Renal Transplant Recipient

Adult

Well in advance of renal transplantation, assess the patient for the following: risk of renal disease recurrence in the kidney transplant, active infection, active malignancy, probability of perioperative mortality, compliance, and unsuitable conditions for technical success. Evaluate the transplant candidate for vascular disease and for the status of the urinary bladder or its substitute. In patients with poorly controlled hypertension, persistent urinary tract infections, significant renal stone disease, prior urinary diversion, or severe reflux, the native kidneys are often removed before transplantation. The native kidneys can be removed by bilateral posterior incisions, laparoscopic-assisted procedures, an open transperitoneal approach, or flank approaches. Indications for nephrectomy in autosomal dominant polycystic kidney disease are recurrent pyelonephritis, hemorrhage, early satiety, and indeterminate renal mass or size that will not allow renal transplantation into the pelvis. Native nephrectomy is usually performed weeks before transplantation unless the recipient is to receive a kidney from a living renal donor and there is no active renal infection.

Preparation

Just before surgery, perform a brief history and physical examination to be certain that no intervening problems have occurred that will compromise the transplant procedure and induction immunosuppression. Confirm that the donor and recipient are ABO-compatible and that the cytotoxic lymphocyte cross-match results are acceptable. If necessary, dialyze the patient for hyperkalemia or fluid overload. Prepare a “cheat sheet” for the anesthesiologist. It should contain requests and/or recommendations for the following: a prophylactic antibiotic, a 3-way central venous catheter (for blood samples, rapid infusion of intravenous fluid, and central venous pressure monitoring), immunosuppressants to be administered during the procedure, dosage and timing of intravenous heparin administration, goals for blood pressure and central venous pressure at the time of release of vascular clamps, and dosage and timing of diuretic administration.

Instruments

Provide a self-retaining retractor that attaches to the operating room table; a general laparotomy set with vascular instruments; a variety of vascular clamps; 5- and 6-mm vascular punches; heparinized saline solution; bacitracin-neomycin irrigant for the bladder and the wound; 2-0 and 4-0 silk ties; small, medium, and large hemostatic clips; 0- or 1-synthetic absorbable monofilament sutures; 3-0 synthetic absorbable sutures; 4-0 synthetic absorbable sutures; 5-0 synthetic monofilament absorbable sutures; 5-0 and 6-0 monofilament vascular sutures; 3-0 monofilament nonabsorbable sutures; umbilical tapes (to make Rummel tourniquets); a Foley catheter (20F for an adult; a smaller one based on urethral calibration for a child); a flat, soft suction drain (two if the patient is obese); a Y-connector (or a three-way Foley catheter); cystoscopy tubing; and a urine drainage bag.

Position

The patient should be supine; break the table slightly to hyperextend the abdomen and rotate it slightly toward the surgeon. Although the kidney is preferably placed in the opposite iliac fossa so that the renal pelvis is the most medial of the hilar structures, the right iliac fossa is preferred in an obese recipient, regardless of which donor kidney will be transplanted because the iliac vessels are more superficial than on the left, and the right common iliac vein lies lateral to the right common iliac artery rather than passing under its bifurcation as it does on the left. Remove hair with clippers and prepare the entire abdomen. Insert a 20 Foley 5-mL balloon catheter into the bladder and with a Y-connector (or use a 3-way Foley catheter); hook it up to a drainage bag and cystoscopy tubing ( Fig. 19.1 ). Connect the cystoscopy tubing to a liter bag that contains one ampule of bacitracin-neomycin solution. Rinse the bladder a time or two with the antibiotic solution and leave 100-mL indwelling by clamping the in-flow and out-flow tubes. Place the clamped urine drainage bag under the head of the operating room table so the anesthesiologist can fill and empty the bladder for you later in the case. This will facilitate bladder identification in a scarred pelvis and performance of an extravesical ureteroneocystostomy.

Technique

1.

Make a 20-cm straight lower quadrant (modified Gibson or Rutherford Morison) incision from the pubic notch toward the costal margin about 3 cm medial to the anterior superior iliac spine. Incise the anterior rectus sheath and external oblique in the directions of its fibers. Preserve the rectus abdominis muscle.
2.

Divide the inferior epigastric vessels between 2-0 silk ligatures ( Fig. 19.2 ). Leave the inferior epigastric artery long if it might be necessary to anastomose it to a lower-pole segmental renal artery. Divide the thin inner layer of the transversalis fascia and enter the extraperitoneal space between the partially filled bladder and the external iliac vessels. Sweep the peritoneum medially from the iliac vessels and posteriorly from the transversalis fascia and transversus abdominis muscle. Incise the internal oblique muscle, transversalis fascia, and transversus abdominis muscle in the line of the fibers of the external oblique.

FIGURE 19.2

Division of inferior epigastric vessels.

In the female, ligate and divide the round ligament. In the male, identify the spermatic cord and free it to its entry into the inguinal canal so that it can be retracted medially. Division of spermatic vessels or vas deferens is rarely necessary. Develop the extraperitoneal space over the iliac fossa to expose the distal common, external and internal iliac arteries and the external and common iliac veins. The end point for the medial dissection is the ipsilateral sacral promontory. The ureter and gonadal vessels will be swept medially with the peritoneum.
3.

Insert a self-retaining Bookwalter or similar retractor ( Fig. 19.3 ). A ring retractor with fixation to the operating table via a post permits many different exposures using a variety of fixed and adjustable blades. Be certain that a retractor blade does not compress the psoas muscle and the underlying femoral nerve.

FIGURE 19.3

Insertion of retractor.
4.

Palpate the iliac arteries and select a preliminary target for the arterial anastomosis ( Fig. 19.4 ). Arteriosclosis of the internal iliac artery usually begins in the posterior common iliac artery. Start the dissection over the external iliac artery, elevate the tissue anteriorly with right-angle forceps, and divide overlying lymphatics between 2-0 silk ligatures. Ties are better than clips to prevent lymphoceles because clips may be dislodged with the suction device. Continue up onto the common iliac artery for a few centimeters. The genitofemoral nerve lies lateral to the external iliac artery and may cross it distally. Do not mistake it for a lymphatic. Now dissect the internal iliac artery if that is to be used for the renal artery anastomosis.

FIGURE 19.4

( A , B ) Palpate the iliac arteries and select a preliminary target for the arterial anastomosis.
5.

Dissect the external iliac vein and consider dissection of the common iliac vein ( Fig. 19.5 ). Ligate and divide the overlying lymphatics. Look for venous tributaries posteriorly. When they are found, doubly ligate and divide them. This can be facilitated by encirclement of the vein with a 0-silk tie, tagging the tie with a medium clamp and hanging the clamp over the side of the ring retractor; this retracts the vein anteriorly and pulls it out of the pelvis and extends it for ligation. Avoid double clamping, this may avulse these delicate vessels. The iliac vein anastomosis site can be isolated with Rummel tourniquets or a large Satinsky clamp or with a bent-handled DeBakey curved aortic clamp on the vein proximally and an angled DeBakey clamp distally. Place the prepared, cold kidney graft into the wound, check for the best fit, make a final selection of the sites for the renal artery and venous anastomoses, and decide which anastomosis will be done first. Many surgeons prefer to do the arterial anastomosis first because it is the smaller of the two vascular anastomoses and the kidney can be moved about to better expose the arterial suture line than when the venous anastomosis has been completed first.

FIGURE 19.5

Dissect the external iliac vein and consider dissection of the common iliac vein.

End-to-Side Anastomosis to External Iliac Vein

6.

Before the first vascular anastomosis, administer heparin to the recipient and start a mannitol infusion. Incise the external iliac vein longitudinally and irrigate the lumen with heparinized saline.
- a.
  
  Place four 5-0 double-needle cardiovascular sutures, one at each end and one at each side of the venotomy (quadrant technique) ( Fig. 19.6A ).
  
  FIGURE 19.6
  
  ( A – C ) End-to-side anastomosis to external iliac vein.
- b.
  
  Pass the four sutures from the iliac vein through the wall of the renal vein in the appropriate quadrants, and tie the ones at the ends ( Fig. 19.6B ). Leave the lateral and medial stay sutures untied. Pull on the shod-clamped medial and lateral stay sutures and drape them over the ring retractor to separate the suture lines.
- c.
  
  Run the sutures up or down the lateral and medial sides and tie them. Pull on the stay sutures to be certain that the medial and lateral walls of the vein have not been sewn to one another ( Fig. 19.6C ). Tie or remove the stay sutures.

End-to-End Anastomosis to Internal Iliac Artery

7.

If the renal vein anastomosis was completed first, place a bull-dog clamp on the renal vein, and remove the vascular clamps or tourniquets from the iliac vein. Place vascular clamps on the external iliac and common iliac arteries to avoid vascular clamp injury to the internal iliac artery. Spatulate the internal iliac and renal arteries or bevel-cut them.
- a.
  
  Bring the renal and internal iliac arteries together in a gentle curve ( Fig. 19.7A ). Place 5-0 or 6-0 vascular sutures in the opposite ends of both vessels and leave them untied. Place stay sutures at the midway points of the proposed suture lines.
  
  FIGURE 19.7
  
  ( A – C ) End-to-end anastomosis to internal iliac artery.
- b.
  
  Run the first suture line or use interrupted sutures if the anastomosis is small ( Fig. 19.7B ).
- c.
  
  Change sides of the table or have the assistant do the other suture line ( Fig. 19.7C ). Tie the sutures.

Alternative: End-to-Side Arterial Anastomosis

8.

If the internal iliac artery is unsuitable because it is too short, arteriosclerotic, or the opposite internal iliac artery was used in a prior kidney transplant in a man, do an end-to-side anastomosis to the external or common iliac artery. Pick an anastomosis site that will result in a smooth, unkinked renal artery after revascularization.
- a.
  
  Occlude the iliac arteries with vascular clamps; try to avoid atheromatous plaques. Make a longitudinal incision in the anterior surface of the artery with a no. 11 knife blade ( Fig. 19.8A ).
  
  FIGURE 19.8
  
  ( A , B ) End-to-side anastomosis to the external or common iliac artery.
- b.
  
  Enlarge it with a vascular punch that will match the diameter of the renal artery (usually 5 or 6 mm) ( Fig. 19.8B ). Irrigate the lumen with heparinized saline.
9.

Insert a superior and an inferior suture of 5-0 or 6-0 cardiovascular suture through the iliac and renal arteries and leave them untied ( Fig. 19.9A ). Place quadrant sutures. Run the suture lines as you did for the venous anastomosis ( Fig. 19.9B ). Administer furosemide to the recipient as the second suture line is being completed.

FIGURE 19.9

( A , B ) Suturing of iliac and renal arteries.

Check the blood pressure; make sure the systolic BP is >90 mm Hg. If not, ask the anesthesiologist to make it so with IV fluid or a renal-friendly vasopressor such as dopamine or dobutamine. Release the cephalad venous clamp or tourniquet first, followed by the distal arterial clamp, proximal arterial clamp, and finally, the distal venous clamp or tourniquet. Check for hemostasis and a pulse in the iliac artery distal to the anastomosis. If renal perfusion is slow, replace the vascular clamp on the distal external iliac artery for a few minutes until the kidney pinks up. If the microcirculation appears to be in spasm, consider injection of a calcium channel blocker into the external or common iliac artery upstream from the renal artery anastomosis while a vascular clamp remains on the distal external iliac artery.