A donor nephrectomy is indicated for living donor renal transplantation. Potential donors are carefully selected to minimize the risk to the donor and to optimize the success of transplantation.
Before undergoing laparoscopic donor nephrectomy, donor blood type (ABO) and immunologic (HLA) compatibility with the recipient are established. The potential donor’s creatinine clearance is measured to assure normal renal function. If needed, the donor is evaluated with appropriate cardiovascular and pulmonary screening. Potential donors with a diagnosis of hypertension must undergo 24-hour ambulatory blood pressure monitoring to more closely examine their blood pressure status. An abdominal and pelvic computed tomography (CT) scan or magnetic resonance imaging (MRI) is obtained to confirm that the donor is anatomically suitable for kidney donation and for preoperative planning. Renal stones are ruled out using either a plain abdominal x-ray or the noncontrast phase of the CT. A contrast CT or MRI ureterogram is obtained to examine the renal collecting system. In selecting the donor kidney, the first order of priority is the well-being of the donor; if a mild abnormality is present, the abnormal kidney is donated. If there are no imperatives regarding the donor, then the best kidney for transplantation is chosen. A kidney with a solitary renal artery is preferred. If both kidneys have a single artery, the left kidney is selected because of its longer renal vein. Two units of packed red blood cells are typed and crossed.
General anesthesia with endotracheal intubation is required for the laparoscopic donor nephrectomy. Complete neuromuscular blockade is necessary. Intravenous antibiotics (usually a first-generation cephalosporin, or vancomycin if allergic) are given. The patient is liberally hydrated (2–4 L). Long-acting local anesthesia may be given prior to skin closure. Before emergence from anesthesia, the patient must be protected against postoperative nausea and vomiting with ondansetron, phenergan, or their equivalents. Special attention is given to minimize pain in these volunteers. Postoperative opiates are given, usually via a patient-controlled analgesia (PCA) pump. Supplemental opiates (if the patient gets behind on the PCA) and ketorolac may be given.
POSITIONING AND OPERATIVE PREPARATION
To minimize the risk of deep venous thrombosis, sequential compression devices must be in place and working before the induction of anesthesia. The patient is initially placed in the supine position to permit safe induction of anesthesia and line placement. An orogastric tube and a Foley catheter are placed after induction. The patient is aligned such that their iliac crest lies over the flex point in the bed. The patient is then placed in the lateral decubitus position with the nephrectomy side up (Figure 1A). The bed is flexed to open up the space between the 12th rib and the iliac crest (Figure 1B). A beanbag (or large gel pads) is used to help secure the patient in the lateral position. Further ...