Open Donor Nephrectomy in the Era of Laparoscopic Donor Nephrectomy

Fig. 13.1

Figure shows the operative instrument trolley

13.2.2 Patient Positioning [3] (Figs. 13.2 and 13.3)

1.

Lateral decubitus: operative side up.
2.

Flank placed over the kidney bridge.
3.

Ipsilateral leg extended and contralateral leg flexed, with a pillow between the two legs.
4.

Patient on the ipsilateral edge of the table.
5.

Kidney bridge raised.
6.

Table flexed.
7.

Head end lowered.
8.

Patient supported medially with sand bags.
9.

Head supported with a ring pillow.
10.

Ipsilateral arm rested on a mayo stand and contralateral arm rested on an arm rest.
11.

Patient strapped at the level of nipples and anterior superior iliac spine.
12.

All pressure points are padded.

Figs. 13.2 and 13.3

Shows patient positioning

Anti-embolism stockings should be used in all cases.

13.2.2.1 Surgical Steps

Principles

1.

Good exposure
2.

Gentle handling of tissue to prevent arterial spasm
3.

Preserving the golden triangle of fat
4.

Maintaining renal turgidity and diuresis throughout the procedure

Incision [3]

Incision is planned as per the location of hilum on CT angiography. It can be an 11th or 12th rib cutting incision. Incision starts over the rib on the posterior axillary line extending along the rib and then downward and medially in the direction of the umbilicus. The length of the incision will vary according to the habitus of the patient; it can be anywhere between 15 and 20 cm [3].

Skin, subcutaneous layer and the first muscle layer are incised (Figs. 13.4, 13.5 and 13.6). The rib is then encountered, and its periosteum is incised and elevated using a periosteal elevator and then the periosteum is stripped of the rib. After this, the rib is cut using a rib cutter (Fig. 13.7). At the tip of the 11th/12th rib, the retroperitoneum is entered and peritoneum is swept medially. Muscles cut from superficial to deep are serratus posterior superior (posteriorly) and latissimus dorsi followed by external and internal oblique; transversus abdominis is encountered medially (Figs. 13.5 and 13.6, and 13.7).

Fig. 13.4

Figure showing surface marking

Figs. 13.5 and 13.6

Figure shows layers of abdominal wall cut during the open surgical donor nephrectomy

Fig. 13.7

Figure showing 11th rib being cut

At this point transversalis fascia is opened, peritoneum swept medially, pleura cranially, and Gerota’s fascia identified. Gerota’s fascia is opened between two Babcock clamps and perirenal space entered; perirenal fat is separated from the renal capsule, and the kidney is exposed laterally from the upper pole to the lower pole; dissection is continued medially taking care not to enter the hilar fat (Fig. 13.8). Now a self-retaining retractor can be placed; it is our practice to use a Finochietto self-retaining chest spreader with two Deaver’s retractors to retract the peritoneum and to expose the upper pole. A Balfour’s retractor can replace the chest spreader. A single Omni-Tract retractor can accomplish this job [3].

Fig. 13.8

Figure shows intragerotal dissection done to expose the kidney

The proceeding after this step is side specific:

13.2.2.2 On the Left Side

The renal vein is identified anteriorly, it appears as a blue hue under perirenal fat, and in obese individuals, the gonadal vein can be identified and traced to the renal vein (Fig. 13.9). Once the gonadal vein is identified, uretero-gonadal packet is lifted en masse and slinged (Fig. 13.9). The adrenal vein is dissected by exposing the upper border of the renal vein; it is then ligated and cut (Figs. 13.10 and 13.11). The renal vein is now dissected circumferentially and toward the aorta till the aorta is clearly visible; in doing so, one may encounter the lumbar veins, which are ligated and cut. The upper pole is now separated from the adrenal gland. The kidney is dissected posteriorly and renal artery pulsations are identified. The renal artery is dissected gently, and the small adrenal artery may be encountered, which is to be ligated. The artery is dissected till its origin from the aorta.

Fig. 13.9

Figure showing uretero-gonadal packet being lifted and the renal vein dissected

Fig. 13.10

Figure showing completed dissection of the renal vein and ligation of the adrenal vein

Fig. 13.11

Showing completed dissection of the renal vein with ligation of the adrenal and gonadal vein

Preserving the golden triangle of fat between the lower pole ureter and gonadal vein completes dissection of the uretero-gonadal packet (Fig. 13.9). The ureter is disconnected at a point where it crosses iliac vessels [3].

13.2.2.3 On the Right Side (Fig. 13.12)

The renal vein is identified and its junction with IVC (Inferior Vena Cava) exposed; IVC is dissected free of tissue for some distance so that Satinsky clamp can be applied on the vena cava. The gonadal vein can be spared on the right side, or it has to be ligated and cut separately. Once the renal vein is dissected, the renal artery is identified and dissected posteriorly and till a retrocaval location.

Fig. 13.12

Diagrammatic representation of the right kidney and hilum

Retrieval

Before retrieval one should ensure:

1.

Brisk diuresis.
2.

The kidney is turgid and pink
3.

Furosemide and mannitol are given.

If the above is not satisfactory, one should check blood pressure, check hydration status, give mannitol, instill papaverine, not handle the kidney, and wait for 15 min or till the kidney becomes firm and has diuresis. Aminophylline drip can be used in cases with severe spasm.

Surgeon should check with assistants and staff that all the things are in place and clamps, ties, and sutures are ready. Some centers give heparin (70 u/kg) on clamping the artery. The artery followed by the vein is clamped, doubly ligated, and then cut (Fig. 13.13). On the right side after cutting the artery, two Satinsky clamps are placed one above the other, the vein is cut above the second clamp, and the stump is then sutured with 5-0 Prolene (Ethicon, Somerville, New Jersey) in two layers.

Fig. 13.13

Diagrammatic representation of the left kidney and hilum

The kidney is now flushed with 1 l chilled Ringer’s lactate to which heparin (5,000 iu) and hydrocortisone (100 mg) are added. In cases with multiple vessels, largest vessel is to be ligated at the last.

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Tags: Laparoscopic Donor Nephrectomy

Oct 2, 2017 | Posted by admin in UROLOGY | Comments Off

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Open Donor Nephrectomy in the Era of Laparoscopic Donor Nephrectomy