A. Preoperative Transplant Care

Selection of the cadaveric kidney transplant recipient usually occurs shortly after procurement of the kidneys. The recipient is admitted to the hospital, reevaluated, and a final decision made whether or not to proceed with surgery. The re-evaluation emphasizes work-up for infectious disease, or other medical issues that would contraindicate surgery. It is necessary to determine if dialysis is required prior to transplantation. If the patient is on peritoneal dialysis, occult peritonitis should be quickly ruled out by gram stain while the culture results of the peritoneal fluid are pending. Because patients may be on the waiting list for years, significant progression of previously insignificant medical problems may have occurred. Suspicion of cardiac disease is obtained through history and physical exam and EKG. Sometimes it is necessary to proceed with invasive tests to conclusively rule out significant coronary artery disease. It may be most prudent to proceed directly to coronary arteriography to do so. This would then require post-procedure dialysis to eliminate the contrast material. The re-evaluation admission also affords time to review the sequence of transplant events with the patient and family members. It is also during this time that informed consent may be obtained if the patient is to be included in any study protocols.

B. Special Surgical Considerations During Organ Procurement

The kidney transplant procedure begins with the organ procurement process. It is essential that the organ procurement team exhibit knowledge of the important anatomical variations of the renal vasculature and collection system. Inadvertent transection of renal vasculature or the ureter can significantly compromise the success of the transplant. Communication between the procurement team and the implantation team is valuable.

C. Kidney Transplant Surgery

Kidney transplantation is not a technically demanding procedure but it is unforgiving of even minor technical misadventures. The surgical procedure is uniform, but no two kidney transplants are exactly alike. A typical uncomplicated kidney transplant can be performed in 3 (± 0.5) hours. Technical complications resulting in graft loss are very uncommon.

Several procedures are carried out prior to the skin incision. Patients are administered perioperative antibiotics. Intra-operative immunosuppressive induction agents may be given, including the corticosteroids and anti-lymphocyte antibody induction agents. After induction of general anesthesia, a central venous catheter may be placed. A large Foley catheter is placed in the bladder and the bladder infused with about 200cc of antibiotic fluid by gravity. Another approach is to utilize a Foley extension that allows cysto-tubing to be connected for infusion of fluid into the bladder during the case after vascular reconstruction. The Foley catheter should be very securely taped to a shaved spot on the thigh with use of benzoin and 2 inch-cloth tape. Ted hose and pneumoboots are often applied to minimize the chance for development of deep venous thrombosis. Naso/orogastric tubes are generally not used. The abdomen is then prepped and draped in a sterile manner.

Figure 6.3 illustrates the anatomic position of the heterotopically placed kidney transplant. The transplant site is the iliac fossa. Generally, the right iliac fossa is favored because the vessels are more superficial. Also, on the right, the proximal common iliac vein lays lateral to the artery and is easily accessible in obese and deep patients compared to the external iliac vein. This may be particularly important if living donor kidneys are used with short renal vessels. The exception are patients with Type 1 diabetes that may be candidates for a subsequent pancreas transplant. In this situation the left iliac fossa is used for the kidney transplant.

The skin incision is made either as a curvilinear hockey-stick type incision relatively medial compared to the alternative straighter and more diagonal and lateral incision. The incision is carried down through the external oblique aponeurosis through the oblique musculature to the peritoneum. The inferior epigastric vessels are suture ligated and divided. In females, the round ligament is divided. In males, the spermatic cord structures are preserved and mobilized medially. The

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