The assisting surgeon’s right hand is introduced into the abdominal cavity, and the descending colon is retracted medially and freed from lateral peritoneal attachments exposing the left paracolic gutter. The operating surgeon controls the electrocautery hook with his right hand and bipolar pickups with the left hand. The descending and the sigmoid colon are then fully mobilized. The splenocolic ligament is also transected and additionally cauterized with bipolar pickups. Following the exact plain between the mesentery of the left colon and the Gerota’s fascia allows bloodless exposure of the anterior surface of the left kidney even in cases with significant intra-abdominal adiposity. Occasionally, if the lower pole of the spleen overlays the upper pole of the kidney, the posterior splenic attachments are transected and the spleen is partially mobilized. The operating surgeon has to be very cautions to avoid injury of the body and tail of the pancreas, which may also be overlaying the upper pole of the kidney.

The mobilized left colon is retracted medially by the assisting surgeon, and the retroperitoneal space is exposed. The dissection is carried along the anterior surface of the left psoas muscle, starting from lateral towards medial until the left ureter is identified. The three-dimensional (3D) view offered by the robotic system allows a quick and safe identification of the left ureter. The ureter is circumferentially dissected and mobilized distally to the point where it crosses the iliac vessels. A generous amount of adipose tissue should be conserved around the ureter in order to preserve its blood supply. A short Penrose drain is introduced, placed around the mobilized ureter, and clipped to itself to hold the ureter. This technique allows atraumatic lateral retraction of the ureter by the assisting surgeon using a locking grasper. This maneuver keeps the ureter in view and prevents injury during the dissection around the lower pole of the kidney. If a lower polar artery, originating from distal abdominal aorta is present, this vessel needs to be identified and exposed carefully because its unintentional injury would deprive the ureter of blood supply.

The gonadal vein is identified medial to the ureter and dissected off superiorly until its junction with the left renal vein. This maneuver allows safe identification of the renal vein at the proper distance from its bifurcation within the renal hilum. The tissue in front of the vein is transected and the vein exposed medially to its junction with the inferior vena cava (IVC). In rare cases, with retroaortic left renal vein, the dissection is carried as medial as possible. The gonadal vein is transected between two robotically placed hem-o-lock clips. Along the upper border of the renal vein, the left adrenal vein is identified. It is circumferentially dissected, double clipped, and transected (Fig. 27.4).

In most of the cases, at least one lumbar vein will be joining the left renal vein. We have identified up to five lumbar veins, forming a venous network and draining into the lower and posterior surface of the renal vein. The precision during the isolation and transaction of these veins cannot be overemphasized. In these cases, the articulating skills of the robotic system and the 3D vision give significant advantage over conventional laparoscopic instruments.

The adrenal gland is identified proximal to the left renal vein. The plain between the gland and upper pole of the kidney is followed, and the adrenal is left intact. The adrenal artery, which originates from the left renal artery, should be divided between clips whenever it presents. The upper pole of the kidney is then fully mobilized; this maneuver can be facilitated by the assisting surgeon exercising gentle distal hand retraction of the kidney. If a sizable upper polar artery is present, extra care should be taken to preserve this vessel, since it could supply 20–30 % of the kidney mass. Small upper polar arteries give <5 % of the parenchyma blood supply, and they are not involved in the vascularization of the pelvis, therefore, can be safely sacrificed.

The previously mobilized ureter is clipped with two robotic hem-o-lock clips where it crosses iliac vessels and sharply transects right proximal to the clips. Bleeding from the transected surface is a desirable sign, and the small amount of free urine flow in the retroperitoneal space has no consequences. The posterior attachments of the kidney are divided with the assistance of the assisting surgeon’s hand, as well as the articulated robotic instruments. During this maneuver, surgeons have to be cautious to avoid much tension on the hilar vessels or to unintentionally rotate the kidney to 180°, which would lead to strangulation and vascular injury.

After completed posterior mobilization, the kidney is gently retracted medially. This allows an easier identification of the renal artery. The ganglionic and lymphatic tissues surrounding the renal artery need to be transected, allowing exposure of the artery. The vessel needs to be circumferentially dissected at the level of its origin from the aorta. Be very careful to not injure possible early arterial branches. If multiple arteries are present, every vessel has to be dissected freely as described. After completion of the dissection, the only connection of the kidney is the renal artery and vein. The precision during this part of the operation cannot be overemphasized, and the advantages of the robotic system are evident.

After the kidney is completely mobilized and the vascular dissection completed, 5,000 U of heparin is given intravenously to the donor and left circulating for 2–3 min. The kidney is supported medially by the assistant’s hand. The left robotic arm retracts the artery gently, while the right arm holds the robotic hem-o-lock clip ready. The assistant surgeon advances the Endo TA stapler, with vascular load, through the 12-mm left lower quadrant port. Utilization of the Endo TA stapler allows additional length of the artery to facilitate the implantation of the graft. The renal artery is stapled as close as possible to its origin from the aorta. After checking the proper deployment of the stapling line, the robotic clip is placed to enhance hemostasis. The artery is sharply divided with robotic scissors at least 3–4 mm distal from the stapler line. If multiple arteries are present, they are sequentially stapled and transected in a similar fashion. After completing the artery division, 50 mg of protamine is given intravenously to the donor to counteract the effect of heparin. Of note: It is not safe to only use a hem-o-lock clip for securing the arterial stump. The use of a stapler device is mandatory. We only use a hem-o-lock to avoid minimal bleeding at times observed from the staple line.

The kidney is now placed in a lateral (natural) position and the renal vein exposed. The operating surgeon exercises gentle lift and traction to the hilum, straitening the vein. The vessel is divided as medial as possible with an Endo GIA vascular stapler and, subsequently, inserted by the assisting surgeon through the left lower quadrant assisting port. Care should be taken to avoid engaging previously placed plastic clips into the stapler line. Using angulations of the shaft of the stapler is helpful.

The kidney graft is rapidly removed from the abdominal cavity and placed in a container with cold solution with the temperature below 4 °C and flushed with cold preservation solution.

Once the kidney graft is removed, the cavity is inspected for bleeding. The arterial and venous stumps are visualized, and the condition of the stapler line verified. If any doubt about the reliability, it should be over sawn with 5-0 Prolene suture, which is relatively easy with the articulated robotic arms. Some bleeding from left over adipose capsule is controlled with electrocautery. Be cautious to the presence of chylous and lymphatic leak. If any of these situations are identified, it should be controlled with suture ligation.