In this narrated surgical video, Chris Friese, MD, performs a right laparoscopic donor nephrectomy.
I'm dr chris freeze interim chief of transplant at the University of California san Francisco. And today we'll be performing a right laproscopic donor and a friend to me this is a young woman who's volunteered to donate a kidney or choosing the right kidney because the left kidney would likely have two arteries. Therefore the right kidney will hopefully have a single artery in a single vein in the room next door. We'll have the recipient being prepped for the site for implantation of the kidney by dr Garrett role. And when he is ready with his dissection, he'll actually come into our room and that's when we'll hand off the freshly removed kidney to him to flush out and so on to his recipient. Thanks for watching this video today. We'll see you in the operating room. Okay, So we use the opti view ports to access the peritoneal cavity on the right side. Since the various needle has been known to poke a hole in the liver. So, this is a I think a safer way to get in. So, I'll take a quick look around this is where our extraction incision will be. I'm sure we didn't hurt the liver. Looks good. Ok, so you're gonna go in right there, right knife to him just to one side of me and there's no bigger. Make it too big. The ports will slide in and out. Good. Mhm. We can turn our room lights down now, please. Alright, so we're on the right side doing the right kidney. And the reason is the left kidney had an early bifurcation of the green lottery. So we ended up with two arteries. We're going to try and get one artery here on the right side. Alright, so the first move we're gonna try and do is to identify the vena cava. Starting to do that. We'll have to mobilize the liver off the off the kidney, coming with your camera. Good. Slow down where the kidney is. Good. Let's look back down here, grasshopper. So the trick is to figure out the duodenum from the cave A this looks like duodenum here. So this will be being a cave underneath here. So we want to expose that. Yeah. And once we've identified the cable, we just follow parallel to it until we get to the lower pole. Obviously taking care to make sure that the duodenum rolls off retro peritoneum. Mhm. And the key is to get in the space between the vena cava in the yard or the kidney by mobilizing this pleasant area. They sending colon off the retro peritoneum look more lateral over here to the left. Sure, the appendix is not in play as well. Right? So you can see that's the lower pole, it's just some parametric fat. Retro peritoneal fat. And then I'm back to trying to get into the space. So here's cave all right in here. Give me here. So right in this space is where we'll find the year. There. It is and that'll be the soas muscle underneath all this tissue. Mhm. Okay, good. Let's sit down here. Now. Usually the gannett vein on the right side is preserved. So it's gonna devein should be down here somewhere a lot of times. Don't even see it right angle, see the ureter, peristalsis absolute when we use these vessel loops to mark important structures, usually the ureter the artery and the vein so that we can easily access them and when we're ready to divide them and also use these to help with traction. All right now, once we've had the Euro identified, we'll march back towards the hill um kidney again, keeping away from the order and not too close to the cave. So in between those two structures with my lateral hand, I use that as constant traction on the kidney to put the hill um on a little bit of a stretch. Good. So again, here's the vena cava. We'd expect the renal vein to come off somewhere along in here. So that's actually banana vein right there. We're gonna come in a little bit. We're gonna come along here just very carefully layer by layer donors that don't have a lot of retro peritoneal fat. These structures are usually pretty obvious right in the beginning. But here we have to carefully dissect through this extra tissue. Looks like the renal vein might be coming off right here. You can see we've returned back to the area we originally dissected to separate the kidney from the liver. This is the renal vein starting to show itself. You want to get as much of this tissue cleared off because eventually when we I want to put the stapler fire across here, we wanna have a nice clear path to the junction of the right vein and vina cave. It all needs to be cleared. You're going to get good length on the vein. There's often a little branch that comes off right at the liver corner of the junction of the renal vein with the cave. I can see it right in here and you have to be careful not to shear off that branch. Otherwise it leads to some bleeding. That's very hard to control. All right. So, once we have the vein identified, then the artery will usually be at the cod head side of the vein. So, right in here, we'll peel through the tissues there to identify it in a minute. Say about probably 90% of the time. You'll easily find the artery on this edge of the renal vein. But sometimes it'll be on the cephalopod side, closer to the liver. So, if you don't find it in here, you have to look to the other side. This artery also has a fairly low branch point. So, we're gonna have to do a little extra work to make sure we have all the length we can get if we want to give the recipient surgeon a single artery just starting to see a pulsation under there. So we're close to the artery, a little edge of adrenal tissue right here. Yeah. And here we're on the upper pole. Mhm. So, I took that little vein of sorrow there. So, we don't tear it. We can look down in here and see if we get any hint of the artery up above the vein. Yeah. Mr. Yeah, go fast. So sometimes it helps to get your loop around the vein early and then you can use that as traction on the vein to help find the artery. I'm just gently probing behind the vein here. Very gentle as you come around this vein. It's very thin and tearing a hole in it on the back side would be very difficult to control. And almost likely lead to a need to open. Like to avoid that. You can see now the pulsation. So, this is where the artery is going to be. So, having that loop in there gives us much better exposure. I suspect there's one branch there and one branch there. So, we're still at the point where it hasn't come together as a single artery. Just a little vein there, we don't want to get into. You see the thunder beat. Look over by this part of the kidney, you're gonna get your grasp on here and just give me some forward track. So, I've decided that we're gonna try and get the artery from behind with the kidney rotated forward. I just don't have a good angle on it. So, usually you can stay right on the kidney and peel all this fat off of it. It's a very nice plain easy to see where you're going, rather than taking all the fat with the kidney. Yeah. Mhm. Yeah, very nice tissues. Young, healthy tissues. So, normally, if I had looped the artery from the front, I'd be able to see my vessel loop back here. So, now I have to be very careful as I look for the artery. Okay, now we're starting to see it. So there's a loop around the vein and there's the artery that we can see better from behind than we could in the front. Mhm. Okay, get that plane right on the artery. They get to this wad. It would help a lot. And I think that's a vessel they have to do is just loop this whole lot of stuff and then clean it up and I can use the loop to better control that. So, there's you can see the bifurcation is right there. If we can get our staple load below there, then he'll have a single artery. It's gonna be a little challenging back at the liver here. It's gonna hold up that leverage, relax on what you're holding there. Come up, look up here. Hello. So, let's see. You've given a total 6.25 of Mannitol 12. And a half. Okay. Okay, so in a little bit here, we're gonna ask you for another 12.5 Along with 20 of Lasix. I'll tell you when to give that. Okay, now, everything from this point on is extra credit to try and get them single artery because the kidney could be removed right now. So, for these low branching arteries, some teams will actually go in between the aorta and the vena cava to get a single artery. I haven't thought that was super safe. So, I don't do it. But that is an option for people who think differently. Most times you can get a pretty good length on the artery just with some careful traction, basically, the two loops have to touch. That tells you when you got all the intervening tissue taken care of. So, I think we're there important if you are putting traction on the artery that you give it a chance to breathe every few a few seconds, of course, you don't want to hold too much because you can create a flap monday section. So, I want you gently just hold the artery that way. So, what we're gonna do now is get a little more length on the ureter so, I can see the veins. I don't want to get into that. You want to stay a ways away from the yarder. So you don't interrupt its blood supply. Show me back at the kidney. That's a pretty good length there. So stop there. You can just let go of that loop. So let's just plan out how we're going to take these vessels. So, one option is to get it from. Most times you take it from the front. I think it's gonna be difficult to do it this way. So, relax on that. So, I think what we'll do, let go of the loop when we take the artery, we'll take it with the kidney rolled forward. Look, so, and then what you're gonna do is hold this out of the way liver out of the way and I'll be able to come in with the stapler, go like this. Hopefully get them some very okay, spring. Usually we need about 2.5 to 3 inch incision to extract the kidney. Nothing. Hold this guy and about it so clear. Alright, so I get the stapler one, reload extraction bag, extra ports. So, generally, once we have the dissection completed, I like to decide if late, let the abdomen sit A good 15 minutes to take the kidney out of any spasm and improve the blood flow to the kidney. And usually you'll see the urine output. Really picked up while we're waiting that period of time. And during that time we're usually making our decision. It is important to give the kidney a period of time where it's not under pressure from the insulation. My name's Garrett role. I'm a transplant surgeon at UCSF assistant professor of surgery today, we're gonna be doing a living donor kidney transplant from a sister into a brother. When we use a right kidney from a living donor, we do a vein extension with third party cata Varick iliac vein grafts. So we're expecting a relatively simple operation except for a venus extension graft, possibly. Thanks for joining me today. Sorry Mark. The pubic synthesis. Find the midline here. Top of the pubic synthesis, is there S. I. S. Is there a finger breadth above? And we want to make our incision that goes up along the edge of the rectus here about the level of the belly button or a little bit below. Yeah. Yeah. So there's a pubic synthesis. We want to get in the fashion about a finger breadth above the pubic synthesis, just until he sees the vertical muscle fibers there they are right angle. Just go towards the edge of the rectus here and then turn up. Think there's the edge of the rectus right there. So you get both layers of the fashion here, go posterior to that right angle, basically take the rectus down off the interior fashion there and then open this leaflet, making our way to the inferior gastric right there. Get around them and use oh tie paired veins and an artery push that tissue towards the end of the gas tricks and find the dramatic chord. It's gonna be just superior. And we can see it coming into view there and right behind it. We can see the iliac vein there. Get around the chord structures and put a vessel loop there. It's our cord. Yeah. Yeah. And this is the space we use developed to find the iliac fossa. So as we're gonna roll the peritoneum off the interior surface here, rolling it with my fingers and then um bovie. Alright, is it time for me to go next door yet? All right. I'll be back. All right. You can turn our lights down again please. And the gas on. Take A. D. N. So, it's gonna be close if I get you a single artery really close, I think I can do it. And then the bigger scissors. That was the ureter being clipped and now divided and put this clip on the recipient side just to keep any little bleeding from the end being a problem, the recipient surgeon will take it off when they flush. Be careful. We don't twist it. Look down here. Yeah, I think we'll get one here. I hope so. I don't want to flip it or spin it. Look up. Look up here. You gonna hold that leverage. You can go ahead and give the pro to me now. So you want to be 50 mg? Two. Yeah. Yeah. Heavy scissors. Mhm. Come back here. Right, good luck. Alright, my slap please. And you're giving the pro. That's good. You're giving the pro to me now. Great. Good. Mhm. Yes. Take the money. Thanks. So let's run our fluids at 1 25 an hour overnight. And she just gets in the recovery room and one tomorrow morning. That's right. That's a loop on the vein there. Huh. Mhm. Just taking the staple line off the main. We'll have the egress of blood. There's our arterial stample line. I'm gonna open it up. So, now we're gonna flush the renal artery of the kidney. You see the flesh coming out of the renal vein there trying to take the clip off the ureter during the flush to allow the Small little vessels in a year or two. Get flushed. Now that flush is starting to come out clear, beautiful kidney. Well flushed and start on the vein. Let's just take this whole thing off. It's not gonna mobilize the vein a little bit here, unique. Yeah. Looks like a little branch actually there. Let's take that. Alright, that's enough because we're gonna put a vein extension on there. We don't need to do too much on the artery. It does kind of branch early. So, let's tie this junk hair. Right, So, we try to tie off big lymphatic in the hill. Um just to reduce the risk of a limb flick later. Alright, so there you can see a renal artery with our two branches there and there and here's our renal vein. All right, kidney. So, it's a shortish reno vein Not too bad. But we're gonna put a vein extension on and will make it easier to implant. Let's just take the other the rest of the fat off the kidney here and then we'll do the van extension. No. All right now let's do our vein reconstruction. So here's our ureter their artery. A renal vein is Right in there, see how short that can kind of appear. Alright, so here's our 3rd Party iliac vein from a deceased donor. Is it a good size match? Just confirm it's a reasonable size match. It's in wall there man. So he's outside, he's going to go outside to n and then he's gonna run towards himself. We could put something to put some tension on the end of that vein. So it pulls it away. You see that thin walled right renal vein which is short which is why we put the vein extension on sometimes because you have a short vein and the recipient with a high risk of bleeding with that thin wall it can be challenging to deal with once year, once you've been planted the kidney and the vein is underneath the kidney. See how thin wall that is compared to the iliac vein which was sewing it too. It's a thin wall to the other side is thin walls on the backside there not this side when it opens up. I can like see through the other side. So he pulls the needle out and he loads it right there where we're working rather than moving it somewhere and loading it somewhere else. Alright great. So that's our vein extension. So the short right renal vein which is connected to the iliac vein here when we implant it. We'll cut this off somewhere probably about here. Well so this part to the patient's iliac. So this will be the renal vein anastomosis. Here's the renal artery, you can see the inferior pole branch here and the superior pole branch there. So bifurcated right about there and it's a beautiful living donor artery. You can see the bifurcation there from the inside. And here's our ureter which will probably cut off somewhere around there before we implant it. Alright we're gonna package this up and finish up the dissection in the recipient. So you can see here's the iliac artery and vein, we're just gently pushing the tissue away and pulling the peritoneum towards me. So emphatic tissue goes down and the peritoneum is towards me. Here's the recipient? Native ureter right there right where we expected to be coming over the iliac. Alright so so as iliac artery iliac vein under their neuro vascular tissue on the top or a limp oh vascular tissue on the top. Native ureter peritoneum bladders under there. So we started on the iliac artery. Probably about there. Yeah. And you can see a lymphatic right there. So these are the target of this dissection is to get the lymphatic over the iliac vessels And to tie them tie 30. So using the right angle and then a big spread and then we tie both sides. Key to success to this part is a good spread. And then pulling apart as the other person is tying providing tension that they can tie against so they can get the tie towards themselves, bobby the tissue on the side and post area to iliac vessel because there's not as much lymphatic tissue there. We try to tie that just your anterior the iliac artery because that's where the lymphatic generally are. Oh so here's our iliac vein and he's just gonna mobilize anterior surface of iliac vein. Similar kind of concept. You can see a lymphatic running right there so he's avoiding that one. Um Yeah the ghost. So when we put the tie in we drape it down the handle of the clamp like that. So it always feeds nicely rather than rather than bring it in like this this doesn't work. So you have to bring it towards the handle and then drape it down the handle and then I'll always feed nicely branch going down there gently up branch right there. I think we have to take that to be able to clamp safely. So you can see that branch of the iliac vein there which can be a very dangerous branch. Kind of a lot of Brittain for this type of work. Just gonna put a six pro line on the tie. So it doesn't pop off during the clamp they're just cinching that tie on vain. Okay yeah it's a good idea with any sizable vein coming off the vein it's broad based. The tie will pop off. He's gonna tie the other side now and then he's gonna put a medium clip. He's gonna take a 60. Pro line after the ties baby. Yeah. Yeah. All right again just plastering the tie to the veins. It doesn't come off later when you're assisting working on a big vein you probably want to pick ups to be able to control the vein or a sucker and a pickup. But you're gonna be using both hands. Yeah. Okay. Oh I'm gonna cut your time. We're about ready to sew in our kidney. We're gonna put the iliac vein. The renal vein with our iliac extension right here we're gonna so the renal artery onto the iliac artery right about here. Here's our external iliac artery and the internal comes off somewhere in there right there. So that's the internal and here's the common up here. This is the spot where you generally always put the first kidney transplant. So here's our kidney with our ureter down here. The vein extension here and artery there. So the Hiler structures come out that little window there, fold the ureter up in there. So let's cut our iliac vein a little bit here. So on our vein extension to be approximately as long as the artery. It's too much longer, it gets unwieldy. So let's do something like just under that branch. Alright, great. There's our iliac bay. Yeah, yeah snap. Gonna open the vein, keep sailing. Alright, huge. Or if it's on our extension so All right, that's good. So he goes out to end on the renal vein. We'll call it and into out on the iliac vein. Sorry they go basically at the halfway point. This is just a stay stitch. He's going to go into out stitch. I'm gonna go out to n and out sean. Alright, so now we're ready to take the kidney out of slush. So this is gonna be the start of the warm ischemia time. He's gonna tie both sides of the vein and then so from the head towards the feet. Yeah, We're gonna take a six. So punch on the artery. Yeah that's good. Take one five or 6 in there and then take a bite. He'll take a needle driver back. So when you put the Alice on there you gotta make sure you don't like rotate the kidney kind of in this way where the highland sticks out says happy, they're right here, yep. Yeah that's good. So here's our artery can hook it up right there. So go into out on the artery usually is always the best way so you don't develop an intimate flap. Don't go out and go into out. So we'll put that one down and use the next one will go into out on the iliac see the follow is away from me towards the person sewing. So it pulls the back wall away from the front wall. Yeah, let's get the artery stitch from the other side. Running around The corners are hired to do them in two. Alright, about a minute from an clamping so I'll be ready for some volume if you need to give it. How's the blood pressure now? All right, alright, clamps are off four by four. A whole bleeding. But there's something that every day I have to get on the other side eventually we'll see what settles out. four x 4. Just feel the artery pulses here. So iliac pulse above. Hello? She feels the same great pulses in the renal arteries there. The plumbing is okay. Unwrap the kidney looks good, you can see here. Okay. R right renal vein are venous extension graft and the iliac vein here, the artery is under there. So these are arterial anastomosis and are venus and esteem assis nice, beautiful kidney. So, we just get these little tiny vessels on the kidney. The bo br the argon kidneys nice and pink, feels good. Nice and nice amount of firmness. Not too firm but not too soft. Alright, let's just look at the renal vein skin clamp and fill the bladder please. He makes a lot of urine. So, this bladder should be nice and big. I think it is. Right. Right. Mhm. Right. Alright, so there's our bladder. He's gonna make a hole in the bladder section. I like to do it more kind of in this way. Not like this because I think it's really hard to so if it's too much like that. Yeah. So kind of like towards the shoulder. Yeah, exactly. Just towards the shoulder, basically. Yeah. Take a max on ready. So he's gonna make a pinhole in the bladder mucosa little bit down. Right. Yeah. Okay, vertical pots. Mhm. Yeah. Yeah. Right. Yeah, wow. Right. Mhm. You can see if you watch closely there's already urine coming out of the urine tube going into the bladder there. It's so hard to see. But very small bites in the corner. You saw the mucosa there on the Great, so he's seeing the bladder mucosa with every stitch because we don't get the mucosa to the mucosa. You get a leak, small bites back in this corner and they get bigger and bigger as you go around the horn. Yeah. Right. See the bites have gotten much bigger since the first couple in the corner. So this first bite in the corner is very small. See there's the orifice we easily could get instructed by a big bite and Yeah. Right. Right, so the ureter anastomosis is done. We're just gonna make a little anti reflux tunnel. Okay, it just creates a little bit of a tunnel so that when bladder fills up and squeezes. Doesn't reflux into the year. Alright, so native ureter iliac artery renal artery renal vein. With our extension graft iliac vein. Ureter bladder. All right, great. I'm just gonna position the kidney and then we're all done. Yeah. Alright. I got 1234 mm. It's a good name. My stitch, please. Right, you never know. Yeah. So we did a living donor kidney transplant to the patient from his sister. He's young and relatively healthy and pre dialysis and expect to have a really good outcome. Otherwise it was a really uncomplicated operation and he should do well be in the hospital about three or four days and then go home. Kidney is already making urine. So he should have good renal function.