Cadaveric Donor Nephrectomy

Kidney procurement usually follows removal of the heart, lungs, liver, and pancreas. Many of the preliminary steps are common with multiorgan procurements, as described earlier. Once the abdominal viscera are flushed with the preservation solution, the kidney dissection is carried out in a bloodless field. A Cattell maneuver is performed to expose the aorta and inferior vena cava (IVC). The right lateral peritoneal reflection along the line of Toldt is incised, and the right colon is mobilized by retracting it superiorly and medially. Next, the small bowel mesentery is incised and swept up. The duodenum is mobilized (Kocher maneuver) and the pancreas is mobilized upward to expose the left renal vein, which is caudal to the celiac trunk and the superior mesenteric artery (SMA); these arteries are later ligated and then divided. The distal infrarenal aorta and IVC at the bifurcation are encircled with two umbilical tapes each (Fig. 9.1a).

The kidneys are dissected through Gerota's fascia, avoiding the renal hilum. To expose the left kidney, the left lateral peritoneal reflection of Toldt and splenic flexure are incised and the left mesocolon is divided. The ureters are transected distally as close to the bladder as possible. Periureteral areolar tissue containing the blood supply to the ureter is preserved. The ureters are retracted and freed to the level of the lower kidney pole. The IVC is divided just at the bifurcation. The

Figure 9.1a. Setup for procurement in cadaveric donor nephrectomy.

Transection of

Right Renal Left Renal vein Left Renal artery ostia artery and vein next to IVC / _

Transection of

Right Renal Left Renal vein Left Renal artery ostia artery and vein next to IVC / _

Figure 9.1b. Setup for procurement in cadaveric donor nephrectomy.

left renal vein is transected next to the IVC at the origin of the left renal vein to allow a panel graft of IVC to be created for extension of the right renal vein; the entire IVC stays with the right kidney. The aorta is then transected distally at the bifurcation and proximally, above the kidney. The kidneys, aorta, IVC, and ureters are retracted upward, and all tissues posterior are divided, while staying above the prevertebral fascia at the level of the paraspinal muscles. The aorta and IVC are incised vertically in the midline of the anterior wall to examine the orifices of the renal artery(ies) and vein(s) (Fig. 9.1b).

A Carrel's patch is created by dividing the posterior wall of the aorta vertically between the orifices of the renal arteries and the mirror-image orifices of the lumbar arteries. Care must be taken to identify multiple renal vessels, which are present in about 20-40% of cases. Sufficient perinephric fat should be excised in order to visualize the surface of the kidneys to rule out renal tumors and gross abnormalities. Before closing the abdomen, lymph nodes are taken from the small bowel mesentery or retroperitoneum, and a piece of spleen is removed for tissue type and crossmatch. The kidneys are packaged separately in plastic bags with University of Wisconsin (UW) solution and transported in ice coolers.

0 0

Post a comment