Left Laparoscopic Donor Nephrectomy

CHAPTER 1

Hi, I am Doctor Kawai, transplant surgeon at Massachusetts General Hospital. We are going to perform left laparoscopic donor nephrectomy today. The patient will be positioned in the lateral position, left side up, and we make a small Pfannenstiel incision, and then place the laparoscope ports. After placing ports, we create a pneumoperitoneum, and the first we mobilize left colon medially to expose the left kidney, then identify the left ureter, and the left ureter will be freed up up to pelvic space. We completely mobilize kidney from the upper pole to the lower pole, then continue dissection to the hilum over the kidney. There, we identify the renal vein, then identify the renal artery, and dissect the connective tissues between those vessels. Then finally, we staple and transect those vessels. Then the kidney will be extracted from a small incision in her lower abdomen. Then, immediately we perfuse it with cold, preservation solution on the back table. Then the kidney will be transferred to the recipient room.

CHAPTER 2

So we make a 6-cm long Pfannenstiel incision. She had a previous history of hysterectomy, and she has some scar here, so she may have some adhesions. Just make a 6-cm incision here. To here. All right, knife down. Adson. Adson, please. Can I have a Weity?

All right, I’ll take a hand port. So we install the hand port. We’re not going to put the hand in today, but… I’ll take a - 12-mm port. So we put the 12-mm port through the hand port, and make a new pneumoperitoneum now. Can you - gas on, please?

So port position - I put the 12-mm port in the navel, and one more 12. One more 12 in the left abdomen. So two 12s, then one 5 in the upper abdomen on the midline. Do you have an Adson? I’ll take the 12 now.

One more 12. She's very easy. Okay, lights down please now.

CHAPTER 3

So she has some adhesions on this side.

CHAPTER 4

So now we mobilize the colon medially. So this is Gerota’s fascia - so we’re going to open up Gerota’s fascia to expose the kidney. So once we open this, we’re supposed to see the left kidney. So we start to see the left kidney here and continue dissection toward the upper pole. Mobilize the plane a little bit. Okay go back down and you continue dissection of the kidney. Can you see colon? Just make sure the colon is here so we are safe. And then continue dissection a little bit more front.

This is a lower pole of the kidney. We just more expose the lower pole. This is almost hilum, so we’re not going to do so much here, just a little bit - tiny bit more. Let's try to mobilize a little bit more the upper pole. Okay. So we need the retractor now - the liver retractor.

Now we're trying to find out the ureter now. We're supposed to see ureter here. So... Yeah. This is ureter here. It needs to be long enough.

Okay, so the ureter is done. So then we’re going to upper pole now. We’re supposed to not have upper pole branch today, but you just have to careful if you dissect around here. It's getting closer to the hilum, so you just need to be very careful. So this is enough.

CHAPTER 5

Now we start to find out the renal vein. Okay, see the kidney? Okay. Then go down. The ureter is here. Today the patient had a big cyst here, so it might be a bit different from… Can I take a picture - CT scan? Just make sure the branch of the artery… One more down. This one? Yeah. No branch. Go back - no, it’s a cyst. All right, so let’s see. Let's just show me a bit lower? Yeah, okay. Until we see the whole structure, we just go slow. So this is the gonadal vein. Go down. So this is going too high. I don't know why - this one might be… Today's donor has a big cyst in the hilum, so it’s a bit different anatomy. Usually, drop this down, we’re supposed to be able to see the main renal vein. Around here. But, another vein can branch off the upper edge of the renal vein. Here - here. The vein, right? So this should be safe too. I hope this should not be in front of that vein. Can you just put the retractor here. Yep.

I’ll take a right angle. So this is gonadal vein on the main renal vein. And we tried to come around the gonadal vein. Often we have lumbar vein right behind the gonadal vein, so we have to be careful. Small branch in back of the gonadal vein. Hope it’s not the - hope it’s not the lumbar vein. We just transect this one. Okay. So we just transect through the gonadal vein. LigaSure is very reliable to do this.

Next we try to find out the adrenal vein. Small branches. Different from lumbar vein, nothing to worry about the adrenal vein - usually nothing. So now, we transect the adrenal vein with LigaSure. We try to stay away from the main renal vein at least 5 mm. Now, adrenal vein is done. And I need to see…

So behind the adrenal vein, we're supposed to be able to see the renal artery. So now we try to find out the renal artery next. It’s somewhere around here today. It’s about... Can you go closer? So this is the renal artery here. So above the tissue - above the renal artery - it is okay to cut. Right here. One more - a bit more dissection. Should be enough - yeah. Let’s go look. Go back to the... The ureter here, we just got... Let's go…

So now we trying to dissect back of the renal vein. We expect some lumbar vein.

So this is lumbar vein. So now, we transect lumbar vein with LigaSure. Big lumbar here. One branch going up. Yeah, that's right. So we found the big lumbar vein here. Right angle. Yeah, very big one. Yeah. So since this is very big lumbar, we're gonna clip this one. I’ll take the LigaSure. With this, I should be able to cut through with the LigaSure, but… Lumbar vein is done. I can expose the artery even more. Okay, set the back table. Can you ask the recipient if we can take it out or not? Yes, I will.

CHAPTER 6

So now we are ready to take the kidney out. So now we clip the ureter as distal as possible. Clips on - one more, clip. Scissors, please. Now the ureter will be cut.

So, put in the Endo Catch now. So now we - capture the kidney by the Endo Catch. Now take this one.

And now staple the renal artery first. Okay. TA-30. Stapler. Close clamp. Yep. And the Hemlock. Large. A big one. So now staple with a TA. And then put one more clip over the staple. Scissors please. Then cut the artery. And one more staple.

Scissors, next. Now staple - we staple the renal vein and then cut the renal vein now. Okay. Okay. And then just squeeze this guy. Stuck? LigaSure. Grasper.

Come out. Okay. All right, room lights up, please. Just cut this one. Okay.

CHAPTER 7

Okay. Yep.

CHAPTER 8

That's artery. So this is artery. Make sure there's no bleeding from the artery.

This may not be necessary, but just to - I prefer to use this seal. And prevent oozing and also prevent lymphocele. Okay. Then put the colon - left colon back in the normal place now.

So put the colon back in the original place.

Next, we close this one. Can I have an Endo Close? We close this with an Endo Close. A grasper? I need one more Endo Close after this. I need one more. All right, let me see, so take out the last port - the 5-mm port we're not going to close. That's good, and I think that’s - everything’s done.

Then we'll close the incision in four layers.