Donor nephrectomy for renal

transplantation
Living Donor
• Donor Nephrectomy
• Postoperative Care and Complications
• Open versus Laparoscopic Nephrectomy

Cadaver Donor
• Removal of Kidneys Alone
• Removal of Kidneys with Other Organs
 LIVING DONOR
Donor Nephrectomy
• The technical details of donor nephrectomy
vary among different centers—some favor an
anterior transperitoneal approach, whereas
others favor the lumbar approach

• Many centers have embarked on laparoscopic

living donor nephrectomy as the standard
 LIVING DONOR
Donor Nephrectomy
The principles :
(1) adequate exposure;
(2) careful handling of the tissues, especially during
periarterial dissection to limit vascular spasm;
(3) preservation of adequate perihilar and
periureteral fat to ensure adequate vascularity to
limit the possibility of subsequent ureteral
necrosis;
(4) maintenance of active diuresis, which makes
prompt post-transplantation function more likely.
 Open vs. laparoscopic nephrectomy

(1)lack of surgical expertise with laparoscopic

nephrectomy
(2)lack of resources for laparoscopic nephrectomy
(3)previous abdominal surgery in the donor in
which the laparoscopic technique is unlikely to be
feasible
(4)need for greater donor vessel length in cases in
which the blood vessel anatomy is marginally
acceptable
 DECEASED DONOR
• The most commonly practiced procurement
technology today continues to be retrieval of
viable organs for transplantation from brain-
dead patients who are maintained in stable
physiological balance by artificial support
• This approach gives the term heart-beating
cadaver donor.
 DECEASED DONOR
• The donor may require large volumes of intravenous fluids
to restore blood volume, which typically has been severely
depleted by premortem attempts to decrease brain
swelling and achieve neurological resuscitation

• Diuretics, mannitol, and vasopressors are administered as

needed to promote diuresis during the nephrectomy
procedure

• Some groups systemically heparinize the donor and

administer vasoactive agents, such as
phenoxybenzamine or phentolamine, to combat vasospasm
in the kidneys.
 DECEASED DONOR
• In situations in which the criteria for brain death
have been fulfilled, but the concept of heart-
beating donation has not been accepted, or in
which there is irreversible brain injury, but not
fulfilling the criteria of brain death, respiratory
support is discontinued in the operating room
(termed donation after cardiac death [DCD])
• After cardiac function ceases, the donor is
declared dead, and the surgical procedure is
performed
 DECEASED DONOR
• In situations of donation after cardiac dead
(DCD) the kidneys must be removed and
chilled more rapidly than in the heart-beating
donation procedure to minimize ischemic
damage to the retrieved organs.
The goal is to limit the warm ischemic period,
whenever possible, to less than 30 minutes.
 DECEASED DONOR
• Several studies have confirmed that significant numbers of
patients die in emergency departments or intensive care
units without brain death being declared.
• Presumably, suitable allografts could be salvaged from such
potential donors if reliable methods could be identified to
control the ischemic damage that occurs shortly after
death.
• Current approaches include combined in situ kidney
flushing and core body cooling by femoral artery and
peritoneal catheters placed at the bedside immediately
after cardiac arrest.
• The non–heart-beating donor can be transported to the
operating room for bilateral nephrectomy
 Cadaver donor nephrectomy
Removal of kidneys alone
• If only the kidneys are to be removed, bilateral nephrectomy
is accomplished through a long midline incision.

• The objective is to take both kidneys with the full length of the renal artery and
vein, preferably on aortic and vena caval cuffs.

• This approach limits the possibility of injuring accessory vessels, which are present
in 12% to 15% of normal kidneys.

• The technique we prefer entails en bloc removal of both kidneys with an intact
segment of aorta and inferior vena cava to allow early in situ cooling of the
kidneys.

• This approach reduces the time required for the nephrectomies because the fine
dissection necessary for identification and isolation of the artery and vein can be
performed after the kidneys are removed. With this technique, the risk of
damaging accessory vessels is essentially eliminated.
Cadaver donor multiple organ retrieval
• The more typical situation involves multiple organ
procurement from the same donor. Acceptable donors
for heart, liver, or pancreas transplantation are younger
(generally <70 years old) and hemodynamically more
stable than some donors from whom kidneys alone can
be retrieved.
• Kidneys suitable for transplantation can be salvaged
from a donor after cardiac function has ceased,
whereas multiple organ procurement is rarely
accomplished from a non–heart-beating donor
cadaver.
Cadaver donor multiple organ retrieval

• Requires careful coordination among three surgical teams to

ensure that there is no compromise in viability of any
transplantable organ.

• It is crucial to have anesthesia support to monitor and maintain

cardiovascular integrity of the donor during the extensive
dissection, which may take 1 to 3 hours.

• Although the details differ, depending on the combination of

organs to be removed, certain common principles prevail,including
wide exposure, dissection of each organ to its vascular connection
while the heart is still beating, placement of catheters for in situ
cooling, and removal of organs while perfusion continues,
usually in the order : heart, lungs, liver, kidneys, and pancreas.
Cadaver donor multiple organ retrieval
• If the heart is to be retrieved, it is usually partially
mobilized as the first maneuver so that it can be
removed quickly at any later stage should vascular
instability occur during the dissection of the other
organs.
• The preparatory steps for cardiectomy require
opening of the pericardium, mobilization of the
superior vena cava, and separation of the aorta from
the pulmonary artery
Cadaver donor multiple organ retrieval
• Dissection is undertaken to mobilize the liver or pancreas,
or both.
• If the pancreas is not to be used, the splenic and superior
mesenteric arteries may be ligated or divided, or both. The
common bile duct is transected and the gallbladder is
incised and flushed with cold saline to prevent biliary
autolysis. The portal vein is dissected to the confluence of
the splenic and superior mesenteric veins where a catheter
can be placed into the splenic vein for subsequent rapid
portal perfusion .
• Alternatively, the inferior mesenteric vein is used for the
placement of the portal vein catheter. Isolation of the liver
is completed by mobilizing the vena cava posteriorly.
Cadaver donor multiple organ retrieval
• If the pancreas is to be transplanted, the
spleen is mobilized, the short gastric vessels
are divided, and the spleen and pancreas are
retracted to the right. The body and tail of the
pancreas are carefully dissected free.
• More commonly, the entire pancreas and a
segment of duodenum can be mobilized for
pancreaticoduodenal transplantation.
• The kidneys and major abdominal vessels are
exposed next by retracting the ascending colon
and small bowel to the left and lifting the
mobilized duodenum anteriorly .
• The kidneys are elevated from the
retroperitoneum and the distal aorta and vena
cava are completely freed.
• The donor is given heparin and mannitol, after
which a perfusion catheter is placed in the aorta,
and a venous drainage catheter is placed in the
vena cava.