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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

Transcription

CHAPTER 1

Hello, my name is Nahel Elias. I'm the surgical director of kidney transplant at Massachusetts General Hospital. The procedure we're doing today is a kidney transplant from a live donor. The main purpose of the procedure is to restore kidney function to this patient who has advanced stage kidney disease. In this case, it's secondary to diabetes, which is the most common cause of kidney disease in the United States. Kidney transplant is performed heterotopically. The transplant is performed in the iliac fossa, extraperitoneally. And in this situation, we have a live donor who is the patient's sister. She is actually HLA identical, which carries some minor advantage with minimizing immunosuppression. The procedure itself, we will expose the iliac fossa, expose the external iliac artery and vein where the kidney will be implanted and the bladder where we will drain the ureter of the donor kidney. The procedure starts with a lower quadrant incision, modified Gibson incision is what we use, the right side or the left side is acceptable. In general, the right side is easier. Although this patient has type one diabetes and she is also listed awaiting pancreas transplant, that we would prefer the right side to transplant her pancreas in the future. And for that reason, we're planning on transplanting the kidney into the left iliac fossa. So we'll make an incision, dissect the skin subcutaneous tissue down through the lateral abdominal wall muscle layers: the external oblique, internal oblique, and transversalis fascia. Mobilize the peritoneum medially, and expose the external iliac artery and external iliac vein. Both these vessels have no branches and the pelvis, which makes it easier and we can dissect them free fully and retract them. I usually retract the artery medially and do the venous anastomosis lateral. This permits the arterial anastomosis without the vein being in the way. This is not routine and some anastomose the vein medially and then the artery lateral. Once we completed the vascular anastomosis, that's when we reperfuse the kidney and assure the hemostasis with the vascular anastomoses. And afterward, we take the ureter down to the level of the bladder where we perform the typical Lich-Gregoir ureteroneocystostomy In the iliac fossa, when we mobilize the vessels, it's important to pay attention to the inferior epigastric vessels, which most of the time we divide them. This is a female, so we will have the round ligament, and we usually divide that. In men, the spermatic cord will be transversing the iliac fossa, and we usually maintain that and retract it as we mobilize the vessels. And we usually pass the ureter posterior to the spermatic cord. In preparation for this procedure, we also place a Foley, and with a Foley catheter, I usually have an infusion, which is saline with methylene blue to identify the bladder and distend it. Occasionally, patients with prior surgery in the area, or depending on their body habitus, it may be difficult to identify the bladder. So distending the bladder would be easier. Additionally, I use antibiotic irrigation, usually gentamicin, especially for patients who are anuric and have been on dialysis for a long period of time, as their bladders may be colonized. And especially that we are opening the bladder in the field, and antibiotics would minimize the risk of infection around the new allograft. The vascular anastomoses are performed in an end-to-side fashion. So we usually clamp the external iliac vein first. I use a Satinsky, create a venotomy, and then anastomose the renal vein to the external iliac vein. I prefer to clamp the renal vein and release the Satinsky off the external iliac vein to test the venous anastomosis and also restore continuity of the iliac vein flow. Following that, I clamp the external iliac artery, create an arteriotomy, and anastomose the renal artery to the external iliac artery, also in an end-to-side fashion. If the kidney comes from a live donor, this is where the vessels will be shorter. Obviously living donors have a much better quality kidney compared to deceased donors. These kidneys tend to be younger, and we know that the half-life of a kidney from a live donor is longer than that from a deceased donor. On the other hand, deceased donor kidneys have longer vessels, as we recover the aorta from the deceased donor, and we would have an aortic patch on the artery. Depending on the quality of the artery of the recipient, we will decide if that is necessary to be used, in that situation the anastomosis will be potentially larger using an aortic patch from the donor. Some patients have multiple vessels with their kidneys. So depending on the donor anatomy, as far as the renal vessels, that will make the decision about using multiple vessels. If it's a deceased donor, multiple vessels could come on a common patch from the aorta of the donor and we can anastomose that, or occasionally preparation on the back table prior to transplanting the kidney is necessary to connect the vessels together, depending on the type of vessels we have and the length of them, different types of anastomoses could be performed either a side-to-side or an end-to-side or from a deceased donor, occasionally the aortic patch is available but too long, that could be shortened by cutting the distance in between the two vessels. It is important to maintain flow to the lower pole vessels, regardless of their size, more so than upper pole, specifically to maintain blood supply to the ureter as the donor ureter will be supplied primarily by the renal vessels in this situation. And that is the main reason we shorten the donor ureter prior to implanting it into the bladder, to assure that it has distal flow and blood supply to the tip of it to maintain that anastomosis healing after the transplant. On the venous side, if there are multiple veins, most of the time, the smaller veins could be ligated. If they're equal size and they're together on a common patch, it could be used and it could be drained fully. Prior to transplanting the kidney, the kidney is prepared on the back bench and specifically identify the vessels, assured their patency, assure there are no branches that needed to be a ligated, and obviously in a kidney that comes from a live donor, during the dissection of the kidney in the living donor, many of these branches have been already divided and either cauterized or ligated that the majority of the time there is no need for too much work on the back bench. From a deceased donor kidney, this is where the kidney usually has more perihilar fat and perinephric fat. And there is more work than needs to be done on the back bench in preparing the kidney.

CHAPTER 2

So to plan the incision, the superior anterior iliac spine, this pubis tubercles. I usually mark by one fingerbreadth of both.

Incision. A bovie, please. So we're just going through this skin and subcutaneous fat down to the abdominal wall muscle layers. Can I have a Weitlaner up? Another one. This is the external oblique, and we're going to go through it. Give me a buzz right here.

You have an Army-Navy? So you see the rectus extending to here. I like to stay in lateral to the rectus. And going through the internal oblique and transversalis fascia gets us down to the peritoneum, which we're seeing right here. Buzz me. There will be a point where we we'll fix it. Just a couple of minutes. Now we're all the way down. So that's good exposure. I think I need to divide it. Yep. Do you have a right angle? 2-0 silk tie. I'm dividing the inferior epigastric vessels.

So now we're going to mobilize the peritoneum off the muscle and stay lateral to it. Looks like the transversalis fascia. We hadn't gone through it yet.

We're now in the preperitoneal space. We dissect the peritoneum down to the retroperitoneal space. Small vessels will be crossing in here, and we'll just assure hemostasis through cauterizing. This is mostly blunt dissection. Careful, close to the peritoneum. Here's the vessel there. And here's the external iliac artery. Continue mobilizing Peritoneum, exposing the psoas, external iliac. That's the round ligament. You can put ties on it. 2-0 tie. Obviously in men, this will be the spermatic cord. Then we would not divide it.

DeBakey. Once the round ligament is divided, the rest of the retroperitoneum is exposed. I usually like to put lap sponges to create that dissection, two or three, depending on the size of the patient and the size of the kidney. That creates enough space to place the kidney. And we can get our retractor set up.

There you go. So we'll take - how about the small right angle blades? So we retract the peritoneum medially. On the lateral retraction, we make sure we're above the pelvic bone so we don't cause any nerve injury here. DeBakey? And right angle, short right angle. So this is the psoas, this is the external iliac artery, we can see it. And we're just going to expose it. Quick buzz. Can we turn the Bovie down, please, to 20? We had decided to place this kidney on the left side because - do you know why, Maggie? So, I thought the artery crossed over the vein on the left. Yeah. Oh, she might get a pancreas transplant. Correct, so - she's a type 1 diabetic, she's listed for a pancreas transplant. In general, the right is easier because of the cava being lateral on the right, so it's easier to expose the vein. And for that reason, patients who are potentially a pancreas transplant candidates, we prefer to put the pancreas on the right. So we would put the kidney on the left side. She's getting a living donor kidney, so you don't want to burn that bridge. Dissecting some of the lymphatics around the external iliac artery. If we find a large lymphatics, I usually ligate it with a 3-0 silk tie, but everything we're seeing here is small. There may be a lymphatic that's not crossing across the artery. And we can just maintain it. I like to retract the artery with a Penrose. The angulation of the retraction is less, so it's softer than a vessel loop. Dissect here on the artery and free it up.

Can you grab the vein? Again, just like the artery, dissect the vein free. Right angle? DeBakey?

CHAPTER 3

Can we confirm the ABO, please? Can I get the Q-tips, please? Can you open the donor just to make sure the UNOS ID and the - do you have the donor? All right, we can do it on the field then. So this is the live donor kidney. It's already been flushed in the donor room, where the blood has been flushed out of it, and preservation solution has been used. We maintain the kidney cold while it's ischemic. So this is the donor artery, the donor vein. Another Pickup? And this is the donor ureter. We position the kidney. So this is superior pole, inferior pole. And this is a left kidney. And the left renal vein has multiple branches into it. This is a lumbar vein. This is the adrenal vein. And this is the gonadal vein. Stevens scissors? Can you grab the adrenal and pull the vein over to you? Actually, let me have the vein, yeah. So this is anterior to the vein. There may be a small branch in here. Jake, you want to tie this one? We can tie this one, sure. Okay, you can ligate this if you want. Can I get a 3-0 silk tie? Actually, let me have a 4-0 first. Let me just tie this off. Tie this. Jake - going to grab the vein over here. Any branches in here, yeah? Uh, I don't know. We'll check on those. Thank you. So we're dissecting the perihilar lymphatics and the fat to get adequate length on the vessels and better exposure and especially anterior to the vessels and superior.

We can do that quite liberally, posterior and inferior, this is where we got to maintain the blood supply to the ureter and here can see the ureter. And it's ureteropelvic junction. So the ureter blood supply is lateral from the lower pole of the kidney. And this is where we can dissect that free here. See the ureter from its origin at the renal pelvis. Occasionally, there are some larger vessels or lymphatics in here, and we can ligate those. 3-0 silk? Can I have a Jake? Jake? Yep.

So, dissect the perinephric fat, to free the kidney fully. Occasionally, deceased donor kidneys are also biopsied, and that biopsy site needs to be closed if the donor surgeon did not close it.

So in this situation, the renal artery origin was significantly higher than the renal vein. And that's why we have additional length on it. It's not unusual to have a small dissection. And we're going to shorten that. Stevens? Heparinized saline?

We test the artery for any branches that we missed. We don't see any.

We'll see how we are going to spatulate it. So we can use the gonadal to make the venous anastomosis longer. You want to cut into that and then you'll cut the gonadal. Stevens scissors? We can come across. Longer. Yes. You want to cut that? Looks good. So this, I would say, we'll ligate it here. Heavy needle holder? 3-0 silk tie. Hep saline?

DeBakeys? When I occlude the vein at the hilum. Jake? 4-0 silk tie? This is exactly why we test this. Hep saline. DeBakey. Good. All right, perfect. Maintain the kidney on ice.

DeBakeys? Quick check for the positioning of the kidney. We'll clamp the artery. I think that looks great. More inferior.

Since the artery is going to be inferior, we can spatulate the upper pole. Can we get Stevens? So we'll make a larger anastomosis. And can I get the ruler, please? And the venous anastomosis is large given that we elongated it using the gonadal and the - I mean, the gonadal and the adrenal vein. It's about 3 cm.

CHAPTER 4

So we're going to start the anastomosis, and about 20 minutes from now, we'll give the manitol and the Lasix, please. A folded blue towel - two of them.

So we use the 12 blade to create the venotomy. 11 blade is also… So something like this. Stevens. Stevens. Let me just take this off, let go. The 5-0 Proline. I prefer U stitches in the corners. Obviously, some may just place regular suture, all right? Nope, you're outside. You're going outside-in.

We'll start with the… Forceps. Nope, this is fine. I don't need it anymore. So that's the corner stitch. It's a U stitch. And I start with a U stitch while the kidney is still on ice to minimize the warm time. Yep. Take the basin and save it, please. All right. Can bring the kidney down. Hold on to this. Sorry, this. Can you hold the kidney with a forceps or something? Ice cold on my hand, please, and on the kidney, Some wrap the kidney with an icy wrap. I don't find it always necessary. As long as we maintain it cold by irrigating with ice cold saline. Let me retract - let me follow you. It's essential to evert the edges to have intima-to-intima opposition with the anastomosis. It's also essential to separate the front from the back wall while doing this anastomosis to assure you are not taking the back wall in the stitch. Some perform this anastomosis from inside the lumen from the other side, but I prefer to do the anastomosis from outside the lumen. You need to pronate. Can I have a right angle? Let me see. Can we do this.

Let me have that. Two needles back to you. So as I mentioned, I usually clamp the renal vein with a vascular clamp. I'll take the malleable. Release the… Satinsky. Make sure that the anastomosis is hemostatic.

CHAPTER 5

Ureter - I'll take that. And the renal artery - it wants to sit on this side of the vein, which is perfect. We'll anastomose it over here, I'll take a fresh icy wrap. The artery could be clamped with a softer, Fogarty-type clamp. Or a Satinsky is fine.

Hep saline. Renal artery forceps. Pots angled. Yeah, my arteriotomy is too small. Looks about right? Maybe a small bite in here. 6-0 BV-1.

Shard. You get a - grab the adventitia on the artery. Shard. Okay, let go of the needle, don't grab it. Grab it from the other side. Bring the loop where you want it. So now that we completed the back wall of the artery - Hep saline. See that the front wall of the renal artery is already somewhat everted.

Looks good. Can you give the manitol, please? Metzenbaum scissors. Ice cold, you got warm ready? My left. You can cut the other corner stitch.

So we unclamp the artery. And we see that the renal artery is nicely perfused. Then we release the vein, and the kidney reperfuse nicely. Warm saline, kidney reperfusion now.

The kidney usually gets warm with good volume and gets bigger. We recheck the anastomoses.

Let's see. We obviously don't have to check the vein because we had tested it earlier, but we can see them nicely over here. We also check around the hilum. Any of the lymphatics or small vessels that we had not ligated may bleed, and that will need to be ligated, but in this case, everything looks… So this is the renal artery and the anastomosis of the renal artery to the external iliac. And this is the renal vein. And the anastomosis of the renal vein to the external iliac vein. And here's the ureter. And shortly, we expect her to make some urine.

CHAPTER 6

You can see that there's - the tip of the ureter is also perfused, which is a good sign. 4-0 silk tie. You want a pass, or...? Pass, please, yes. Shorter. There you see the bladder distended by filling it up. Please, hold on a second. So you want to do something like this? Perfect.

All right, can we turn the Bovie down to 20, please? Jake. Jake Schnidt. You want the Bovie down to 20? Yeah, Bovie down to 20, please. Give me a buzz right here. Then I get the renal artery. Right angle. You got a little more muscle. That's the detrusor muscles that are divided. We identify the mucosa. You know the mucosa, right? Bulging through the muscle. We separate the muscle, lateral and medial. So we have a large surface of the mucosa identified to be able to anastomose the ureter to it. The kidney's still soft. Can we do a little more volume?

Jake Schnidt. 3-0 silk tie. Stevens. Short. Stevens. So we shorten the ureter. We want to make sure it's got a reasonable blood supply, and we can see that there's bleeding from the tip. And then we position it. Do we got the - the fine forceps, the fine titanium. That's good. Another blue, fine. There's some urine. And there's some urine. There's some bleeding. It looks like some - white towels. And that's going to be yours, at the tip, loaded.

You can unclamp the Foley. Where is it? Unclamp the Foley. Unclamp the Foley? Yep. All right, it's unclamped.

Go ahead. Big bite. So the suture is full-thickness on the ureter. You need suction? You need some - hold the sucker. Yep. And mucosa only on the bladder. And as I mentioned, this is the fluid that filled the bladder that's draining into the field. And that's why…

Okay, hold on to this. You got it. DeBakey if you're able to - yeah. You can let go of that. Don't grab the ureter.

You took both already, didn't you? Thank you. Can I have a squirt? You got 5-0 Vicryl, RB-1? I'll take a blue pickup, titanium blue. Warm saline. Asepto. One more. Not much travel. Yeah. Warm saline, asepto.

But I don't know why it's not making urine. It's all the way up? Thank you. All right, I'm just going to close. Let it warm up. Hanky?

CHAPTER 7

[No Dialogue.]

CHAPTER 8

This was a live donor kidney transplant implanted into the left iliac fossa. The procedure included first exposing the left iliac fossa, dissecting free the external iliac artery and vein in preparation for the anastomoses. Then, because we had a little extra time waiting for the kidney to arrive from the donor room, we also dissected the bladder and had it ready. The kidney was brought over from the donor room and it had excellent anatomy with single artery, single vein. The vessels were prepared, and the kidney was ready. We implanted it by anastomosing the renal vein to the external iliac vein in an end-to-side fashion, and then the renal artery to the external iliac artery in an end-to-side fashion. The kidney reperfused and it had excellent reperfusion. We then anastomosed the ureter. The ureter is anastomosed in the typical Lich-Gregoir fashion. We used an absorbable suture for that, anastomosing full-thickness ureter to the mucosa of the bladder. Then closed the muscularis with interrupted Vicryl. The ureter, because we had some - what appeared to be slight fullness of the renal pelvis and concern for the kidney having extra renal cyst, which we knew about, we decided to place a stent. This is not routine, but we occasionally do it. The kidney appeared excellent and had excellent reperfusion throughout, and we closed, and we will see how the function of the kidney - and obviously, this patient will require immunosuppression as every kidney transplant recipient does.