Place the patient on a padded operating table. Following induction of anesthesia and intubation, place a Foley catheter and an orogastric tube. Mark the lower midline and the planned Pfannenstiel incision line while the patient is supine. This will help keep the incision symmetric following placement of the patient in the lateral decubitus position (Fig. 110.1A, the arrow points to the line of the Pfannenstiel incision). Electrocautery pads are attached. Then position the donor in the right lateral decubitus position as shown (right side down). Place a right axillary roll. Hold patient in place with a bean bag or laminectomy gel rolls. Bend the bottom leg to a neutral position and pad the ankle. Drape the Foley posteriorly through the patient’s legs and place it where the anesthetist can see the filled container. Place pillows between the legs and slightly
flex the top (left) leg. Secure patient with a wide tape to the table at the hips and legs without direct contact of tape with the patient’s skin. Place the left arm in the Krause arm support in a neutral position pointing diagonally cephalad across the face so that it is well away from the operative field. The arm is generously padded and secured to the sling. Pad the area between the face and the sling. It is important for the anesthetist to protect the patient’s face and endotracheal tube during arm positioning.

Prep and drape the patient. A prefabricated laparoscopic drape is useful. Bring the camera, light source, insufflation tubing, and harmonic scalpel off the left side of the patient and cautery and irrigation equipment, off the right side. Place an additional pocket made from a pillowcase and x-ray cover off the left side below the operative field (Fig. 110.1B).

Perform a time out, including a check of the patient’s UNOS number, and blood type of the donor and the recipient. Insert the Veress needle below the left costal margin lateral to the edge of the rectus and insufflate after confirmation of Veress position with aspiration and saline drop test. Place the first 12-mm port about the level of the umbilicus in the midclavicular line. Introduce a 30-degree laparoscope and inspect the abdomen for Veress needle trauma or bleeding. Remove the Veress needle. Insert the second 12-mm port near the umbilicus. The position of this port site is variable and depends on the patient’s body habitus. It is helpful to position this port site more cephalad and medial in larger patients. Switch the camera to this port site where it remains for the rest of the case. Place the first 5-mm port near the Veress needle insertion site, although the port can often be placed several centimeters more cephalad once the abdomen is insufflated. Place the second 5-mm port in the left flank in the anterior axillary line after the colon is mobilized. Secure all ports to the skin with 2-0 silk suture. This is important to help prevent accidental port extraction later in the case when passing the stapling devices during the extraction phase of the nephrectomy.

The inferior epigastric artery runs in the lateral aspect of the rectus sheath and should be avoided when placing the trocars.

Incise the white line of Toldt superiorly from the descending colon to the sigmoid colon (Fig. 110.2A). Retract the colon medially (Mattox maneuver) taking care not to penetrate the mesocolon and making sure that all pulsatile vessels which are part of the colonic mesentery are swept medially. Mobilize the spleen medially by dividing the splenorenal ligament (Fig. 110.2B) and the splenocolic attachments with a hook cautery to provide maximal medial retraction of the descending colon. This will expose the Gerota fascia along with the gonadal vein (Fig. 110.2C) and ureter.

The white line of Toldt is the peritoneal thickening where the visceral peritoneum of the colon meets the parietal peritoneum of the lateral abdominal wall. It is an avascular line for entrance into the retroperitoneum. Once entered, the colon can be dissected medially by dividing the alveolar tissue that secures it to the retroperitoneum.