Steps for left RLDN. Differences for right-sided procedure are described subsequently.

Position: The patient is catheterised and placed in a standard flank position on the edge of the operating table. The flank muscles are placed on stretch by breaking the table or using a bridge (Fig. 8.2). Secure fixation is achieved by using adhesive tape or broad straps. The patient is draped to include the tenth rib and the ipsilateral groin in the operative field.

Port placement: Port placement (Fig. 8.3).

The landmarks are as follows:

Port sites:

STEPS: Open access to the retroperitoneum is carried out by placing a 1.5 cm incision. The lumbodorsal fascia is similarly incised, allowing the paranephric fat to be seen. Craniocaudal movement to the paranephric fat with respiration aids in its identification. A peanut is used to sweep the Gerota’s fascia and its contents anteriorly off the psoas muscle, to create space for a balloon. The balloon is inserted in the retroperitoneum and inflated with saline to create the retroperitoneal space. About 500 ml of saline is used. A palpable lump confirms the extraperitoneal situation of the balloon. The balloon is then deflated and removed and must be visually inspected to ensure intactness (Fig. 8.4).

Fixation sutures of no.1 silk are taken, preferable incorporating some of the muscular fascia. However this might be difficult in an obese donor and may be omitted. The port is inserted and insufflation with C02 started. The 10 mm laparoscope is then inserted into the retroperitoneum and intactness of peritoneum confirmed. The scope is withdrawn 1 cm into the port and the port withdrawn until the fascial edges are visualised and then slightly advanced until the edges are no longer seen. This ensures that the inner end of the port is at the edge of the operative field and maximises the visual field. The port is then fixed by securely tying the fixing sutures around it. This step is unnecessary if using self-retaining ports. The laparoscope is inserted and rotated to the 30 ° up position to view the abdominal wall anterior to it. The reflected edge of the peritoneum should be looked for, and digital pressure on the site of the second port should confirm that the site of entry is posterior to the peritoneal reflection (Fig. 8.5); a 5 mm port is inserted and fixed securely. The vision is now directed posteriorly and inferiorly and the site confirmed by digitally indenting the skin over the renal angle. Overlying adherent paranephric fat or Gerota’s fascia may be swept away using blunt or sharp dissection with an instrument inserted through the second port. A 10 mm port is inserted. The insufflation tube is shifted to this port and pneumoperitoneum maintained at 12–15 mmHg.

Landmarks: The major landmark in retroperitoneal laparoscopy is the psoas muscle (Fig. 8.6). This should be prominently seen and kept in a horizontal orientation at all times. Gerota’s fascia is seen anterior to the psoas muscle, although it may be obscured by abundant paranephric fat. Anterior to this the peritoneal reflection is seen. Using an energy source, the Gerota’s fascia is incised from the mid-ureter to the upper pole of the kidney, close to the psoas muscle (Fig. 8.7). This brings the perinephric fat, ureter and tissue surrounding the renal hilum into view. The ureter is bluntly dissected, keeping the periureteric fascia intact. Energy may be used sparingly to control the segmental blood supply. It is not necessary to remove the gonadal vein along with the ureter.

The kidney is elevated using a blunt instrument in the 5 mm port, thus placing the renal hilum on stretch. Preservation of the posterior layer of perinephric fat cushions the renal parenchyma from injury due to the lifting instrument. Hook with electrocautery or bipolar energy is used to divide the fibro-lymphatic tissue overlying the renal hilum (Fig. 8.8). This step brings the renal vein with its tributaries and the renal artery into view. The pattern of renal vein tributaries on the left side is variable, and therefore the anatomy should be clearly delineated prior to division of any vessel. The lumbar vein is a posterior tributary of the renal vein and is often closely applied to the renal artery as it courses into the posterior abdominal wall (Fig. 8.9). Care should therefore be taken to achieve separation from the renal artery before application of energy. This vessel may be divided between 5 mm titanium or polymer clips or sealed and divided using energy sources such as LigaSure. The distal gonadal vein is traced until its confluence with the renal vein, where it may be controlled and divided or retained as a stay to keep the renal vein stretched and facilitate its dissection.

A combination of blunt and sharp dissection is used to bare the proximal renal artery and a few millimetres of the aorta surrounding its origin (Fig. 8.10). Great care should be taken to avoid thermal injury to the renal artery. The posterior layer of perinephric fat may be excised using hook electrocautery, thereby baring the posterior surface of the kidney. The kidney is progressively mobilised from the upper to the lower pole anteriorly, and the kidney is pushed inferiorly and posteriorly. Care should be taken not to unduly stretch the renal artery. Vessels coursing towards the adrenal gland from the hilum should be controlled and divided. The renal vein can be dissected medially at this stage as the kidney is flipped posteriorly.

The lower pole is then flipped laterally and superiorly and dissection commenced in a plane between the periureteric fat and the peritoneum. Care must be taken to avoid injury to the ureter and peritoneum. This lateral displacement completes the mobilisation of the kidney and separation from the peritoneum. Any remaining attachments can be divided, including the gonadal vein if not previously done. The ureter is clipped as low as possible and divided using cold shears just proximal to the clip.

A 6–7 cm long incision is made about 1.5 cm superior and parallel to the inguinal ligament. The external oblique fascia is sharply divided and the transversus abdominis and internal oblique fibres split to expose the preperitoneal fat, which is kept intact to minimise loss of CO2. The wound is packed with a wet mop to minimise gas loss.

The renal artery is first controlled with a stapler or two polymer clips [12] and divided with Endo Shears. When polymer clips are used, care must be taken to leave at least 2–3 mm stump of the renal artery beyond the clip. The artery must be dissected cleanly all around, and a distinct click sound should be heard at the time of application of the clip. The renal vein is then put on stretch and similarly controlled. Care should be taken during control of the renal vein not to dislodge clips on the arterial stump. Security can be augmented by using a combination of polymer and titanium clips [13]. The surgeon’s left hand is then inserted into the extraction incision and the kidney retrieved, placed in ice slush and perfused.

The retrieval incision is closed in layers. Pneumoperitoneum is re-established and the retroperitoneum inspected for haemostasis and appropriate measures taken to control bleeding vessels. Inspection should be performed with a pneumoperitoneum of 5 mmHg to look for venous bleeding which could be tamponaded by higher gas pressures. It is our practice to clip large lymphatic tissue around the renal artery stump to minimise chances of lymphatic or chylous collections, which are a rare but serious complication of left donor nephrectomy. These vessels may sometimes by observed to ooze milky fluid. The second and third ports should be removed under vision. An attempt should be made to close the sheath of the camera port, but this may be difficult in individuals with abundant subcutaneous tissue and may be omitted. The skin is closed with Monocryl subcuticular sutures.