The donor is placed in a full flank position, on the opposite site with respect to the procured kidney; during the operation, the operating table should be flexed so that the hyperextension of the flank elevates the kidney for a better exposure. The lower leg is bent, and three pillows support the upper leg. After creation of the pneumoperitoneum (12–15 mm water), the camera is introduced through the umbilical port. Three ports are mandatory and are the following: a 12-mm umbilical port for the camera, a 12-mm port between the umbilicus and the anterior iliac spine homolateral to the side of the nephrectomy, and a 5-mm port 3 cm lateral to the umbilicus and 3 cm below the costal border. An additional 5-mm port may be used for retraction and placed on the anterior axillary line. First the surgeon incises the lateral peritoneal reflection from the splenic or hepatic flexure to the pelvic inlet and dissects the Gerota fascia from the colonic mesentery. The surgeon then mobilizes the spleen (for left nephrectomy) or the liver and duodenum through kocherization (for right nephrectomy). The gonadal and adrenal veins are sutured, and the upper pole of the kidney is separated from the donor adrenal gland. When preparing the hilum, the lumbar veins are ligated to fully mobilize the renal vein, and the arterial vein can then be dissected. For right nephrectomy, some authors suggest performing interaortocaval space dissection in order to ligate the renal artery at its origin from the aorta. The lower pole of the kidney can then be dissected and separated from the posterior attachments. The ureter is clipped at the level of the iliac vessels and dissected together with the periureteral fatty tissue. If the retrieval is performed through an endobag, it should be placed within the abdominal cavity and around the kidney before the vessel is sectioned. The sequential ligation of the renal artery and vein is then performed with a GI vascular stapler, which should be oriented in a plane parallel to the inferior cava vein. In right nephrectomy, the surgeon may want to use a TA stapler which only fires two staple lines, leaving the surgeon the option of cutting the vessel open at the time of retrieval and gaining extra length for the anastomoses on the recipient. Otherwise, a Satinsky clamp can be used to obtain a cuff of cava vein, which is then sutured. The kidney is finally retrieved through either the extension of one of the incisions or through a Pfannenstiel incision [8].

The donor is placed in a flank position. The incision is performed below the tip of the 12th rib, at the angle of the 12th rib and the lateral margin of the iliocostal muscle. The retroperitoneal space is reached after sectioning the thoracolumbar fascia and then expanded through a balloon device, which is then replaced by a 12-mm camera port. A 10-mm port is placed between the iliac crest and the 12th rib on the axillary line. A 5-mm port is inserted 5 cm above the anterior spine of the iliac bone. The pneumoperitoneum is created with a pressure of 5–10 mmHg. The kidney and ureter are dissected retroperitoneally; the renal artery and vein are identified from the posterior side and separated from the perivascular lymphatic and fatty tissue, after dissecting and sectioning the lumbar, gonadal, and adrenal veins. The perinephric fat and the fibrous capsule are then dissected, and the kidney is totally isolated from the adrenal gland and surrounding structures. The ureter is then sectioned at about 20 cm from the hilum. A 5-cm Pfannenstiel incision is then performed and an anterior vesical space created by finger dissection connected to the retroperitoneal space. A LapDisc is placed in the Pfannenstiel incision to maintain the pneumoretroperitoneum, through which an endobag is introduced in order to retrieve the graft. The renal artery and vein are then sectioned through a vascular staple. Finally the graft is removed through the Pfannenstiel incision. For right nephrectomy, the retroperitoneoscopic approach allows better access to the hilum and a good length of both artery and vein. This approach also allows the use of a Satinsky clamp to gain extra length for the right renal vein [9].

The hand-assisted procedure has been described both for the transperitoneal [10] and for the retroperitoneoscopic approaches [11]. The position of the patient on the operating table and the number and sites of the ports are similar to those described above for the pure retroperitoneoscopic and transperitoneal laparoscopic approach. The difference is mainly due to the site of the larger incision for the introduction of the operating hand.

For the retroperitoneoscopic technique, the surgeon performs a Pfannenstiel incision through which the preperitoneal space is created through blunt manual dissection. Using a hand-assisted device (LapDisc, HandPort, Omniport), the surgeon introduces his left hand between the abdominal wall and the peritoneum, and then all the other ports can be placed. For the transperitoneal approach, the HandPort is placed through the periumbilical incision extended for 7 cm.

The introduction of the hand facilitates the process of vascular exposure, shortens the cold ischemia time because the graft can be easily removed, and increases donor safety. In the case of sudden bleeding, the surgeon can immediately clamp the vessel with the fingers while the assistant performs the laparotomy, reducing the blood loss.

The donor is placed on the operating table in the lateral decubitus position (opposite to the side of the nephrectomy). The table is then flexed in order to open the angle between the costal margin and the anterior iliac crest. In the case of hand assistance, the incision for the HandPort is performed infraumbilically on the midline for an extension of approximately 7 cm; a Pfannenstiel incision is performed for the graft extraction in the case of pure robotic technique. The ports are then placed in the left lateral wall and inguinal region (12 mm) and in the subxiphoid lower lateral abdomen (8 mm). The da Vinci robot is brought to the operating table, and the arms are connected to the trocars; the surgeon operates from a remote console, which controls the movements of the articulated robotic arms mimicking the human hand. The surgical steps are similar to transperitoneal laparoscopic nephrectomy [12, 13].