The Laparoscopic Donor Procedure

Laparoscopic live donor left nephrectomy is performed under general anesthesia with the patient placed in the right decubitus position. The operating table is flexed at a point midway between the patient's iliac crest and ribcage, and a kidney rest is elevated in order to maximize exposure during the procedure. Positioning of the patient and draping is carried out to allow—if necessary—for open conversion to an extended subcostal, or standard flank approach for completion of the procedure. Orogastric suction, foley catheter bladder drainage, prophylactic antibiotics and antithrombotic sequential leg compression devices are routinely used. The patient receives a bowel prep with magnesium citrate the night before surgery to help decompress the colon. The operating surgeon stands on the patient's right, with the camera operator caudad. An assistant and scrub nurse stand on the patient's left. Two television monitors are placed at the head of the operating room table. Standard laparoscopic instrumentation, along with a 30° laparoscope and ultrasonic scalpel are used. A pneumoperitoneum of no more than 15 mm Hg is created by Verres needle insertion in the left subcostal location. After creation of the pneumoperitoneum, the laparoscope is introduced into the abdomen using a 10 mm Visiport™. Two additional 12 mm operating ports are placed in the left subcostal location, as well as a 5 mm port in the left posterior axillary line. Port placement will vary slightly from patient to patient depending upon patient girth and the length of the torso. The operation is conducted as follows: mobilization of the left colon and spleen, dissection of the renal vein, dissection of the renal artery, dissection of the adrenal gland off the upper pole of the kidney, dissection of the ureter, mobilization of the kidney, creation of an extraction incision, systemic anticoagulation, division of the ureter, renal artery, and renal vein, and renal extraction. During the dissection, adequate urine output is maintained through vigorous intravenous hydration. Osmotic diuresis is instituted following volume loading, and at the beginning of the vascular dissection, with 12.5 grams of mannitol and 10-20 mg of furosemide. Renal artery vasospasm can be minimized through the use of topical papaverine. Once the kidney is completely free except for its vascular and ureteral attachments, a 6-7 cm extraction incision located either around the umbilicus or in the left lower quadrant is made without violation of the peritoneum. The patient is then anticoagulated with 5000 units of I.V. heparin sodium. The distal ureter is clipped and divided. Division of the renal artery, followed by the renal vein, is performed with a linear vascular laparoscopic stapler. The peritoneum at the extraction incision is opened, and the kidney is delivered through this wound by the surgeon's hand into an iced saline solution. The staple lines on the allograft are removed, and the kidney flushed with Collins solution. Heparin is reversed with protamine sulfate while the extraction incision is closed. Pneumoperitoneum is re-established and inspection of the operative field is performed. Once hemostasis has been deemed adequate, ports are removed under direct visualization, the abdomen desufflated, and the incisions closed.

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