Laparoscopic Right Sided Live Donor Nephrectomy

Indications for laparoscopic procurement of the right kidney have been outlined earlier in this chapter. Patient positioning and trocar placement mirror those used for a left-sided dissection (Fig. 12).

An extra 5-mm trocar is placed laterally in the mid-axillary line to accommodate an instrument for retraction of the right lobe of the liver. Alternatively, this fourth trocar may be placed along the costal margin.

The operative steps for a right-sided dissection are similar to that on the left, with modification of the technique used for hilar dissection due to the presence of the inferior vena cava and the anatomically short right renal vein (26-28).

The dissection of the white line of Toldt is carried upward to the lower pole of the kidney at which point it is continued medially, staying several centimeters away from the ascending colon. This allows complete colon mobilization while keeping the lateral attachments of the kidney intact, thereby facilitating the hilar dissection later in the procedure. Continuing in a cephalad direction toward the diaphragm, the triangular and coronary ligaments of the liver are divided up to the diaphragm, allowing mobilization of the lateral aspect of the right lobe of the liver off of the upper pole of the right kidney. The liver may be retracted using a variety of instruments, including the PEER Jarit retractore or the diamond flex triangle retractor.f

Kocherization of the duodenum is performed to mobilize it medially and skeletonize the anterior and lateral surfaces of the inferior vena cava. Minimal electrocautery is used to avoid thermal injury.

The duodenum must always be identified before dissection of the vena cava is initiated.

Adequate renal vein length and vascular control are primary concerns when performing right laparoscopic live donor nephrectomies. Gently retracting the renal vein and skeletonizing the anterior and lateral borders of the vessel initially identify the renal artery (29).

FIGURE 12 m Trocar placement for right-sided laparoscopic live donor nephrectomy. An extra port is needed for liver retraction.

Liver retraction

12mm working

Liver retraction

12mm working

icra

5mm working port icra dInlet Medical, Eden Praire, MN.

eJ. Jamner Surgical Instruments, Hawthorne, NY.

fGenzyme Surgical Products, Tucker, GA.

Once the posterior and lateral attachments are released, the kidney is gently placed on its anterior surface and the renal artery dissection is completed posteriorly.

The use of an articulating stapler positioned parallel to, and flush with, the inferior vena cava allows procurement of the entire length of the right renal vein.

Once the posterior and lateral attachments are released, the kidney is gently placed on its anterior surface and the renal artery dissection is completed posteriorly. This allows the retrocaval dissection of the renal artery that is necessary to obtain adequate vessel length. The renal vein is dissected down to the level of the vena cava. Once the allograft is placed in the Endocatch bag, the artery is ligated at a level medial to the vena cava, and the renal vein is transected flush with the vena cava. Although the length of the right renal vein harvested laparoscopically is slightly shorter than that procured via the open technique, meticulous hilar dissection of the vessel on the bench table combined with extensive mobilization of the recipient external iliac vein typically provides sufficient length for a tension-free allograft venous anastomosis.

Technical modifications have been designed to optimize renal vein length and maximize safety during hilar dissection. The use of an articulating stapler positioned parallel to, and flush with, the inferior vena cava allows procurement of the entire length of the right renal vein.

Hand-assisted laparoscopy has been used as a method to improve retrocaval dissection of the renal artery, achieve maximal renal vein length, and simplify kidney extraction (30-34). The hand port incision that is required is usually made in the right lower quadrant. The hand-assisted approach does not add morbidity to the procedure for the donor patient and is an acceptable alternative to the pure laparoscopic transperitoneal approach.

Groups at several institutions have addressed concerns regarding harvesting a shorter renal vein by placing a clamp on the inferior vena cava and including a vessel cuff, mimicking the open approach. Turk et al. describe placing a modified laparoscopic Satinsky clampg across the vena cava after the kidney has been placed inside the Endocatch bag and the artery transected (35). The allograft is then safely delivered, the extraction site closed, and the cavotomy closed with a laparoscopic running suture. Another modification described involves making a transverse subcostal incision over the renal hilum at the end of the procedure as an alternative to a Pfannenstiel extraction site (10). The hilar vessels are transected using the standard open technique, including a cuff of vena cava. Although this incision is not optimal with respect to postoperative pain and cosmesis, it ensures excellent control of the renal hilum with minimal warm ischemia time.

The cumulative experience with laparoscopic live donor right-sided nephrectomy is significantly less compared to the left-sided procedure. However, many studies have specifically examined right laparoscopic live donor nephrectomies and suggest that in experienced hands, it is safe for the donor patient and produces excellent immediate graft function. Boorjian et al. described a series of 40 right-sided laparoscopic live donor nephrectomiess where donor morbidity and recipient allograft function did not differ from those seen with left kidneys procured laparoscopically (33). Similarly, Abrahams et al. reported on a similar series of patients where donor and recipient outcomes were equivalent between left-sided and right-sided procedures, without technical graft loss in either group (26,27). Although technically challenging because of the potential problems with dissection of the renal hilum, the right kidney can be procured laparoscopi-cally when indicated and when an experienced surgeon is present.

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