Left Laparoscopic Donor Nephrectomy
Chronic kidney disease (CKD) is characterized by a gradual decline in kidney function over a period of months to years. It affects 10% of the population worldwide, and millions die each year. Common causes include diabetes mellitus, hypertension, glomerulonephritis, and polycystic kidney disease. There are 5 stages of CKD depending on the level of kidney function as estimated based on the calculated glomerular filtration rate (GFR). Stage 1 is defined as kidney damage with normal or increased GFR (≥90 ml/min/1.73 m2); Stage 2 as a mild decrease in GFR (60-89 ml/min/1.73 m2); Stage 3 as a moderate decrease in GFR (30-59 ml/min/1.73 m2); Stage 4 as a severe decrease in GFR (15-29 ml/min/1.73 m2); Stage 5 as kidney failure with a severe decrease in GFR (<15 ml/min/1.73 m2). Kidney failure, or end stage renal disease, requires either a renal transplant to replace the failed kidneys or renal replacement therapy to filter and remove toxins from the blood through dialysis. A kidney transplant involves placing a healthy kidney into a person whose kidneys are no longer functioning. It is often the treatment of choice for patients with kidney failure compared with a lifetime on dialysis. This is due to better quality of life, lower risk of death, fewer dietary restrictions, and lower treatment costs. The procedure is classified as either deceased/cadaveric donor or living donor depending on whether or not the donor was alive at the time of harvesting the organ. Only one kidney is needed to replace two failed kidneys, making living donations an option. Here, we present a left laparoscopic living donor nephrectomy from a healthy female; the harvested kidney was later transplanted into a patient with kidney failure.
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2. Incision and Port Placement
- Perform Pfannestiel Incision
- Insert Hand Port and Create Pneumoperitoneum
- Mark Locations for Ports
- Insert Tracers Under Laparoscopic Guidance
3. Left Colon Mobilization
4. Left Kidney Exposure and Mobilization
- Dissect Gerona's Fascia
- Expose and Mobilize Lower Pole
- Identify and Dissect Left Ureter
- Mobilize Upper Pole
5. Left Renal Hilum Dissection
- Dissect Renal Vein
- Ligate and Transect Gonadal Vein
- Ligate and Transect Adrenal Vein
- Dissect Renal Artery
- Dissect Posterior Aspect of Renal Vein
- Ligate Lumbar Veins
6. Left Kidney Extraction
- Ligate and Transect Left Ureter Distally
- Place Kidney in Endo Catch
- Staple and Transect Renal Artery Proximally
- Staple and Transect Renal Vein Proximally
- Remove Kidney
7. Reperfusion of Kidney
- Assess For and Control Bleeding
- Apply Precautionary Seal
- Reposition Colon
- Close Ports
- Close Pfannenstiel Incision
Hello, 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 - we mobilize left colon medially to expose left kidney, then identify left ureter, and left ureter was - 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 renal vein, then identify renal artery, and dissect the connective tissues between the - those vessels. Then finally, we staple and transect those vessels. Then the kidney will be extracted from 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.
So we make a six centimeter long pfannenstiel incision. She had a previous history of hysterectomy, and he has - she has some scar here, so she may have some adhesions. Just make a six centimeter incision here - to here. Alright, done. Pass the adson please. Can I have a Weit-y?
Alright, 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 millimeter port. We put the 12 millimeter port through the hand port, and make a new pneumoperitoneum now. Can you gas on please? So port position - I put the 12 millimeter 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 Alison? I’ll take the 12 now. One more 12. She's very easy.
Okay, lights down please now.
So she has some adhesions on this side.
So now we - we mobilize colon medially. So this is Gerota’s Fascia - so we’re going to open up Gerota’s Fascia to expose the right kidney. So once we open this, we’re supposed to see left kidney. So we start to see left kidney here and continue dissection toward the upper pole. Mobilize plane a little bit. Okay go back down and continue dissection of the kidney.
Can you see colon? Just make sure colon is here so we are safe. Then continue dissection a bit more front. This is a lower pole of the kidney. We just more expose the lower pole. It’s 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. Okay. Okay, so we need a retractor now. Z-body retractor.
Now trying to find out the ureter. Supposed to see ureter here. So this is ureter here. This should be long enough.
Okay, so ureter is done. So we’re going to upper pole now. We’re supposed to not have upper pole branch today, but you just have to be careful if you dissect around here. It's getting closer to the hilum, so you just need to be very careful. Just enough.
No we start to find our the renal vein. Today's the patient had her baby sister here, so it might be a bit different… Can I take a picture of CT scan? Just make sure the branch of the artery… One more down. No branch - go back - no, it’s a cyst.
Alright, so let’s see. Show me... Until we see the whole structure, we just go slow. So this is 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, you 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 renal vein. Here - here. The vein, right? So this should be safe to take. Small piece should not be in front of that vein. 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 just transect through the gonadal vein. It’s very reliable to do this.
Next we try to find the adrenal vein. Small branches. Different from lumbar vein - nothing to worry about the renal vein - there’s nothing. So now, we transect the adrenal vein ligasure. We try to stay away from the main renal vein - at least 5 mil - 5 millimeter. Now, adrenal vein is done.
So behind the adrenal vein, we supposed to be able to see the renal artery. So now we try to find out renal artery next. It’s somewhere around here today. It’s about... 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 - bit more dissection. Should be enough - yeah. Let’s go back. Go back to the ureter here where we started. Let’s go back. So now we trying to dissect the back - back of the renal vein. We expect some lumbar vein.
So this is lumbar vein. So now 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. So since this is basically big lumbar, clip. Clip this one. I’ll take ligasure. With this type of pull, I should be able to cut through with the ligasure, but… Lumbar vein is done. I can expose the artery even more.
Okay, set up back table. Can you - can you ask the recipient if we can take it out or not?
So now we are ready to take the kidney out. So now we crap - clip the ureter as distal as possible. Clips on - one more, clip. Scissors please. Now ureter will be cut.
So put in the Endo Catch now. So now we’ve captured the kidney by the Endo Catch, and now staple the renal artery first. Okay. TA 30. Stapler. Close clamp on the hemlock. So now staple with TA and put one more clip over the staple. Scissors please. Then cut artery. And one more staple. Scissors next. Now staple - we staple the renal vein and then cut the renal vein. Okay. Just squeeze this guy. Stuck. Rigasha. Grasper. Come out.
Alright, room lights up please. Cut this one. Okay.
So this is artery. Make sure there is no bleeding from that - this may not be necessary, but I prefer to use this here to prevent oozing and prevent lymphocele. Then put the colon - left colon back in the normal place. Put the colon back in the original place. Alright, then next we close this one. Can I have a Endo Close? We close this on an Endo Close. Can I have a grasper? Need one more Endo Close. Alright, so let me see, so take out the last port - the 5 millimeter port - and then we’re going to close. That’s good. And I think that’s - everything’s done. And then we close the incision in four layers. I’ll take the PDS. One more Richardson please.