Place the donor in the right lateral decubitus position (right side down) and flex the table (Fig. 91.1A). Accurately plan and mark the following trocar sites and incision lines (Fig. 91.1B). The inferior medial (camera) trocar site is placed 2 to 3 cm inferior and 5 cm to the left of the inferior margin of the umbilicus (estimate the lateral edge of the hand-assist device to be sure to be lateral to it). The lateral trocar is placed 3 cm medial and 2 cm inferior to the iliac crest.

Make a 1.5-cm incision at the medial site (being careful not to burn the skin edges) and insert a Veress needle (or Hasson port). If adhesions are suspected, make the midline hand incision first (or use a Hasson port) and then place the ports under direct vision. Insufflate the abdomen and place the 12-mm medial trocar. Insert the laparoscope and place the 12-mm lateral port under laparoscopic guidance.

Next, create the midline hand-port incision. Draw a line beginning at the inferior edge of the umbilicus and extending 7 cm superiorly (depending on glove size) and make an incision just large enough to permit the hand. Insert the hand-port and subsequently use the left hand to retract the kidney atraumatically and facilitate dissection.

Incise the white line of Toldt laterally to the descending and sigmoid colon, beginning with the splenic attachments (Fig. 91.2A). Retract the colon medially (Mattox maneuver). Take care not to penetrate the colonic mesentery, which is often quite thin. Mobilize the spleen medially by dividing the splenorenal ligament (Fig. 91.2B). To provide maximal medial retraction of the descending colon, carefully divide the splenocolic attachments with ultrasonic dissecting shears. Open Gerota’s fascia over the anterolateral aspect of the kidney and establish the plane between Gerota’s fascia and the capsule (Fig. 91.2C). Open this superiorly.