising the lateral peritoneal reflection of Toldt. Keeping the lateral attachments of the kidney intact is a key step which results in suspension of the kidney. This in turn aids in hilar dissection at later stage. It is paramount to identify the avascular plane between the colonic mesentery and the Gerota’s fascia. The two could be distinguished from one another by the color and contour of the fat. Colon mobilization should extend to the level of the iliac vessels so that the colon passively reflects downward and out of the way from the renal hilar field. Surgeons should now take a moment to identify and distinguish the IVC from the duodenum. The duodenum is now Kocherized in order to expose the IVC as well as the renal hilum. In this step, it is best to lift the fibers just lateral to the edge of the duodenum up and away from IVC and preferably perform sharp dissection. Thermal dissection is minimized, and the surgeons should avoid excessive manipulation and handling of the duodenum. Furthermore, duodenum should always be dissected prior to dissection of the IVC.