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Recipient Kidney Transplant from a Living Donor

Maggie L. Westfal, MD, MPH1; Nahel Elias, MD, FACS2
1 Massachusetts General Hospital, General Surgery Resident
2 Massachusetts General Hospital, Transplant Surgery Department

1. Introduction

  1. Anesthesia
    1. This procedure is performed under general anesthesia.
  2. Patient Positioning
    1. The patient is positioned in the supine position on the operating room table. In cases of ipsilateral native nephrectomy consideration, a small bump under the flank is recommended.
    2. A foley catheter is inserted after induction of anesthesia and an antibiotic solution with blue-coloring is infused into the bladder.
    3. The abdomen is prepped and draped in the standard sterile fashion.
  3. Discussion of Surgical Approach
    1. The transplanted kidney may be placed in the left or right iliac fossa.
    2. The access to the right iliac vein and artery is easier in general.
    3. Given that pancreas allografts are often placed in the right iliac fossa, a patient that is first undergoing a kidney transplant will often have the kidney placed in the left iliac fossa.
    4. Future pancreas after kidney transplant is a consideration relevant to the patient presented in this case given her history of diabetes.

2. Exposure of Iliac Region

  1. Modified Gibson Incision
    1. A left lower quadrant incision was made.
  2. Dissect through Lateral Abdominal Muscles
    1. This resulted in entering the left iliac fossa.
  3. Mobilize Peritoneum Medially
    1. Notes of any defects in the peritoneum were made as these would have to be closed primarily.
  4. Dissect to Retroperitoneal Space
  5. Divide the Round Ligament
  6. Expose External Iliac Artery
  7. Expose External Iliac Vein
  8. Expose Bladder

3. Preparation of the Kidney

    1. Simultaneous to the dissection described above the backbench preparation of the donor kidney was occurring.
  1. Verification of Kidney
  2. Improve Length and Exposure of Vessels
  3. Expose Ureter
  4. Dissect Perinephric Fat
  5. Shorten Renal Artery
  6. Test Artery for Missed Branches
  7. Test Vein for Missed Branches
  8. Check Positioning
  9. Spatulate Upper Pole

4. Renal Vein Anastomosis

    1. The external iliac vein was clamped.
  1. Venotomy Incision
    1. A venotomy was created.
  2. Back Wall Anastomosis
    1. The donor renal vein was then anastomosed to the recipient external iliac vein in an end-to-side fashion using a running 5-0 Prolene suture.
  3. Front Wall Anastomosis
    1. After completing the anastomosis, we clamped the renal vein and unclamped the external iliac vein to make certain the venous anastomosis was hemostatic.

5. Renal Artery Anastomosis

  1. Arteriotomy
    1. The external iliac artery was then clamped.
    2. An arteriotomy was created using a 4 mm aortic punch.
    3. The recipient artery had no evidence of atherosclerosis.
  2. Back Wall Anastomosis
    1. The donor renal artery was anastomosed to the recipient external iliac artery in an end-to-side fashion using a running 6-0 Prolene suture.
  3. Front Wall Anastomosis
  4. Kidney Reperfusion
    1. The kidney was then reperfused and had excellent reperfusion and hemostasis.
  5. Assess Volume Status

6. Ureter Anastomosis

  1. Divide Muscle to Mucosa
    1. The ureter was then passed to the level of the bladder. This is usually posterior to the spermatic cord in men, but in women we divide between ligatures the round ligament.
    2. The inferior epigastric vessels may need to be divided depending on their location, the patient’s body habitus, and the exposure.
    3. The bladder had been distended by clamping the drainage tubing and infusing the blue-colored antibiotic solution into the foley catheter.
    4. The muscularis was incised and the mucosa of the bladder was identified.
  2. Shorten Ureter
  3. Bladder Incision
  4. Spatulate Ureter
  5. Anastomosis
    1. It was then anastomosed to the mucosa of the bladder using a running 6-0 Maxon suture.
  6. Place Stent
    1. Prior to completing the anastomosis, a 4.7 Fr double J stent was mounted on wire and placed into the ureter because some fullness of the renal pelvis was noted prior to completing the anastomosis.
  7. Finish Anastomosis
    1. The anastomosis was completed and the muscularis was then closed with interrupted 5-0 Vicryl sutures. This created a non-refluxing tunnel in the standard Lich-Gregoir technique.
  8. Evaluate Blood Flow
    1. The total warm ischemia time was 31 minutes, and the total cold ischemia time was 36 minutes.

7. Closure

  1. Use RF-Sensitive Wand
    1. The retroperitoneum was inspected to ensure hemostasis.
  2. Close Wound
    1. The abdominal wall muscle layers were closed with 0 PDS sutures.
    2. A 3-0 vicryl was then used to close the subcutaneous tissues.
    3. A running 4-0 monocryl was used to close the skin.
    4. A sterile occlusive dressing was applied.
    5. A drain is not necessary in most cases.
  3. Postoperative Care
    1. The patient was extubated in the operating room and brought to the postanesthesia care unit in stable condition.
    2. The patient received a dose of 12.5 gm of Mannitol and 60-100 mg Furosemide (Lasix) just prior to completing the vascular anastomoses and reperfusion of the allograft.
    3. There is evidence that intraoperative diuresis with lasix has decreased the risk of ischemia reperfusion injury.18 It is our practice that the patient remain on a continuous rate of D10 at 30 cc/hr.
    4. It is imperative that the urine output of the patient be monitored hourly to assess the function of the newly implanted allograft. The hourly urine output is also matched 1:1 with lactated ringers. This is continued for the first 12-18 hours postoperatively. The patient’s foley catheter remains in place until postoperative day 3 when it is then removed.
    5. Without any postoperative complications, patients receiving a kidney transplant are most often discharged on postoperative day 3.

9. Possible Complications

  1. General
    1. Primary Nonfunction
    2. Acute Rejection
    3. Infection
    4. Disease Recurrence
    5. Bleeding
  2. Delayed Graft Function (DGF)
    1. This is seen in up to 20% of deceased donor kidney transplants but only in less than 3% of living donor kidney transplants.4 This complication is a manifestation of acute kidney injury and is defined by the need for dialysis within seven days of kidney transplant. Patient with this diagnosis should undergo biopsy, if it persists beyond 14 days postoperatively, to exclude acute rejection and differentiate it from other causes (ATN, disease recurrence, infectious, etc.).19
  3. Vascular and Urologic Complications
    1. Fluid Collection (lymph, blood, urine)
    2. Ureteral Leak or Stricture
    3. Vascular Thrombosis
    4. The above two complications are rare and only occur in 1-2% and 4% of transplant respectively.4 Ultrasonography of the renal allograft is extremely useful in making the diagnosis of complications postoperatively as it diagnoses renal perfusion, perinephric fluid collection, and hydronephrosis. If negative, it is followed by a biopsy, and the two diagnostic tests are the cornerstone of working up any renal allograft dysfunction early or late in the post-transplant period.