Renal transplant recipient- surgery

1. Renal transplantation
recipient surgery
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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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.
Dept Of Urology, KMC and GRH, Chennai
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3. Introduction
• surgical techniques for organ transplantation / vascular anastomosis - in animal models by Carrel
and Guthrie in the early 1900s
• First clinical deceased renal transplanton - in 1933 by the Ukrainian surgeon Voroy, with
unsuccessful results secondary to the immunologic barrier
• First successful transplant of a kidney between identical twin brothers was performed on
December 23, 1954 in Boston – Murray et al
• Today, kidney transplantation has become a common procedure performed all over the world.
Dept Of Urology, KMC and GRH, Chennai 3

4. General considerations
• Surgery and general anesthesia - impose a significant cardiovascular stress.
• subsequent lifelong chemical immunosuppression - associated with considerable morbidity.
• Therefore, evaluation of a potential recipient must focus on identifying risk factors that
contraindicate a transplant
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5. Allograft Preparation - Benching
• Meticulous preparation of the renal allograft is essential
• kidney - properly oriented in its anatomic position to allow for careful inspection
• Renal vessels and ureter should be identified / Parenchyma inspected
• Parenchyma - inspected for evidence of lesions or traumatic injury
• Adipose tissue surrounding the kidney parenchyma is carefully dissected off the vessels
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6. • Benching
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7. • Renal artery is dissected free
from the surrounding hilar
tissue and an appropriate
sized aortic patch
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8. RENAL VEIN
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9. Renal vein lengthening
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10. • Vessels - inspected for evidence of damage
• Branches that drain into the renal vein should be ligated
• Small accessory renal veins may be ligated and divided to increase the length of
the main renal vein
• Caution is advised in ligating large / medium-size accessory veins, because venous
congestion has been observed
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11. • Arteries - inspected for evidence of damage or atherosclerotic disease
• Arterial branches greater than 0.5 mm in diameter should be preserved if possible
• Fatty tissue close to the renal hilum should be ligated –Risk of lymphocele
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12. Anesthetic considerations
• Supine position
• AV fistla must be protected – wrapped in padding
• Venous & arterial line / BP cuff – placed in opposite arm
• Central line
• CVP – more than or equal to 10-12mmhg
• MAP – More than 80mmhg
• Diastolic pulmonary arterial pressure > 15mmhg
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13. • Maintenance of BP - good reperfusion of graft kidney – Immediate better
function of graft and less possibility of ATN
• IVF – Ideal NS , 60 -100ml in some studies
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14. Anaesthesia
• GA - preferred
• Ideal induction agent – Propafol, Thiopentone
• Maintenance : Inhalational – Isoflurane
• Muscle relaxant – Non depolarising : Atracurium and vecuronium
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15. Procedure
• Supine position
• Urethral catheter is placed and attached to a three-way tubing system
• Allows for bladder filling and drainage
• Bladder irrigant - broad-spectrum antimicrobial solution bacitracin or neomycin–
polymyxin B.
• Bladder should be rinsed with this solution before start of the operation
• If bowel has been used for urinary reconstruction, all mucus should be completely
irrigated
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17. Gibson’s incision
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-Right or left iliac fossa
-Excellent exposure of the
iliac vessels & urinary
bladder

18. • midline incision - vascular target includes the aorta and inferior vena cava
• On rare occasions the vascular targets - include the splenic and/or portal
systems.
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19. • Incision is deepened to the fascia.
• Starting medially, and going laterally incised
• Laterally/Superiorly -muscles needs to be
divided with this approach
• Medially / inferiorly - not necessary to divide
the rectus muscle, but mobilizing it down to
its attachment to the pubic bone helps in
exposure of the bladder.
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20. • inferior epigastric vessels- gently
retracted
• may be divided if surgical exposure is
compromised.
• Round ligament may be preserved in
females.
• Spermatic cord is identified in men as it
travels inferiorly exiting the peritoneum
and is carefully preserved
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21. • Peritoneum is retracted medially
• Retroperitoneal space overlying the iliac
vessels is developed using a
combination of blunt dissection and
electrocautery.
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22. • Iliac vessels (black arrow) - base of the
wound, genitofemoral nerve (yellow arrow)
laterally, & native ureter (blue arrow)
medially
• Ureter enters the pelvis - good landmark to
locate the bifurcation of the common iliac
artery
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23. • self-retaining retractor is placed, without compression of the femoral canal
• Iliac vessels are exposed using the electrocautery
• Lymphatic tissue overlying Ext Iliac vessels should be ligated or sealed with
electrocautery
• Care is taken to avoid injury of the genitofemoral nerve that lies anterior to the
psoas muscle just lateral to the external iliac artery.
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24. • External iliac artery -
dissected free to allow for
subsequent clamp
placement and
anastomosis.
• Lymphatics (yellow
arrow) overlying the
artery should be carefully
ligated - diminish risk of
lymphocele
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25. • once the vascular dissection is finished
• Place the kidney in the iliac fossa to
determine the best location to perform the
venous and arterial anastomosis.
• These locations can be marked with a
marking pen
• Before anastomosis the kidney can be
wrapped with sterile saline ice to keep the
graft cool until reperfusion.
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26. • venous target is occluded using vascular
clamps or Rummel tourniquets according to
surgeon preference.
• venotomy is performed with a curved-blade
scalpel
• Heparinized saline solution is injected directly
into the venotomy site to clear any blood or
clots.
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27. • several ways to perform the actual
anastomosis
• Place four sutures made up of poly
propolene
• one each on the two sides (broken
lines).
• one at the upper end of the
anastomosis, one at the lower end
(solid lines),
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28. • renal vein is anastomosed to the iliac
vein in an end-to-side fashion
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29. • Arterial anastomosis is performed in a similar fashion.
• Patients with ESRD / long-standing diabetes are commonly found to have significant
arteriosclerosis,
• Great care should be taken to recognize and avoid intimal disruptions that may lead to arterial
dissection.
• A 2.7- to 6-mm punch facilitates the recipient arteriotomy if a donor arterial patch is not
available
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30. • Aortic punch technique
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31. • With Aortic cuff
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32. • Once the vascular anastomoses have been completed, the occluding clamps are
removed—venous followed by arterial
• kidney reperfused.
• Urine output / Jet assessed
• Hemostasis to be achieved
• kidney is rewarmed with copious amounts of warm sterile saline
• Allograft is then positioned in the iliac fossa such that there is no kinking of the
transplant vessels
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33. ureteroneocystotomy
• Preferred technique - create an
antirefluxing, extravesical, stented
ureteroneocystostomy
• Lich – gregoir / Barry technique
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34. Barry
technique
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35. Multiple Renal Arteries
• Multiple renal arteries are present in 10% to 15% of cases
• Many different options are possible for reconstruction, depending on size of the
vessels, location of the vessels, donor source (living vs. deceased), and quality of the
recipient vessels.
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36. • Two arteries (yellow and blue arrow) are implanted separately, either to the external or
common iliac vessels
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37. • One to the external iliac
and one to the internal
iliac artery
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39. 4. Another option is to connect one vessel to the other in an end-to-side fashion
• In this example with three renal arteries, artery 1 and 2 have been sewn together
with a common patch (broken blue line), while artery 3 has been anastomosed to
artery 1 in an end-to-side fashion (broken yellow line)
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41. Catheter / Drain / DJ stent
• Catheter to be removed on 3 rd day ( 3-7 Days)
• Drain – 24 hrs later / less than 20ml
• DJ stent removal / Sutures removal – 3rd week
Based on institute / Individual preference
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