Chapters Transcript Video Living Donor Renal Transplant In this narrated surgical video, Chris Friese, MD, performs a right laparoscopic donor nephrectomy. I'm Doctor Chris Friese, interim chief of transplant at the University of California, San Francisco. And today we'll be performing a right laparoscopic donor nephrectomy. This is a young woman who's volunteered to donate a kidney. We're choosing the right kidney because the left kidney would likely have two arteries. Therefore, uh, the right kidney will hopefully have a single artery and a single vein. In the room next door, we'll have the recipient being prepped for the site for implantation of the kidney by Doctor Garrett Roll, 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. So we use the OptiView port to access the peritoneal cavity on the right side since the varus needle has been known to poke a hole in the liver. So this is a, I think a safer way to get in. So, we'll take a quick look around. This is where our extraction incision will be. Um, sure we didn't. Hurt the liver looks good. OK, so you're gonna go in right there, right, knife to him, just a 1 centimeter incision, no bigger. Make it too big. The ports will slide in and out. You can turn our room lights down now, please. All right, so we're on the right side, doing the right kidney. The reason is the left kidney had an early bifurcation of the renal artery, so it ended up with two arteries. We're going to try and get one artery here on the right side. All right, so the first move we're going to 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. Come in with your camera a little bit. Good. Slip down where the kidney is. Good. Let's look back down here, grasp her. So, the trick is to figure out the duodenum from the cava. This looks like duodenum here, so this will be vena cave underneath here, so we want to expose that. And once we've identified the cava, we just follow parallel to it until we get to the lower pole. Obviously taking care to make sure that the duodenum rolls off the. Retroperitoneum And the key is to get in the space between the vena cava. In the ureter of the kidney. By mobilizing this. Mesentery of the ascending colon off the retroperitoneum. Look more lateral over here to the left. Make sure the appendix is not in play as well. Right, so you can see that's the lower pole. It's just some perinephric fat and retroperitoneal fat. And then I'm back to trying to get into the space. So, here's cava right in here. Kidney here, so right in this space is where we'll find the ureter. There it is. And that'll be the psoas muscle underneath all this tissue. Good. Let's look down here now. Usually the gonano vein on the right side is preserved, so the gonano vein should be down here somewhere. A lot of times don't even see it. Right angle. Let's see the ureter peristalsing. Vessel loop, and then we use these vessel loops to mark important structures, usually the ureter, the artery, and the vein, so that we can easily access them when we're ready to divide them. And also use these to help with traction. All right, now once we've had the ureter identified, we'll march back towards the hilum, the kidney, again, keeping. Away from the ureter and. Not too close to the cava, so in between those two structures. So with my lateral hand, I use that as constant traction. On the kidney to put the hilum on a little bit of a stretch. Um-hum. 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, and donors that don't have a lot of uh retroperitoneal fat, these structures are usually pretty obvious right in the beginning. But here we have to carefully dissect through this extra tissue. It 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. And this is the renal vein starting to show itself. We want to get as much of this tissue cleared off because eventually when we Want to put the stapler fire across here. We want to have a nice clear path to the junction of the. Right vein in the vena cava all needs to be cleared. You're gonna 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 caudad side of the vein. So right in here, and we'll peel through the tissues there to identify it in a minute. I'd 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 cephalad side, so closer to the liver. So if you don't find it in here, you have to look to the other side. And this artery also has a fairly low branch point, so we're going to 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. See a little edge of adrenal tissue right here. See that? And here we're on the upper pole. So I took that little vein of sorrow there. So we don't tear it. Then we can look down in here and see if we get any hint of the artery up above the vein. For the, uh, It's not that. OK. 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. So 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 backside would be very difficult to control and almost likely lead to a need to open, so. Like to avoid that. And 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. And 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 going to get your grass on here and just give me some forward track. So I've decided that we're going to 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 perinephric fat off of it. It's a very nice plane, easy to see where you're going. Rather than taking all the fat with the kidney. Nice. Mhm. Very nice tissues, young, healthy tissues. Good. 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. And now we're starting to see it, see, so there's a loop around the vein and there's the artery that we can see better. From behind than we could the front. Just trying to get that plane right on the artery. If I can get rid of this wad, it would help a lot. I don't think that's a vessel. I may have to do is just loop this whole wad 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 going to be a little challenging. Uh, let's look, look back at the liver here. It's gonna hold up that liver edge. All right, relax on what you're holding there. Mhm. And come up, look up here. You have a little. that So, let's see, you've given a total of 6.25 Amanitol? She got a total of, uh, 12. 12.5, OK. OK. So, in a little bit here, we're going to ask you for another 12 1/2, along with 20 of Lasix. I'll tell you when to give that. OK, now, everything from this point on is extra credit to try and get him a single artery cause 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've got all the intervening tissue taken care of, so I think we're there. It's important if you are putting traction on the artery that you, you know, give it a chance to breathe every few. A few seconds Of course you don't want to pull too much because you can create a flap. Or a dissection, so. Now why don't you gently just hold the order that way. So what we're gonna do now is get a little more length on the ureter, so I can see the gonano veins, so I don't want to get into that. Obviously, you want to stay a ways away from the ureter so you don't interrupt its blood supply. And showing back at the kidney? That's a pretty good length there. So we'll stop there and 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, and 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. We'll, when we take the artery, we'll take it with the kidney roll rolled forward. Look so and then you're, what you're gonna do is hold this out of the way, hold the liver out of the way. And I'll be able to come in with a stapler and go like this. Um. And hopefully get him some arty, OK. Spring. Usually we need about a 2 1/2 to 3 inch incision to extract the kidney. Can I hold this guy? Antibiotic soak lamp. All right, so I got the stapler at one reload. Extraction bag, extra port. So generally, once we have the dissection completed, I like to desufflate, let the abdomen sit um. 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 pick up while we're uh waiting that period of time and during that time we're usually making our incision. It is important to give the kidney a period of time where it's not under pressure from the insufflation. My name is Garrett Roll. 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 cadaveric iliac vein grafts. So we're expecting a relatively simple operation, except for a venous extension graft possibly. Thanks for joining me today. So we marked the pubic symphysis, find the midline here. Top of the pubic symphysis is there. ASIS is there. About a finger breadth above. And we want to make our incision that goes up along the edge of the rectus here. To about the level of the belly button or a little bit below. So there's pubic symphysis. We want to get in the fascia about a finger breadth above the pubic symphysis. Just until he sees the vertical muscle fibers are 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 fascia here and I'm gonna go posterior to that right angle. Basically take the rectus down off the anterior fascia there, and then open this leaflet. Making our way to the inferior epigastrics right there. And you get around them and use an O tie, paired veins and an artery. A one. I'm gonna push that tissue towards the inferior epigastric and find the spermatic cord. 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. And get around the cord structures and put a vessel loop there. It's our cord. And this is the space we use, we developed to find the iliac fossa. Bowie. And so as. We're gonna roll the peritoneum off the. Enter your service here. So I'm rolling it with my fingers and then I'll bovie. All right. Is it time for me to go next door yet? Yeah. All right. I'll be back. All right, you can turn our lights down again, please, and the gas on. Take a DMG. 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. So 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. Got to 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. OK, look up, look up here. Mhm. Good. And I'm gonna hold that liver edge there. And you can go ahead and give the protamine now. So, you want to be, uh, 50 mg. I Cherry scissors. I'm back here. There you go. All right, good luck. All right, moist slap, please. And you're given the pro, that's good. You're giving the pro to me now. OK. Good. All right, I'll take the money. Thank you. So, let's run her fluids at, uh, 125 an hour overnight. OK. And she just gets a recovery room and one tomorrow morning. OK. That's Little vessel up on the vein there. OK. Just taking the stable line off the main. We'll have the egress of blood. There's our arterial staple line. I'm gonna open it up. So, now we're going to flush the, Renal artery of the kidney. You see the flush coming out the renal vein there. Trying to take the clip off the ureter during the flush to allow the, Small little vessels in the ureter to get flushed. Now that flush is starting to come out clear. Beautiful kidney, well flushed. Let's start on the vein. Just take this whole thing off. OK. So we're going to mobilize the vein a little bit here. It's unique. There you go. It's like a little branch actually there. Let's take that. All right, that's probably enough cause we're going to 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 here. So, we try to tie off big lymphatics in the hilum just to reduce the risk of a lymph leak later. All right. So, there you can see. A renal artery with our two branches there and there. And here's our renal vein. The right kidney, so it's a shortish renal vein, not too bad, but we're going to put a vein extension on, and we'll make it easier to implant. Let's just take the other, rest of the fat off the kidney here, and then we'll do the vein extension. Do Yeah Yeah OK. That would be good. That No Oh All right. So, now let's do our vein reconstruction. So, here's our ureter. The artery and our renal vein is. Right in there. See how short that can kind of appear. All right. So, here's our third party iliac vein from a deceased donor. Is it a good size match? Just confirm. It's a reasonable size match. Its wall there, man. Yeah. So he's outside, he's gonna go outside to in. 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. It's cause you have a short vein. And the recipient with a high risk of bleeding with that thin wall can be challenging to deal with once you're. Once you've implanted the kidney and the vein is underneath the kidney. See how thin walled that is compared to the iliac vein. Which we're selling it to. Yeah, it's a thin walled. The other side is thin walled on the backside there, not this side, but. 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. All right, 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. We'll sew 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, it bifurcates 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. All right, 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, lymphatic tissue goes down. And the peritoneum is towards me. Here's the recipient. Native ureter right there, right where we expect it to be coming over the iliac. All right, so, so as iliac artery, iliac vein under there, neurovascular tissue on the top or lymphovascular tissue on the top, native ureter. Peritoneum, bladder's under there. So, we're going to start on the iliac artery, probably about there. And you can see a lymphatic right there. So these are the target of this dissection, is to get the lymphatics over the iliac vessels and to tie them. Tie 30. So use 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. So. Trumbovi, the tissue on the side and posterior to the iliac vessel. Because there's not as much lymphatic tissue there. We try to tie the tissue anterior. To the iliac artery, cause that's, that's where the lymphatics generally are. So here's our iliac vein, and he's just gonna immobilize the anterior surface of the iliac vein, similar kind of concept. You can see a lymphatic running right there, so he's avoiding that one. The results here. The gold light of the new generation. 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 it'll always feed nicely. Branch going down there. Very gently up, branch right there. Yes. Yeah. I think we're going to 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. It's kind of a lot of bruane for this type of work. Just going to put a 60 prolene on the tie, so the tie doesn't pop off during the clamp. Basically just cinching that tie on the vein. Which is a good idea with any sizable vein coming off a 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. before. He's going to take a sixoprole after the ties. Baby. Again, just plastering the tie to the veins, it doesn't come off later. And when you're assisting, working on a big vein, you probably want 2 pickup sticks to be able to control the vein or a sucker in a pickup. But you're gonna be using both hands. Yeah. OK. Oh, I don't got your tongue. Good. 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 sew 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. Renal vein extension here and artery there, so the hilar 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 we want 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. All right, great. There's our iliac vein. Snap. It's going to open the vein. I'm sailing. Not a huge or if it's on our extension, so, all right, that's good. So he goes out to in on the. Renal vein, we'll call it and in out. On the iliac vein, so it's, they go basically at the halfway point, this is just a stay stitch. And he's gonna go in to out stitch. I'm gonna go out to in. And out. Sean All right. So, now we're ready to take the kidney out of slush. So, this is going to be the start of the warm ischemia time. So, he's going to tie both sides of the vein. And then so from the head towards the feet. We're gonna take a 6-0 punch on the artery. Yeah, it's good. Take one. 5 or 6 in there and then take a bite. Yes. He'll take a needle driver back. So when you um put the Alice on there, you gotta make sure you don't um like rotate the kidney. Kind of in this way where the highland sticks out. Says. Happy there and right here. Yeah. Yeah, that's good. So, here's our artery. I can hook it up right there. So we'll go into out on the artery usually is always the best way, so you don't develop it in more flap. Don't go out in, you go in to out. So you know, put that one down and use. The next one, we'll 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. Let's get the. Artery stitch on the other side. And around. And the corners are hard, you do them in two. All right, we're about a minute from unclamping, so be ready for some volume if you need to give it. How's the blood pressure now? 11 hours. All right. All right, lamps are off. And 4 by 4. Needle hole bleeding, but there's something there we may have to get on the other side eventually. We'll see what settles out. 4 by 4. And then we'll just feel the artery pulses here. So, iliac pulse above, below. So it feels the same. Great pulses in the renal arteries there. So, every, all the plumbing is OK. Unwrap the kidney. So, it looks good. So you can see here. Our right renal vein, our venous extension graft, and the iliac vein here, and the artery is under there, so. There's our arterial anastomosis and our venous anastomosis. Nice, beautiful kidney. So, we just get these little tiny vessels on the kidney. The boy or the argon, kidneys nice and pink, feels good, nice and. Nice amount of firmness, not too firm, but not too soft. All right. Let's just look at the renal vein. That's fine. It looks good. A lamp and fill the bladder, please. He makes a lot of urine, so this bladder should be nice and big. I think it is. OK. All right. 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, cause then it gets really hard to sew if it's too much like that, yeah, so kind of like towards the shoulder. Yeah, yeah, exactly, just towards the shoulder, basically. Take a max on already, so he's gonna make a pinhole in the bladder mucosa. Yeah, a little bit down. Vertical pots. You see, if you watch closely, there's already urine coming out of the urine tube going into the bladder there. So hard to say, but Some very small bites in the corner. You saw the mucosa there on the bladder? Yeah. Great. So, he's seeing the bladder mucosa with every stitch. Cause we don't get the mucosa to the mucosa, you get a leak, small bites back in this corner and then they get bigger and bigger as you go around the horn. Yeah. 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. See how easily it could get. Obstructed by a big bite. So, the ureter anastomosis is done. We're just going to make a little anti-reflux tunnel. Right. OK. Just creates a little bit of a tunnel, so the bladder fills up and squeezes, doesn't reflux into the ureter. All right, 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. 7891 our Yeah. Alright, I got 1234. It's it should be. No stitch please right. OK. It down Because you never know like what else. 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 he's expected to have a really good outcome. Otherwise, it was a really uncomplicated operation, and he should do well. Be in the hospital about 3 or 4 days and then go home. Kidneys are already making urine, so he should have good renal function. Published July 15, 2022 Created by Related Presenters Christopher Freise, MD, FACS Transplant surgeon View Full Profile
