The descending colon is mobilized from the spleen to its transition to the sigmoid colon (left-sided nephrectomy) or ascending colon from the hepatic flexure down to and including the cecum (right-sided nephrectomy). On the left side, the surgeon or assistant’s hand pulls the colon gently away from its attachments which are divided along the white line of Toldt with an ultrasonic shears or alternate energy device. The superficial peritoneal attachments are released. The lateral renal attachments are not released in order to prevent medial rotation of the kidney. Gravity will allow the colon to remain deep or medial to the operative region. This will expose the kidney surrounded by Gerota’s fascia and caudal to this the psoas muscle (figure 3).
The ureter is next identified. The ureter will be found 8 to 10 cm caudal to the tip of the inferior pole of the kidney anterior to the psoas muscle and lateral to the aorta (left side) or vena cava (right side) in close proximity and posterior to the gonadal vein (figure 4). The gonadal vein is a good anatomic landmark to help identify the ureter. The ureter is mobilized away from the gonadal vein leaving adequate soft tissue around the ureter to avoid stripping of its blood supply, resulting in ureteral ischemia which could lead to urine leakage in the recipient. Alternatively, the gonadal vein and ureter can be mobilized and removed together to ensure integrity of the ureteral blood supply. Dissection proceeds in a cephalad direction along the gonadal vein until reaching the renal vein (left side) or the vena cava (right side).
On the left side, the gonadal vein is secured with titanium vascular clips adjacent to the renal vein and sharply divided (figure 6). A bipolar energy device may also be used to transect the gonadal vein. If the gonadal vein is removed with the ureter, the vein will be similarly clipped more caudally, at the same level that the ureter is eventually divided. On the right side, the gonadal vein is kept intact unless it is removed with the ureter, in which case it is secured with vascular clips and sharply divided adjacent to its termination at the vena cava as well as at the level that the ureter is eventually divided.
The kidney is next mobilized. Mobilization may begin inferiorly, as shown in the accompanying figures or superiorly. Gerota’s fascia is entered along the anterior aspect of the lower pole of the kidney (figure 4). Then the upper pole of the kidney is dissected (figure 5) and the adrenal gland is retracted medially and dissected away with a bipolar energy device from the upper pole as shown in Chapter 118 (figure 7). In this dissection renal artery branches to the upper pole may be identified and care should be taken not to injure them. After the upper pole of the kidney is released then the lateral and posterior attachments are divided. The kidney may be rotated in the medial direction to facilitate dissection and identify any posterior attachments to the renal artery and vein.
It is preferable to divide all the branches of the left renal vein prior to complete mobilization of the kidney for ease of exposure during their dissection. On the left side, the adrenal vein is dissected at its insertion into the renal vein. It is divided with clips or a bipolar energy device. The left renal lumbar vein should be identified. If present it should enter the renal vein on its posterior aspect. The left renal lumbar vein is found joining the inferior/posterior aspect of the left renal vein anterior to the renal artery. It then courses posteriorly and just lateral to the aorta, inferior to the renal artery, and posterior to the gonadal vein (figure 6). This vein must be divided in order to identify the renal artery that lies immediately posterior. The left renal lumbar vein is carefully dissected, clipped, and sharply divided (figure 6). Occasionally the lumbar vein will be absent and occasionally the predominant venous drainage to the vena cava will be the via lumbar vein posterior to the aorta (retroaortic renal vein). Note that there are no lumbar branches arising from the the right renal vein if the right kidney is being donated. In order to provide adequate length for the anastomosis the renal vein is dissected from all surrounding perivascular attachments to a point medial to the adrenal vein.
The renal artery is identified posterior to the renal vein and bluntly dissected from the surrounding tissues using an ultrasonic device to minimize blood loss. On the left side, an adrenal artery originating from the cephalad aspect of the renal artery is usually encountered and must be clipped and divided or divided with a bipolar vessel sealing device (figure 6). The renal artery is dissected proximately to the aorta (left side) or well posterior of the inferior vena cava (right side). The renal vein should be dissected about 2 cm proximal to the adrenal vein (left side) or to the vena cava (right side) to allow adequate length for the anastomosis. During the renal vessel dissection it is important to maintain the soft tissue lying between the ureter and the inferior pole of the kidney to avoid disrupting ureteral blood supply in this area. Once the artery is circumferentially dissected, the renal vessels are the only intact structures within the renal hilum.
On the right side, the artery is best approached by reflecting the kidney medially and dissecting directly over the renal artery behind the inferior vena cava. There are no renal vein branches to divide. Once the renal artery is dissected, the remaining tissue lying between the artery and the vena cava is dissected. Upon completion the renal vessels are the only intact structures within the renal hilum.
After the kidney is mobilized the patient is administered intravenous furosemide and mannitol. One should avoid administration of these diuretics before the kidney is mobilized as the kidney swells, making the dissection more difficult.
Finally the ureter, with or without the gonadal vein, is dissected caudally until the common iliac vessels are encountered deep to the ureter. The kidney is now ready for removal. The patient is systemically heparinized as the ureter is clipped with vascular clips at the caudal limit of the dissection and sharply divided leaving the proximal ureter open. This preserves adequate length of the ureter (figure 7a and b). The renal artery is stapled close to the aorta (left side) or behind the inferior vena cava (right side) (figure 8). The renal vein is stapled ≥2 cm proximal to the adrenal vein stump (left side, figure 9) or at the vena cava (right side). The kidney is extracted through the hand port. The heparin is reversed with protamine.
The surgical site is inspected to assure hemostasis (figure 10). The previously mobilized colon is placed back in its in situ position and port sites are closed in standard fashion and sterile dressing applied.