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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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