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Transplantation - Practical Manual of Abdominal Organ Transplantation - 2002

Transplantation - Practical Manual of Abdominal Organ Transplantation - 2002

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Published by: basyony1970 on Feb 29, 2012
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The venous anastomosis is usually performed first. Aftertotal control of
external iliac vein is achieved proximally and distally, a longitudinal venotomy is
made in the side of the donor’s renal vein opening. The anastomosis is then
fashioned with 5-0 Prolene running sutures. The traditional arterial anastomosis
with the internal iliac artery has the advantage of gaining some length from the
internal iliac artery to overcome the shortness of the donor renal artery, partic-
ularly in a living kidney donor. This, however, requires more extensive dissection
and ligation of the internal iliac artery, with various potential complications. Most
surgeons prefer anastomosis to the external iliac artery in end-to-side fashion.
When there are multiple arteries, a Carrel patch can be fashioned to include all the
arteries in one patch, if the arteries are close enough in a cadaveric donor kidney.
If the arteries are far apart or in a living donor kidney, then arterial reconstructions
at the backtable will be needed. If both arteries are of equal size, they can be joined
to the external iliac artery separately. In order to reduce the warm ischemic time
during the arterial anastomosis, various techniques of arterial reconstruction can
be performed at the backtable, as described earlier. Sometimes a small upperpole
artery can be sacrificed, if it is too small for reconstruction; on the other hand, the


Shuin-Lin Yang

lower pole artery is very important to the arterial blood supply of the ureter, so
reconstruction shouldalways be attempted. Usually,prosthetic materials (e.g.,
Gore-Tex) are not recommended for reconstruction.
Mannitol and furosemide are given just prior to releasing the vascular clamps
for reperfusion. Upon reperfusion, hemostasis should be obtained by careful in-
spection of both anastomoses and ligation of all bleeders at small branches of the
vessels. Warm irrigation fluid should be applied to help warm up the kidney. The
kidney usually becomes firm and pink a few minutes are revascularization. The
urine may begin to flow out of the uretersoon thereafter, particularly if the ischemia
time was minimal. If the kidney remains flaccid after reperfusion, carefulinspec-
tions of external iliac and renal arteries should rule out any arterial inflow
problems. The systemic pressure and the central venous pressure must be main-
tained at an adequate level to ensureproper renalperfusionpressure. If vasospasm
is suspected, papaverine or verapamil may be injected into the transplanted renal
artery. If after all these measures the kidney is still flaccid and not producing
urine, then the transplant kidney may be suffering from delayed graft function.
Very rarely, hyperacute rejection should be considered as a possibility. A needle
biopsy and/or wedge biopsy is taken at this point as the baseline histology control
to be used for comparison in future biopsies.

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