CHAPTER 52: Implantation of the Kidney

OVERVIEW

Ernesto P Molmenti

Preoperative Considerations

• Complete blood count, electrolytes, and all other preoperative requirements are addressed.

• Meet with recipient immediately prior to the procedure to address any pending questions.

• We routinely implant the kidney on the right lower quadrant.

• Implanting the kidney on the right or left side is based on:

  • Surgeon preference

  • Vascular disease involvement of iliac vessels

  • Previous surgeries (transplants, ostomies, scars)

  • Specific characteristics of the organ being implanted

  • Other factors

• Verify that the correct allograft is the one about to be implanted, and complete required forms.

• Recipient should have adequate venous access—at least two large-bore peripheral IV lines.

  • The decision whether to place a central venous line is based on the specific characteristics of each recipient.

    • Advantages of a central line include:

      • More thorough intraoperative management, especially in instances of cardiac dysfunction where central venous pressure (CVP) readings provide additional information for adequate management

      • Intravenous access in instances where peripheral venous access is limited or absent

    • Disadvantages include:

      • Risk of complications (pneumothorax, vascular injuries)

      • Misplacements (especially in instances where the large veins have become stenotic as a result of previous dialysis catheters)

• Arterial lines are placed if needed based on individual recipient characteristics.

• Urinary catheter is ALWAYS placed prior to the procedure after induction of anesthesia

  • It is useful to be aware of the volume of urine being produced prior to the procedure, especially when monitoring postoperative outputs.

• We routinely maintain sequential compression devices on both lower extremities during the entire case to diminish the incidence of deep venous thromboses.

Timeout

• Performed immediately prior to incision after the abdomen has been painted and draped.

• Review all medications given preoperatively.

• Intravenous antibiotics are administered (assuring that they are received within minutes of incision).

• Other medications administered:

  • Induction agents

  • 500 milligrams solumedrol (or other desired dosage)

  • 25 g mannitol

  • 100 mg of furosemide (diuretics can be administered during the timeout or prior to reperfusion).

Incision and Dissection of the Iliac Vessels

• Curvilinear (right or left) lower quadrant incision extending 1-2 finger-breadths medial to the anterior superior iliac spine (ASIS) to 1-2 finger-breadths superior to the ipsilateral pubic tubercle.

• Subcutaneous tissues and muscles transected with electrocautery

• Extraperitoneal dissection exposes the retroperitoneum

  • If peritoneum entered, it can be repaired in order to prevent visceral hernias through the defect.

    • Some surgeons prefer to purposefully open the peritoneum and subsequently close it in order to allow for the intraperitoneal drainage of potential seromas or lymphoceles.

      • Beware of postoperative urinary leaks in these instances, since rather than forming a contained urinoma, all urine will be diverted intraperitoneally.

      • although highly infrequent, purposefully opening and closing the peritoneum could be associated with localized adhesions leading to small bowel obstruction.

• External iliac vessels are exposed and dissected free of surrounding tissues.

• In instances of kidneys with short renal veins (such as with right kidneys):

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