Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Figure 102-2, A (anterior view) and Figure 102-2, B (posterior view) illustrate the relationship of each kidney to the pleura and rib cage. The parietal pleura reaches all the way down to the spinous process of the 12th vertebra posteriorly and the 10th rib in the midaxillary line. This relationship becomes more important with a posterior approach to the kidney.

STEP 2: PREOPERATIVE CONSIDERATIONS

Each kidney donor must undergo an extensive examination to determine physiologic, psychological, immunologic, and anatomic suitability.

The best kidney must be left in the donor.

Surgical experience of the donor team will determine the surgical technique used in each individual case.

A preoperative bowel preparation, although not essential, can facilitate intraoperative and postoperative management of the donor.

Care should be taken to prevent dehydration of the donor as is apt to occur with preoperative imaging, bowel preparation, and travel from out of town.

Although donor evaluation is similar for both open and laparoscopic nephrectomy, it is important to be familiar with the sensitivities and specificities of preoperative imaging techniques used in your facility.

C H A P T E R 102 • Donor Nephrectomy 1131

Anterior View

Diaphragm

Costal margin

11th rib

A

Posterior View

Lung

B

FIGURE 102–2

C H A P T E R 102 • Donor Nephrectomy 1133

1. INCISION

Placement of trochars is shown in Figure 102-5. There are, however, many variations for trochar and hand-port placement.

Before placement of the pneumoperitoneum, the abdomen is marked for placement of trochars and extraction incision. Each port site is infiltrated with local anesthesic, which can facilitate a reduction in narcotic use postoperatively. The ports are placed as illustrated. A 10or 12-mm port that is primarily used for dissection is placed at the level of the umbilicus, a second 10or 12-mm camera port is placed lateral to the rectus muscle, halfway between the umbilicus and the anterior superior iliac spine. Transillumination of the abdomen can be used to prevent injury to the inferior epigastric artery with this latter trochar placement. A third 5-mm port is placed in the midline, halfway between the umbilicus and the xiphoid process, and a fourth 5-mm port can be placed in the flank for retraction. As the operation progresses, the camera port and dissection ports can be interchanged to obtain optimal exposure. Once the pneumoperitoneum is established, the zero-degree lens camera is replaced with a 30-degree angled scope.

For hand-assisted laparoscopic left nephrectomy, the umbilical port is lengthened in the midline to facilitate placement of a pneumatic cuff or GelPort (Figure 102-6). At least two laparotomy sponges can be introduced at this time.

5-mm port (dissection port)

FIGURE 102–5 FIGURE 102–6

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It is only at this time that the kidney is further mobilized with takedown of the lateral attachments of the kidney. Throughout the procedure, the patient should be well hydrated and actively excreting urine. Once the kidney is completely free, a 6- to 8-cm Pfannenstiel incision is made without entrance into the peritoneum. This incision is unnecessary, of course, with a hand-assisted laparoscopic approach. The ureter can now be transected (see Figure 102-9).

Mannitol (12.5 g) or furosemide (Lasix) (10 to 20 mg), or both, is administered before clamping the renal artery and vein in some centers, but I prefer volume loading to promote natriuresis.

Communication between the donor and recipient team is essential to streamline the sequence of events. If the recipient room is not yet ready for implantation, the pneumoperitoneum can be released in the donor and the nephrectomy can be delayed. When both rooms are synchronized, systemic heparinization of the donor (also optional) can be performed.

An Endocatch bag is now placed through the peritoneum via the Pfannenstiel incision, and the kidney is loaded. It is important that the donor is completely relaxed to minimize trauma as the kidney is removed. The renal artery and renal vein are then transected

(see Figure 102-11) with a vascular linear stapler or clip device, or both, and the kidney is removed to the back table by one of the senior assistants or implanting surgeon.

The staple lines of the donated kidney vessels and ureter are excised and the renal artery is flushed with ice-cold preservation solution.

3.CLOSING

The time from intracorporeal vessel clamping to vessel flushing with ice-cold solution is defined as warm ischemia time and is usually approximately 2 to 4 minutes. The time from vessel clamping to reperfusion in the recipient is cold ischemia time. The donor surgeon, in the interim, is ensuring hemostasis in the donor with reestablishment of the pneumoperitoneum, so that all staple lines can be reevaluated and confirmed to be intact. The use of a linear staple device or clip on the renal artery is a matter of surgeon preference. There is some evidence to support the improved safety of stapling devices versus clips, which can fall off. Reversal of heparin is optional once the donor kidney artery and vein are transected.

Once hemostasis is ensured, the pneumoperitoneum is released and the fascia is closed.

C H A P T E R 102 • Donor Nephrectomy 1137

OPEN LEFT DONOR NEPHRECTOMY

Although most donor nephrectomies are performed laparoscopically, there will always be occasion to perform open donor nephrectomy electively or with laparoscopic failure. Similar to patient positioning for a laparoscopic procedure, the patient is placed in a modified lateral decubitus position with the hips rotated posteriorly. An axillary roll is placed and the arms are flexed at the elbow and padded. A second roll is placed between the patient’s knees, with the lower limb flexed at the knee. The kidney rest is elevated and the patient is secured. The operating table is flexed in the middle so that the patient’s flank is taut

(Figure 102-12).

Incision for open left

nephrectomy

Tip of 11th/12th rib

Edge of rectus abdominis

FIGURE 102–12

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The incision is placed over the distal end of the 11th or 12th rib, extending from the midaxillary line posteriorly to the lateral edge of the rectus abdominis muscle anteriorly at the level of the umbilicus. The latissimus dorsi muscle posteriorly and external oblique muscle anteriorly are first incised, followed by the internal oblique and transversus abdominis muscles to expose the peritoneum and its contents (Figure 102-13).

Although well described, taking the tip of the 12th rib is not usually necessary. Care is taken not to enter the peritoneal cavity medially or the pleural space anterior laterally. The peritoneum and its contents are bluntly reflected medially to expose Gerota’s fascia and the retroperitoneal space (Figure 102-14).

A fixed retractor greatly facilitates exposure. The gonadal vein and ureter are first identified and traced inferiorly to the iliac artery and superiorly to Gerota’s fascia, which can now be opened.

The upper pole of the kidney is then dissected from the adrenal gland, with care given not to injure the pancreas. As with the laparoscopic nephrectomy, the renal vein is identified, and the gonadal, adrenal, and lumbar veins can be divided at this time.

The renal artery is dissected to the aorta, avoiding injury to small polar branches. The surgeon should also try to avoid traction on the kidney, because this can lead to vasospasm and acute tubular necrosis in the recipient postoperatively.

The proximity of the diaphragm and pleural space should be kept in mind to prevent pneumothorax. Just as in laparoscopic nephrectomy, volume loading and saline natriuresis of the donor remains an important component of renal protection and cannot be overemphasized.