A Gibson or Rutherford Morison incision from pubic notch toward the costal margin where it intersects the anterior axillary line is common. The anterior rectus sheath is incised, and the underlying rectus muscle is preserved; it will be retracted medially. The quality of the deep fascia and muscles can be judged during the incision, and a decision made about the type of suture material and whether an interrupted or running closure of the deep wound will be done.

After the inferior epigastric vessels are divided between ligatures, an index finger can be used to develop the plane between the partially filled bladder and the iliac vessels. If the kidney transplant has a separate lower pole artery, the inferior epigastric artery is left long in case it is needed to revascularize the inferior renal segment (Fig. 13.2).

Rotating the finger upward between the transversalis fascia and the spermatic cord or round ligament will allow the development of the extraperitoneal space. The peritoneal edge is commonly adherent to the lateral edge of the posterior rectus sheath. In a woman, the round ligament is divided between ligatures; in a man, the spermatic cord is preserved and retracted medially. The iliac fossa is developed. Insertion of the first two fingers will identify a “ligament” that attempts to hold the peritoneum in the iliac fossa. Cut this and develop the space. Be careful not to damage the genitofemoral or ilioinguinal nerves. The ureter will naturally cling to the peritoneum. Continue to develop the extraperitoneal space until the index finger of the dissecting hand rests on the sacral promontory just above and medial to the bifurcation of the common iliac artery. Attach the post of the self-retaining retractor to the table, attach the retractor ring, and place the first of the padded retractor blades just medial to the sacral promontory. Place the rest of the retractor blades; it usually takes a total of five. Make certain that a retractor blade does not rest on the psoas muscle and compress the femoral nerve. If the bladder is full, have the anesthetist unclamp the drainage tube to give more space. Palpate the iliac arteries to determine where and what type of vascular clamps can be safely applied and the probable site of the renal artery anastomosis. Iliac arteriosclerosis commonly starts posteriorly at the takeoff of the internal iliac artery.

Dissect the iliac arteries (Fig. 13.3). Watch out for the genitofemoral nerve, which sometimes crosses the external iliac artery, is mistaken for a lymphatic, and divided between ligatures. Lymphatics are best ligated and divided. Clips are sometimes dislodged with the suction device later in the case. If the internal iliac artery has been selected for revascularization of the kidney, dissect it and the common iliac artery so that vascular clamps will be placed on the common and external iliac arteries and not the base of the internal iliac artery. This is to prevent vascular clamp injury to the internal iliac artery. Dissect the external and common iliac arteries. Division of the gluteal and internal iliac veins will allow the external iliac vein to be retracted anteriorly with Rummel tourniquets. This will permit the lateral venous suture line to be easily done from outside the vessels because when the iliac vein is deep and immobile, the lateral side of the anastomosis sometimes has to be done from inside the lumen, and this may leave a ridge and contribute to renal vein thrombosis.

If the kidney graft has not been prepared at the back table, do it now. If the kidney is from a living donor, it will be without an aortic patch, and the renal artery is commonly spatulated. If there are multiple renal arteries, and they are close together, they are usually joined together to make a common lumen (Fig. 13.4). A deceased donor kidney usually has its renal artery or arteries on an aortic patch, and the patch is used for the arterial anastomosis. If there are two separate veins of equal size in a living donor kidney, they are often joined, pair-of-pants fashion, to make a common lumen. If one is smaller than the other, it can be safely ligated. The right deceased donor kidney usually has the inferior vena cava (IVC) attached to it. It can be reconfigured in several different ways to extend the length of the short right renal vein (Fig. 13.5).

Place the kidney into the wound to determine the best fit and to select the sites of the arterial and venous anastomoses (Fig. 13.6). Remove the kidney and replace it in the cold slush-filled pan.

Check with the anesthetist and determine the status of the administration of the immunosuppressants. Ask for the heparin to be administered. A minute later, apply the arterial clamps. If there is a plaque in a vertical or lateral plane, use a vascular clamp with jaws that correspond to that plane. This is to reduce the risk of a plaque fracture and dissection. It seems preferable to do the arterial anastomosis first because it is the smaller of the two vascular anastomoses and the kidney is relatively mobile while it is being done. (If the venous anastomosis is done first, the kidney becomes fixed in position, the lateral half of the arterial anastomosis sometimes has to be done from inside the vessels, and a ridge from the arterial suture line ridge is more likely to result.) If the common iliac artery is the target, vascular clamps are placed in the common, external and internal iliac arteries, especially if the common iliac artery is relatively short. If the external iliac artery is the site, the clamps can be placed wherever it results in enough room to do the anastomosis. When the kidney is without an aortic patch, and there is to be an end-to-side anastomosis, make a 5- to 6-mm incision in the target artery with a no. 11 blade and enlarge the arteriotomy with a 5- or 6-mm punch; punch size will depend on the diameter of the donor artery. An aortic patch is common when the kidney is from a deceased donor. In such a case, it is not necessary to use a vascular punch in the recipient artery because the renal artery ostium in the donor aortic patch will hold the incised recipient artery open in the event
of hypotension. If the internal iliac artery is to be used, place the vascular clamps in the external and common iliac arteries, ligate the internal iliac artery distally, divide it, spatulate it in its anterior surface, and flush it with heparinized saline. If there is a plaque, do an endarterectomy, release the common iliac vascular clamp to flush the lumen, reapply the clamp, and reflush the internal iliac artery with heparinized saline.