Renal transplant donor- nephrectomy

1. DONOR NEPHRECTOMY
DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITAL AND KILPAUK MEDICAL COLLEGE
CHENNAI

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
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3. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
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4. Principles of cold storage
Reduction of core temp below 4*c (reduce metabolism 5-8%)
Ice water preserved function for 12hrs
Harmful effects of hypothermic preservation
1. Cell swelling
2. Acidosis
3. Altered enzyme activity
4. Calcium accumulation
5. Production of reactive oxygen species
Hence preservative solutions ae used to counteract these processes
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5. Composition of clinically used solutions
EUROCOLLINS SOLUTION
1. Phosphate for PH buffering
2. Glucose as osmotic agent, source of ATP and lactate
3. Electrolytes chloride, potassium ,sodium
4. Osmolality 406 mOsm
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6. University of Wisconsin solution (UV SOLUTION)
1. Lactobionate and raffinose – osmotic agent
2. Hydroxyethyl starch – colloid- prevent tissue edema
3. Allopurinol and glutathione – prevent ROS
4. Gold standard preservative solution for transplant
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7. Histidine tryptophan ketoglutarate solution (HTK)
1. Cardioplegic solution – open heart surgery
2. Histidine – potent buffer
3. Tryptophan – membrane stabilizer and antioxidant
4. Ketoglutarate – substrate for anaerobic metabolism during preservation
5. Mannitol – free radical scavenging
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8. Hyperosmolar citrate solution (HOC or marshall’s solution)
1. Citrate and sodiumbicarbonate – buffer
2. Mannitol
3. Hypertonic – prevent edema of cells
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9. Celsior solution
1. Similar to UW solution but high sodium and low potassium content
2. Low viscosity
3. No HES
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10. Insitut georges lopez -1 solution
1. Same as UW solution but has polyethylene glycol instead of HES
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11. Hypothermic machine perfusion
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12. CADAVER DONOR NEPHRECTOMY
Cadaver donor nephrectomy is most often performed in conjunction with procurement of other solid
organs for transplantation.
The principles of abdominal organ procurement are the same regardless of the organs removed.
These include wide exposure, cannulation for in situ perfusion, isolation of organs to be removed in
continuity with their central vascular structures and orderly removal of the organs under cold
perfusion.
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13. In the setting of a combined thoracic and multiple abdominal organ donor, the initial dissection
is performed by the thoracic and liver-procurement teams.
After cross clamping and perfusion, the organs are removed in the following order: heart, lungs,
liver, pancreas, and kidneys.
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14. Exposure and Initial Dissection
Following hemodynamic stabilization, the organ donor is
brought to the operating room and placed in the supine
position.
A small rolled towel may be placed between the shoulder
blades, and the neck can then be hyperextended to
facilitate median sternotomy.
A long midline incision from the suprasternal notch to the
symphysis pubis is utilized to obtain exposure
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15. The initial step -exposure of the retroperitoneal structures and
isolation of the distal aorta for cannulation
The retroperitoneum is exposed by incising the posterior
peritoneum beginning near the root of the small bowel
mesentery and continuing
around the hepatic flexure
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16. Division of the inferior mesenteric vein (IMV) allows for improved exposure of the left renal vein.
The SMA should be isolated near its origin from the aorta, as aberrant hepatic arterial branches
may hamper dissection beyond the first 1–2 cm.
for the purpose of kidney only procurement, enables the surgeon to maximize kidney perfusion
(through occlusion of the SMA).
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17. Isolation of the Distal Aorta
The distal aorta from the inferior mesenteric artery(IMA) to the aortic bifurcation is now isolated
The aorta -encircled with an umbilical tape at its bifurcation, and a second umbilical tape should
be passed around the aorta at the level of the IMA or, if this vessel is not visible, 3–4 cm
proximal to the bifurcation
IMA - divided ( ensure it is not an aberrant, low-lying renal artery
Posterior lumbar arteries along the distal aorta - visualized by gently pulling up on the aorta -
should be clipped or tied
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18. incising along the lateral peritoneal
reflection and mobilizing the left
colon medially, the left kidney is
exposed. This ensures that both
kidneys will be in direct contact
with iced slush
Isolation of distal aorta for cannulation
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19. Isolation of the Proximal Aorta
isolation of the supraceliac aorta- abdominal Control or
supradiaphragmatic control
first mobilizing the left lateral segment of the liver -
retracted caudally, -left triangular ligament is divided. -
not to injure the inferior phrenic vein or left hepatic
vein.
patient’s right - gastro hepatic omentum (lesser
omentum) is incised from the lesser curvature of the
stomach to the diaphragm. The diaphragmatic crura
should now be visible.
Exposure of the supraceliac aorta
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20. After division of the diaphragmatic crural fibers,
the aortic adventitia is visualized. The anterior
and lateral surfaces of the aorta are isolated.
Circumferential control of the aorta can be
obtained.
If circumferential aortic dissection is performed,
care must be taken to avoid injury to the
posterior aspect of the aorta or spinal arteries.
Isolation of the supraceliac aorta for cross-clamping
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21. Cross-Clamping and In Situ Perfusion
The anaesthesiologist and other teams -notified that cross-clamping can proceed.
Mannitol (25 g) and heparin (250–300 U/kg) are administered intravenously.
A distal aorta is then exposed, and the umbilical tape along the distal aspect is secured.
An aortic cannula is placed on the field and connected via tubing to cold preservation solution
The anterior wall of the aorta is generously incised, and the cannula is placed within the aorta and secured by tying
the proximal umbilical tape .
The cannula must be passed far enough to be secured at its flange, but passage too far proximally may prevent
perfusion of lower pole renal arterial branches
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22. Cannulation of the distal aorta.
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23. cross-clamping can proceed in the following manner: the umbilical
tape around the SMA is now secured (for kidney-only procurement), exsanguination is achieved
by the dividing vena cava at its junction with the right atrium
The supraceliac aorta is clamped, and, simultaneously, cold preservation solution is infused.
Surface hypothermia is then achieved by liberally placing iced slush solution around both
kidneys.
occluding hepatic and pancreatic inflow, which can be a considerable source of perfusate loss.
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24. Venting venous blood in the chest is preferable since this prevents warm blood from coming in contact
with the kidneys
Venous blood can be vented in the abdomen by dividing the inferior vena cava (IVC) at its bifurcation
cannulation of the IVC with a urinary catheter drainage bag
Approximately 2–4 L of preservation solution are perfused through the aortic cannula. The venous efflux is
evaluated, and when it is clear or slightly blood tinged, perfusion is adequate
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25. Removal of Donor Kidneys
The donor nephrectomy is commenced by first isolating the distal ureters. The ureters are
identified deep in the pelvis and divided. Abundant periureteral tissue should be included in the
dissection of the ureters. Both ureters are freed to the level of the kidneys
The kidneys can be procured separately or in an en bloc manner.
the left renal vein is divided at its entrance to the vena cava
The anterior surface of aorta is visualized by dividing the overlying lymphatic tissue and is
incised immediately along its anterior aspect
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26. The posterior aspect of the aorta is similarly divided.
The paired lumbar arteries can serve as a useful landmark.
The left kidney is then fully mobilized outside of Gerota’s fascia along its posterior and superior
attachments. left adrenal gland is included with the left kidney.
A large fenestration is made in the mesentery of the left colon,and the kidney is passed
medially.
Finally, the attachments posterior to the aorta (left half) are divided, and the kidney is removed
and placed in iced slush solution
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27. In situ separation of right and left kidneys. The left renal vein
is divided at its entrance to the IVC after which the anterior
aspect of the aorta is incised
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28. The right kidney is similarly removed.
After dividing the distal ureter, the
posterior and superior attachments
are freed.
The entire length of the vena cava
(from bifurcation to suprarenal
segment) should be preserved with
the right kidney
Left kidney following separation.
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29. En bloc removal of
the kidneys is an
equally acceptable
technique and
should be the
preferred technique
for pediatric
cadaveric organ
donors
Appearance of en bloc cadaveric kidney specimen
following
division of posterior aorta
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30. The kidneys are then individually inspected for the presence of tumors, cysts, or other
abnormalities.
The number, length, and size of the vessels are verified prior to packaging.
Each kidney is then placed in two sterile isolation bags and then packaged in a sterile plastic
labelled container. It is helpful to remove as much air as possible from the isolation bags,as this
will improve cooling
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31. RENAL PRESERVATION
Successful allograft function after transplantation is highly dependent on minimizing ischemic damage
Ischemic injury to numerous cellular systems begins to occur immediately after cross clamping.
Hypothermia markedly decreases the cellular metabolic demands and thus ameliorates the degree of
ischemic damage.
Hypothermia-induced cell swelling is a significant source of injury during preservation. For this reason,
most organ preservation solutions are formulated to minimize organ damage during
ischemia/reperfusion injury from oxygen-free radicals, prevent cell swelling at cold temperatures, and
prevent cell membrane destruction.
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32. hydroxyethyl
starch, lactobionate, raffinose, and gluconate helps to prevent
hypothermia-induced cell swelling.
ATP precursors such as adenine, adenosine, and ribose
to organ-preservation solution
freeradical
scavengers such as allopurinol and mannitol may
be helpful in reducing free-radical formation and oxidative
damage
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33. the two methods of renal preservation for transplantation include cold storage or continuous
machine (pulsatile) perfusion.
The majority of transplant centers utilize cold storage due to its relative ease, but experience a
higher rate of delayed graft function (DGF) than with pulsatile perfusion.
pulsatile perfusion may be beneficial in assessing organ quality as well as preserving organ
function. Renal hemodynamic perimeters such as perfusate flow and arterial pressure can be
continuously assessed, and, from these, renal vascular resistance can be calculated.
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34. LIVE DONOR
NEPHRECTOMY

35. The role of open donor nephrectomy has been diminished in the past 10 yr. owing to the
development of laparoscopic donor nephrectomy., open donor nephrectomy remains the gold
standard
Although most donors will be candidates for laparoscopic donor nephrectomy, there are
selected circumstances in which open donor nephrectomy is preferable.
extensive prior intraperitoneal surgery
left donor nephrectomy is planned.
very short right renal vein (<1.5 cm) identified by computed tomography(CT) angiography.
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36. The development of laparoscopic donor nephrectomy has lead to improvements in the open
technique.
Incisions are now smaller, and resection of a rib is not mandatory. With appropriate
management of patient expectation and perioperative care, the hospital convalescence may be
reduced to 3 d,
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37. PREOPERATIVE EVALUATION
absence of renal disease or conditions that may affect future renal function. Glomerular
filtration rate must exceed 80 mL/min
no proteinuria (<150 mg/L).
Anatomical evaluation is performed using a CT angiography technique.
The night before surgery, patients are encouraged to take fluids liberally but are given a
magnesium citrate bowel prep. On arrival to the preoperative suite, donors are administered 1 L
of intravenous normal saline before anaesthetic induction.
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38. OPERATIVE PROCEDURE: RIGHT SIDE
The patient is placed in the classic flank position for right donor nephrectomy.
The down side is supported by the kidney rest of the table, then the table is flexed and placed in
slight Trendelenburg position until the flank is parallel to the floor.
A roll is placed in the downside axilla to prevent brachial plexus injury. Legs are appropriately
padded.
11th rib bed incision made, Total incision length should be no more than 15-18 cm.
The retroperitoneum is entered and the diaphragm and pleura are dissected free from under
the lateral aspect of the 11th rib
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40. Isolation of ureter and looping of ureter
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41. Gerota’s fascia is entered, and the kidney is mobilized.
The adrenal is spared
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42. Hilar dissection of the renal vein is then carried out. The renal
artery is typically in a retrocaval position, and additional length
may be achieved by dissected lateral and behind the vena
cava
At the time of renal hilar manipulation, 25 g of
mannitol are given intravenously for renal protection.
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43. After confirmation with the recipient room that the recipient has favourable vasculature and is medically
stable, the ureter can be divided.
As much length as possible should be preserved., Also, the peri-ureteral tissues surrounding the ureter
should be preserved as they contain ureteral blood supply.
The triangle of tissue bordered laterally by the lower pole of the kidney, medially by the IVC and superiorly
by the renal hilum represents the territory of the ureteral vasculature.
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44. The right renal artery is controlled with a right-angle clamp.
The right renal vein encompassing a portion of adjacent IVC is then
secured. Using a scissor, the vein is divided including a cuff of the
IVC with the donor kidney.
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45. The renal artery is doubly ligated with 0 silk ligatures.
The renal vein is oversewn with a continuous 4-0 polypropylene suture.
Closure of the flank incision is in multiple layers using polydioxanone suture. After placing a
retroperitoneal drain
Skin is approximated with clips
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46. OPERATIVE PROCEDURE: LEFT SIDE
The incision for the left side is similar to the right. The retroperitoneum is developed.
The ureter is identified and traced into the pelvis. The gonadal vein is identified as a landmark,
and all tissue between the gonadal vein and the ureter is preserved
the peritoneum is swept medially off Gerota’s fascia.
The gonadal vein can be ligated in the pelvis and then be used a tracer to dissect superiorly until
the renal vein is visualized
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47. Gonadal vein and ureter traced
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48. Gerota's opened and adrenal separated
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49. Adrenal vein ligation
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50. Ureter cut near the iliac vessel crossing
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51. Lumbar vein ligation
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52. The renal artery is clamped as close to the aorta as feasible, ensuring adequate space for
two 0-silk ties.
The renal vein can be clamped over the medial aspect of the aorta to ensure a good length
of vein.
The artery and vein are then divided. The renal artery is doubly ligated with 0-silk ligature.
The vein can be tied with 0-silk ligatures or oversewn if it is too wide
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53. Following procurement, kidneys are flushed with a UV solution and cooled in an ice bath
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54. POSTOPERATIVE CARE
early ambulation.
Clear liquids can be introduced in most patients on the first postoperative day.
Satisfactory intake by 3–4 d is normal.
Most patients can be discharged by day 4-6 .
Laboratory studies to assess renal function and blood counts are monitored in the hospital,
then at return office visit in 4–6 wk.
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55. Living Laparoscopic Donor Nephrectomy
The first laparoscopic living donor nephrectomy (LLDN) was performed by Ratner 10 yrs ago with
the aim of reducing the morbidity associated with the open procedure
Transperitoneal Donor Nephrectomy
Retroperitoneal Donor Nephrectomy
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56. Transperitoneal donor nephrectomy
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57. video
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58. Retroperitoneal donor nephrectomy
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61. video
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