Fig. 5.1
The kidney is oriented in its anatomic position to allow for careful inspection of the renal artery (red arrow), the renal vein (blue arrow), the ureter, and the parenchyma. Placing a small clamp on the distal ureter (yellow arrow) is helpful in keeping the proper orientation of the kidney
The renal artery is dissected free from the surrounding hilar tissue and an appropriate-size aortic patch is fashioned (Fig. 5.2). Care should be taken to identify and preserve early branches/polar branches at all times.
Fig. 5.2
The renal artery is dissected free from the surrounding hilar tissue
The renal vein is then similarly dissected for an adequate length. The tributaries of the left renal vein, including the adrenal, gonadal, and lumbar veins, are ligated and divided. The left renal vein is usually of adequate length and does not include the IVC. The right renal vein usually has no branches (Fig. 5.3).
Fig. 5.3
The tributaries of the left renal vein, including the adrenal, gonadal, and lumbar veins, are ligated and divided
The shorter right renal vein can be augmented by using a segment of the IVC. The edges of the cava superior and inferior to the origin of the renal vein are fashioned and then closed using a fine running vascular suture (Fig. 5.4).
Fig. 5.4
A segment of the inferior vena cava (IVC) can be used to augment the right renal vein. (a, b) The edges of the cava superior and inferior to the origin of the renal vein are fashioned (blue dotted line) and then closed using a fine running vascular suture
A number of other techniques to augment the short right renal vein have been described (Fig. 5.5).
Fig. 5.5
(a) The upper end of the cava can be sutured closed and the lower end used for anastomosis. (b) Vascular staples are fired perpendicular to the length of the cava, along the direction of the right renal vein. (c) The cava is cut along the dotted lines. The renal vein ostium is sutured end-to-end to the cava
The surrounding perirenal fat is removed from the kidney, taking care not to injure the capsule. This is started from the medial aspect of the upper pole, where the adrenal gland is identified and removed. The dissection continues along the upper pole and then the lateral aspect of the kidney (Fig. 5.6). Extensive dissection in the lower pole should be avoided, as it may devascularize the ureter.
Fig. 5.6
Removal of the perirenal fat is started from the medial aspect of the upper pole, where the adrenal gland is identified and removed. The dissection continues along the upper pole and then the lateral aspect of the kidney (small arrows). The fat and tissue in the triangle formed by the lower pole, the hilar vessels, and the ureter (large arrow) should not be dissected from the kidney, to maintain blood supply to the ureter
Minimal dissection should be done around the ureter to maintain blood supply. The accompanying gonadal vein may be removed (Fig. 5.7). The kidney is now ready for implantation.
Fig. 5.7
The gonadal vein accompanying the ureter may be removed
5.3 Adult Kidney Transplantation
The kidney is placed in a retroperitoneal location (heterotopic), in either iliac fossa. The right iliac fossa is preferred, as the right iliac vein is more superficial. The left iliac fossa is chosen if a future pancreas transplant is planned or if a kidney was previously transplanted on the right side. In a few situations, intraperitoneal placement of the kidney is preferred: in simultaneous kidney-pancreas transplantation; in pediatric recipients weighing less than 20 kg, allowing for more space and anastomosis to larger vessels; and in a recipient with multiple previous transplants or procedures on bilateral iliac vessels.
For adult recipients, the vascular anastomoses are usually performed to the iliac vessels. For arterial inflow, the common, external, or internal iliac artery may be used. Generally, the external iliac artery is preferred. If it is diseased or narrow in caliber, there should be no hesitation in using the common iliac artery. The best option is to place the kidney in the fossa prior to selecting a site of the anastomosis, and choose the site where the renal artery will lie most naturally without tension, redundancy, or angulation.
The external iliac vein is most commonly used for outflow. The optimal site depends upon the position and lie of the allograft kidney. The branches of the iliac vein are more variable than those of the artery. There may be one dominant internal iliac vein or several smaller ones. If the graft renal vein is short or if the recipient iliac vein is deep, then the branches of the internal iliac vein can be ligated and divided. This brings the vein to a more superficial position and makes the anastomosis simpler to perform.
Urinary continuity is established by anastomosing the graft ureter to the bladder. This may be done with or without a stent. Several different techniques have been described for performing this anastomosis. It is most important to ensure that the ureter is vascularized and perfused (especially at its most distal position), that it is not under tension, and that it is not excessively redundant. It is advisable to create a tunnel at the distal graft ureter to decrease urinary reflux.
5.3.1 Operative Procedure
With the patient in the supine position, a “hockey stick”–shaped incision is made in the lower quadrant (Fig. 5.8). The incision starts in the midline, one or two finger breadths above the pubic bone, and extends laterally, gently curving upwards until the lateral edge of the rectus muscle is reached. The incision is then extended superiorly along the lateral edge of the rectus.
Fig. 5.8
For adult kidney transplantation, a “hockey stick”–shaped incision is made in the lower quadrant (purple line), starting in the midline, one or two finger breadths above the pubic bone (solid black line). The incision extends laterally, gently curving upwards until it reaches the lateral edge of the rectus muscle (broken brown line). The incision is then extended superiorly along the lateral edge of the rectus
The incision is deepened to the fascia. The anterior sheath of the rectus is incised in a medial to lateral direction (Fig. 5.9). At the lateral edge of the rectus muscle, the fascial incision is continued superiorly just lateral to the edge of the rectus. It is here that the muscular layers of the lateral abdominal wall form the anterior and posterior sheaths of the rectus. Very few muscle fibers need to be divided with this approach. It is usually not necessary to divide the rectus muscle medially, but freeing it to its attachment to the pubic bone helps in exposing the bladder.
Fig. 5.9
(a, b) The incision is deepened to the fascia. The anterior sheath of the rectus is incised in a medial to lateral direction
The inferior epigastric vessels are encountered in the lower half of the incision (Fig. 5.10). These vessels are divided between ligatures.
Fig. 5.10
The inferior epigastric vessels are encountered in the lower half of the incision (broken blue line)
As the incision is deepened, the next structure identified is the round ligament in females and the spermatic cord in males (Fig. 5.11). The round ligament can be divided between ligatures; the spermatic cord is preserved.
Fig. 5.11
The next structure identified is the round ligament in females and the spermatic cord in males (broken yellow lines). A vessel loop is passed around the spermatic cord and it is preserved
The peritoneum is gently reflected medially and the cautery is used to divide loose attachments. This allows visualization of the underlying psoas muscle and the retroperitoneal space (Fig. 5.12).
Fig. 5.12
The peritoneum is gently reflected medially (broken blue line) and the cautery is used to divide loose attachments. This allows visualization of the underlying psoas muscle (broken yellow line) and the retroperitoneal space
We prefer to use a self-retaining (Bookwalter) retractor. The iliac vessels, the genitofemoral nerve laterally, and the native ureter medially are identified (Fig. 5.13). The location of the bifurcation of the common iliac artery is identified at the site where the ureter enters the pelvis. Care is taken to ensure that the blades of the retractor do not impinge upon or occlude the iliac vessels proximally.
Fig. 5.13
Using a self-retaining (Bookwalter) retractor, the iliac vessels (black arrow), the genitofemoral nerve (yellow arrow) laterally, and the native ureter (blue arrow) medially are identified
The external iliac artery is dissected and mobilized to allow for placement of vascular clamps and anastomosis. Lymphatics overlying the artery are ligated and divided to decrease the risk of lymphocele (Fig. 5.14).
Fig. 5.14
The external iliac artery is dissected and mobilized. Lymphatics (yellow arrows) overlying the artery are ligated and divided to decrease the risk of lymphocele
The external iliac vein, which lies just medial to the artery, is mobilized. If the iliac vein is deep or the graft renal vein is short, branches of the internal iliac vein can be ligated and divided to bring the vein to a more superficial position. After the vascular dissection is completed, we prefer to place the kidney in the iliac fossa to determine the best site to perform anastomoses. These locations are marked with a marking pen (broken purple lines) (Fig. 5.15).
Fig. 5.15
The external iliac vein (blue arrow), which lies just medial to the artery (yellow arrow), is mobilized. The best sites to perform anastomoses are marked with a marking pen (broken purple lines)
The venous anastomosis is performed first. Clamps can be placed proximally and distally on the vein, or a single auricular clamp may be used. A venotomy of appropriate size is made. There are several ways to perform the actual anastomosis. We prefer the four-stitch technique. Four sutures are placed: one at the upper end, one at the lower end, and one on each side (Fig. 5.16).
Fig. 5.16
To perform the venous anastomosis, a venotomy of appropriate size is made. We prefer the use of four sutures for the actual anastomosis: one at the upper end and one at the lower end (solid lines) and one on each side (broken lines)
The four sutures are tied and the superior stitch is sewn circumferentially around the anastomosis. The primary surgeon sutures his or her side and the assistant sutures the opposite side (Fig. 5.17). The renal vein is anastomosed to the iliac vein in an end-to-side fashion.
Fig. 5.17
The four sutures are tied and the superior stitch is sewn circumferentially around the anastomosis. (a) The primary surgeon sutures his or her side and the assistant sutures the opposite side. (b) The renal vein is anastomosed to the iliac vein in an end-to-side fashion (blue arrow)
The arterial anastomosis is performed in a similar fashion. The artery is clamped proximally and distally. An arteriotomy of appropriate size is made. If there is no aortic cuff on the donor artery (as with a living-donor transplant), then a small circular arteriotomy is made on the recipient iliac vessel (Fig. 5.18). A vascular punch device can be used for this, as shown (Fig. 5.19). If there is a patch around the donor renal artery, then a linear arteriotomy is made on the recipient vessel, and the patch is sewn to the arterial wall (Fig. 5.20).
Fig. 5.18
To perform the arterial anastomosis, the artery is clamped proximally and distally. An arteriotomy of appropriate size is made. If there is no aortic cuff on the donor artery, then a small circular arteriotomy is made on the recipient iliac vessel (yellow arrow)
Fig. 5.19
A vascular punch device can be used to create the circular arteriotomy
Fig. 5.20
If there is a patch around the donor renal artery, then a linear arteriotomy is made on the recipient vessel, and the patch is sewn to the arterial wall
The clamps are then removed, and the kidney is allowed to reperfuse. The anastomoses and the renal hilum are checked for hemostasis.
There are several methods to perform the ureter-to-bladder anastomosis including the Ledbetter-Pollitano, Litch, and anterior one-stitch techniques. The latter two techniques are described. The distal ureter is prepared by ligating the accompanying ureteral vessels (black arrows), trimming excess length of ureter and spatulating its distal end (Fig. 5.21).
Fig. 5.21
To perform the ureter-to-bladder anastomosis, the distal ureter is prepared by ligating the accompanying ureteral vessels (arrows), trimming excess length of the ureter (broken blue line), and spatulating its distal end
The retractors are repositioned to expose the bladder. It is helpful to fill the bladder and clamp the urinary catheter at this point. An incision is made through the detrusor muscle to expose the underlying mucosa without going through it (Fig. 5.22).
Fig. 5.22
(a, b) The retractors are repositioned to expose the bladder. It is helpful to fill the bladder and clamp the urinary catheter at this point. An incision is made through the detrusor muscle to expose the underlying mucosa without going through it (black arrow)
The detrusor muscle is gently separated from the underlying mucosa (Fig. 5.23). This can be done bluntly with gauze. This step helps in the subsequent creation of an antireflux tunnel.
Fig. 5.23
The detrusor muscle is gently separated from the underlying mucosa. This can be done bluntly with gauze (blue arrow)
With the Litch technique, an incision is made in the bladder mucosa and the distal spatulated end of the ureter is anastomosed to the bladder mucosa using a fine running absorbable suture (6-0 PDS) (Fig. 5.24). This anastomosis can be done with or without the use of an internal double J stent.
Fig. 5.24
With the Litch technique, an incision is made in the bladder mucosa and the distal, spatulated end of the ureter is anastomosed to the bladder mucosa using a fine running absorbable suture (6-0 PDS). We prefer to triangulate the anastomosis. One suture is placed in the heel, and one at each of the two distal corners. The heel stitch is then tied and the anastomosis is performed
In the anterior one-stitch technique (Fig. 5.25), a double-ended suture is placed at the spatulated end of the ureter and both needles are brought out on the “inside” (mucosal) aspect of the ureter. These two sutures are then brought through a small opening made in the bladder mucosa. The needles exit the bladder further distally, and these sutures are used to pull the ureter into the bladder. The ureter is then secured to the anterior wall of the bladder.
Fig. 5.25
In the anterior one-stitch technique, a double-ended suture is placed at the spatulated end of the ureter. Both needles are brought out on the “inside” (mucosal) aspect of the ureter (a). These two sutures are then brought through a small opening made in the bladder mucosa. The needles exit the bladder further distally (b). These sutures are then used to pull the ureter into the bladder. The ureter is then secured to the anterior wall of the bladder by tying the anterior double-ended stitch (c)
With either technique, the detrusor muscle is then closed over the distal 5–6 cm of allograft ureter to minimize reflux (Figs. 5.26 and 5.27).
Fig. 5.26
To minimize reflux, the detrusor muscle is then closed over the distal 5 cm or 6 cm of allograft ureter (broken blue line)
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