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CASE 46: Living Donor Nephrectomy – Open Minimal Incision Approach

Jennifer Yu; Ernesto P Molmenti; Surendra Shenoy

ALTERNATIVE OPEN MINIMAL INCISION APPROACH FOR LIVING DONOR NEPHRECTOMY

  • Open minimal incision technique

  • 6-8 cm flank incision over the tip of the 12th rib (Figure 112-194)

  • Tip of the 12th rib is resected

  • Peritoneum reflected anteriorly and the kidney mobilized starting with release of upper pole

  • Ureter is mobilized after mobilization of the lower pole

  • Hilar dissection performed once the entire kidney has been circumferentially mobilized

  • Ureter is clamped/clipped/tied and transected

  • Artery, vein, and ureter are controlled with a Hendren vascular clamp

  • Kidney is removed via the incision used for dissection (Figure 112-195)

  • Vascular stumps manually oversewn after the kidney is removed

  • Secure individual-layer muscle closure for all three layers of the abdominal wall

  • Preferentially offered for right donor nephrectomies and/or kidneys with multiple vessels with early bifurcation

FIGURE 112-194

The open minimal incision living donor nephrectomy approach entails a 6-8 cm mini laparotomy above the tip of the 12th rib.

An incision in the lower quadrant of an abdomen of a person, secured by plasters.
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FIGURE 112-195

The kidney is removed through the incision after the vessels (and ureter) are clamped and transected.

An intra-operative shows the kidney is extracted through an incision in the abdomen.
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POTENTIAL ADVANTAGES WHEN COMPARED TO HAND-ASSISTED LAPAROSCOPIC NEPHRECTOMY

  • Completely retroperitoneal approach

  • Single flank incision

  • Diminished costs (no disposable laparoscopic instruments)

  • Optimized vessel length [for both artery (Figure 112-196) and vein cuff for right vein (Figure 112-197)]

  • Shorter operative time

FIGURE 112-196

Optimization of vessel length in this living donor with 3 renal arteries allowed for the independent implantation of all 3 arteries (arrows). Note that while 2 arteries (white arrows) were anastomosed in an end-to-side fashion to the external iliac artery, the third one (yellow arrow) was sewn end-to-end onto the recipient inferior epigastric artery.

An intra-operative highlights the renal arteries anastomosed to the external iliac artery and the recipient's inferior epigastric artery.
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FIGURE 112-197

In this living donor right kidney with two renal veins, a patch of donor IVC (arrow) was obtained to allow for better implantation onto the recipient external iliac vein.

An intra-operative highlights the donor IVC.
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REFERENCES

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Shenoy  S, Lowell  JA, Ramachandran  V, Jendrisak  M. The ideal living donor nephrectomy ‘Mini-Nepherctomy’ through a posterior transcostal approach. J Am Col Surg. 2002;194:240–246.
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Subramanian  T, Dageforde  LA, Vachharajani  N, Wellen  J, Doyle  MBM, Lin  Y, Khan  A, Senter-Zapata  M, Chapman  W, Shenoy  S. Mini-incision versus hand-assisted laparoscopic donor nephrectomy in living-donor kidney transplantation: A retrospective cohort study. Int J Surg. 2018 May;53:339–344. doi: 10.1016/j.ijsu.2018.04.003. Epub 2018 Apr 11. PMID:
[PubMed: 29654968] . 

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