• The patient is positioned, trocars such as ENDOPATH XCEL™ Trocars, placed as above.
  • A 30-degree laparoscope is inserted through the left subcostal port.
  • The left abdomen is inspected – any adhesions are taken down.
     
  • Attention is turned to the left colon.  The left colon, including the splenic flexure, is mobilized by incising the lateral peritoneal reflection with endoscopic shears, or other energy modalities depending on surgeon preference.
  • The spleen is mobilized by incising the ligamentous attachments of the spleen. 
  • Mobilization of the left colon and spleen will result in the colon falling medially.  This will expose the left kidney. 
  • The left kidney is identified. 
     

Note – in cases of right nephrectomy, port placement is essentially a mirror image.  The liver is retracted cephalad and the right colon – including the hepatic flexure – is mobilized to expose the right kidney.  The duodenum may need to be mobilized (Kocher Maneuver) to expose the vena cava and the insertion of the right renal vein.

  • Gerota’s fascia is incised and dissected with an energy device such as Harmonic 1100.
  • The ureter is identified in the retroperitoneum between the lower pole of the kidney and the hilum. 
  • The ureter is traced along its course and dissected with an energy device until the point where it crosses the iliac artery. (This further mobilizes the left colon.) Care is taken to preserve sufficient tissue surrounding the ureter to maintain blood supply.
  • Attention is returned to the renal hilum.
  • The renal vein is identified.  Dissection of the vein proceeds with Harmonic 1100 and Maryland Dissectors.  Side branches of the renal vein (adrenal, gonadal, lumbar branches) are identified and divided, secured with either clips or Harmonic 1100.
  • The vein is mobilized circumferentially along its length to ensure maximum usable length for implantation of the allograft.
  • The renal artery is identified and mobilized circumferentially with Harmonic 1100 dissection.  The artery is mobilized to its takeoff from the aorta to ensure maximum usable length of the allograft.
  • The upper pole, lower pole, and posterior surface of the kidney are mobilized with Harmonic 1100 dissection by incising all perinephric fat and attachments. 
  • At this point of the procedure, the kidney should be completely mobilized, held only by the renal artery, renal vein, and ureter.
  • The ureter is ligated distally with clips, and transected sharply. 
  • The extraction site is now prepared.  This can be left lower quadrant (McBurney incision), peri-umbilical, or Pfannenstiel.  The skin incision is made and the dissection is carried through the fascia, with care being taken to maintain pneumoperitoneum.  This enables rapid removal of the kidney once the blood supply has been transected.
  • The kidney is retracted superiorly to extend the renal artery and vein. 
  • The kidney, now completely free, is placed in a specimen retrieval bag which is introduced via a small opening in the extraction site. 
  • The kidney is removed from the abdomen by extending the fascial opening of the extraction site.
  • The kidney is passed off to the back table, where it is flushed with cold preservation solution.
     
  • The fascia of the extraction site is closed with #1 PDS suture.
  • Pneumoperitoneum is re-established.
  • The laparoscope is re-inserted, and a thorough inspection for hemostasis is undertaken with particular attention to the renal artery and renal vein stumps.
  • Ports are withdrawn under laparoscopic vision.
  • Port sites and skin incisions are closed with Vicryl™ Plus Antibacterial sutures and Monocryl™ Plus Antibacterial suture.
  • Suture as per standard practice.
  • Skin adhesive or Steri-strips are applied over the incisions.

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