The patient’s skin is disinfected with a betadine^® solution from the Xyphoid level to the thighs, and up to posterior axillary lines on both sides. This is done twice; first by the circulating nurse, then by the instrumentist or the assistant-surgeon (Fig. 5.2). A four-piece sterile drape is used to circumscribe a large rectangular abdominal space limited by the mid-axillary line bilaterally, superiorly and inferiorly by the xyphoid and the pubis respectively (Fig. 5.3).

As for all laparoscopic procedures, the equipment check is capital before the operation starts. Apart from ensuring all robotic instruments are functioning and the camera is well calibrated, attention is paid to the carbon dioxide tanks. A second spare must be available in the OT room.

The first surgical steps are the same as for all laparoscopic renal surgeries. The summary presented below is given as a general guidance and must be adapted according to the patient’s body habitus since this can affect the placement of the ports: the initial ports may need to be adjusted when the patient has a history of past abdominal surgery in order to address the problem of expected adhesions; all the ports are better moved laterally in obese and superiorly in very tall patients to facilitate lateral and superior perinephric dissection [1].

We recommend the open Hasson technique because of its safety.

For the left side nephrectomy, the first 12 mm-port is created at the intersection between the left pararectal line and an oblique line between the umbilicus and the lowest level of the ribcage. Once the peritoneum cavity access is confirmed, the pneumoperitoneum is created and pressure parameters monitored (Fig. 5.4). The camera is introduced to visualize cannulas introduced from the next ports. These are created in the following order (Fig. 5.5):

Once all five ports are created, the patient’s side robotic cart is obliquely advanced to the patient aiming the camera port in an axis perpendicular to the line between the second and the third ports through which the two most deployed instruments will be used (Figs. 5.5 and 5.6a, b).

The four robotic arms are docked to the cannulas (Fig. 5.7), the instruments are mounted on the robotic arms, the cautery tools are connected to the electro-surgical unit, and the cutting and coagulation values are adjusted according to the Surgeon’s preference (Fig. 5.8).

However it is important to note that experienced Surgeons tend to use only three arms: one for the camera and two for the operating tools (the monopolar scissor or the permanent cautery hook being controlled by the dominant hand, and bipolar forceps by the other hand). This strategy is guided by financial reasons and is particularly feasible in non-obese patients.

Figures 5.9 and 5.10 show the operation site after instruments docking and a whole view of the operating theater when the complete set-up is ready.

For the right nephrectomy, patient’s positioning is mutatis mutandis the same as abovementioned: the patient lies now in a left semi-lateral position with the back turned to the robot cart. The laparoscopic ports’ topography is:

For the sake of clarity, we will initially describe the technical aspects of the left donor nephrectomy, then we will address the particular points of the right side donor nephrectomy, and at the end we will comment on the final common steps.

Generally the procedure starts with the dissection of the splenic flexure of the colon along the avascular Toldt’s white line. However if intra-peritoneal adhesions are present, these will be dealt with first (Fig. 5.11).

The fascia of Toldt is incised to free the left colic angle from the abdominal wall in order to access the retroperitoneal space (Fig. 5.12a, b). Then the phreno-colic, spleno-colic and spleno-renal ligaments are divided (Fig. 5.13). This allows the upper pole of the kidney with its covering Gerota’s fascia to be seen. Dissection is followed downwards along the white line of Toldt through a plane between the Zuckerkandl fascia posteriorly and the mesocolon anteriorly until the left colon falls medially with its attached peritoneum. At this time the kidney with its covering fascia is left attached to the posterior abdominal wall (Fig. 5.14). The dissection of the fascia of Toldt is continued caudally (Fig. 5.15). The retroperitoneal space is entered and fatty tissues are incised using the bipolar forceps and the monopolar scissor (or the cautery hook) until the left gonadal vein is reached. This is then freed from its posterior attachments and the psoas muscle is displayed (Fig. 5.16a, b). At this level, the ureter is seen medial to the gonadal vein. It is delicately held by its surrounding fascia and its loose posterior attachments are released up to the psoas muscle (Fig. 5.17a, b). Now the gonadal vein is followed cranially where it crosses the ureter and lies medial to it. Dissection is continued until the left renal vein is reached and its anterior aspect dissected. The characteristic venous violet cross appears; it is formed by the confluences of the adrenal and gonadal veins into the left renal vein (Fig. 5.18). At this step, the assistant retracts the medial lip of the opened Gerota’s fatty fascia with the aid of a compress held by the suction cannula (Fig. 5.19). This maneuver allows a better exposure and dissection of the adrenal vein which is clipped with two Hem-o-loks distally and one proximally, and sectioned by the robotic scissor (Fig. 5.20a, b). The Prograsp forceps docked to the robot’s fourth arm holds the lateral lip of the Gerota’s fascia and lifts the kidney up. This allows a good exposure of the gonadal vein which is clipped and sectioned to allow dissection of the posterior aspect of the left renal vein (Fig. 5.21). If the monopolar scissor was used so far, it is better replaced now by the cautery hook and further dissection is carried out around the renal vein. This is done with a maximum of patience, millimeter by millimeter, until the reno-azygo-lumbar vein is visualized on the posterior aspect of the renal vein (Fig. 5.22). It is dissected and sectioned between two Hem-o-lok^® clips (Fig. 5.23). Now the renal vein is free all around. Again the cautery hook replaces the monopolar scissor and hilar dissection is performed further posteriorly (Fig. 5.24). The renal artery is soon seen after some fatty tissues have been cleared. When two arteries are present as shown in our selected case, the first artery is seen and dissected all around, then the second (Fig. 5.25a, b). The forthcoming steps are similar to the right side donor nephrectomy and are dealt with in paragraph 6.