Kidney Transplantation: Step-by-Step Surgical Techniques

Foreword to the Polish Edition by Professor Przemysław Pisarski
Preface
Acknowledgments
Contents
1 Basic Anatomy of the Kidney, Ureters and the Urinary Bladder, and Their Functions
	1.1 Kidney Anatomy
	1.2 The Most Common Congenital Anomalies of the Kidney and Urinary Tract
		1.2.1 Anomalies of the Collecting System
		1.2.2 Malformation of the Renal Parenchyma
		1.2.3 Congenital Solitary Kidney
		1.2.4 Anomalies of Kidney Migration
		1.2.5 Kidney Function
	1.3 Blood Flow Through the Kidney—Glomerular Filtration [1–6]
	1.4 Renal Arteries
	1.5 Renal Veins and IVC Abnormalities
		1.5.1 Renal Veins
		1.5.2 The Most Common Anomalies of IVC
		1.5.3 Renal Lymphatic Vessels
	1.6 Ureter—Anatomy, Structure, Function and Vascularization
	1.7 Urinary Bladder—Position, Anatomy, Function and Arterial Blood Supply
		1.7.1 The Position of the Bladder
		1.7.2 Anatomy
		1.7.3 Function
	1.8 Conclusion
	References
2 Non-Laparoscopic Kidney Procurement Techniques from Living and Deceased Donors
	2.1 Introduction
	2.2 Surgical Technique of Kidney Procurement During Multiple Organ Donation from Donation After Brain Death (DBD) and Donation After Circulatory Death (DCD) Donors
		2.2.1 Introduction
		2.2.2 Deceased Donor Kidney Procurement Surgical Technique with Separation in the Donor’s Body. DBD, DCD—Multiorgan Procurement Surgical Technique in Brief. DBD, DCD—New Kidney-only Procurement Surgical Technique
			2.2.2.1 Differences in Steps Between Multiorgan and “Kidney-only” Procurement
			2.2.2.2 Kidney Procurement During Abdominal Multiorgan Procurement from Deceased Donors (DBD and DCD): The Same Surgical Steps in Brief
			2.2.2.3 Adult and Pediatric Deceases Donor “En Bloc” Kidney Procurement
				Introduction: Child Donor Criteria for Kidney Procurement
				Steps
			2.2.2.4 The Surgical Technique used to Separate Kidneys that have been Procured “En Bloc” from a Deceased Donor
				Introduction
				Surgical Steps
	2.3 “Kidney-only” Procurement from Deceased Donors; The Surgical Technique
		2.3.1 Introduction
		2.3.2 Kidney-only Procurement from Donor with Brain Death (DBD) without Sternotomy: A Step-by-step Surgical Technique
			2.3.2.1 Introduction
			2.3.2.2 Surgical Steps
		2.3.3 Kidney-only Procurement from Deceased Donor—with Sternotomy Surgical Technique—brief description
			2.3.3.1 Introduction
			2.3.3.2 Surgical Steps
		2.3.4 Surgical technique for Deceased Donor Kidney Procurement without Sternotomy with direct access to the lumen of the Abdominal Aorta using a large bore cannula
			2.3.4.1 Introduction
			2.3.4.2 Surgical Steps [24, 31]
		2.3.5 Surgical Technique for Kidney-only Procurement from the Donor after Circulatory Death (DCD) with Sternotomy (in Brief)
			2.3.5.1 Introduction
			2.3.5.2 Operation Steps [24, 31]
		2.3.6 The General Principles of Abdominal Organ Procurement from Donors After Circulatory Death (DCD) and Donors after Brain Death: The Same Steps at Different Time Periods—An Attempt to Undertake the Standardization of Surgical Techniques
	2.4 Surgical Technique for Living Kidney Donation: A Minimally Invasive, Open, Retroperitoneal Approach [51–58]
		2.4.1 Introduction: Anatomical Basis of This Surgical Technique
		2.4.2 Surgical Technique Step-by-step
	References
	Further Reading
3 Kidney Transport, Inspection and Preparation for Transplantation
	3.1 Introduction: Some Definitions
	3.2 Shipping a Kidney from the Donor to the Recipient’s Hospital
	3.3 Kidney Transport to the Operating Room
	3.4 Preparation of the Operating Room for Kidney Inspection Before Transplantation: Necessary Surgical Tools and Materials
	3.5 Removing the Kidney from the Transport Box and the Bags (Unpacking Procedure)
	3.6 Kidney Removal from the Transport Device for Continuous Hypothermic Kidney Perfusion
		3.6.1 Introduction
		3.6.2 Steps for Removing the Kidney from the Hypothermic Machine Perfusion: The LifePort Kidney Transporter of Organ Recovery Systems [4, 5, 7]
	3.7 General Rules for Kidney Inspection
		3.7.1 Step-by-Step Preparation of the Left Kidney for Transplantation
			3.7.1.1 Introduction
			3.7.1.2 Kidney Position and Left Renal Vein Preparation in Steps
			3.7.1.3 General Rules for the Preparation of the Artery Before Any Vascular Anastomosis, Regardless of Its Thickness and Severity of Arteriosclerosis
			3.7.1.4 Preparation of the Left Renal Artery in Steps
			3.7.1.5 Kidneys with Multiple Renal Arteries
				Introduction
				MRA: Most Common Techniques for Back Table Reconstruction
		3.7.2 Testing of Renal Vascular Tightness and Renal Parenchyma Perfusion Quality: Detection of Mechanical Damage or Stenosis to the Renal Mediastinum and Ureter
			3.7.2.1 Testing the Renal Artery and Vein Separately
			3.7.2.2 Quality of Parenchyma Rinsing
		3.7.3 Control of the Ureter for the Presence of Diseases or Mechanical Injuries and Constrictions
		3.7.4 Assessment of the Severity of Atherosclerosis of the Abdominal Aorta Wall and Ostium of the Renal Artery
	3.8 Preparation of the Right Kidney
		3.8.1 Introduction
		3.8.2 Right Kidney Inspection: The Most Important Steps
	3.9 Surgical Methods of Elongation of the Right Renal Vein with the IVC
		3.9.1 Introduction
		3.9.2 Kidney with a Short Renal Vein, Which Cannot be Lengthened
			3.9.2.1 Introduction
			3.9.2.2 Renal Transplantation with Recipient Iliac Vein Transposition
			3.9.2.3 Right Kidney Placed in the Right Iliac Fossa in the Inversion Position
		3.9.3 The Most Popular Surgical Techniques for Lengthening the Right Renal Vein
			3.9.3.2 Elongation of the Right Renal Vein with IVC Using a Vascular Stapler
			3.9.3.3 Short Cut Left Renal Vein: Reconstruction with Interposition Allograft
				Introduction
				Brief Case Description
				Ex Vivo Vein Reconstruction with Interposition Allograft Step by Step
			3.9.3.4 Other Techniques for Lengthening the Renal Vein
	3.10 Difficult Kidney Inspections and Preparation—Decision Making—Cases
		3.10.1 Right Kidney Procured with Three Renal Veins on a Patch from the IVC, but Without a Whole IVC from the Right Renal Vein up to Its Bifurcation
		3.10.2 Reconstruction of Two Renal Arteries of the Same or Different Diameter
			3.10.2.1 Introduction
			3.10.2.2 The Problem of Two Renal Arteries of the Same or Different Diameter Can Be Solved in Several Ways
				Renal Artery Reconstruction Using the Recipient’s Internal Iliac Artery
				Introduction
				Reconstruction “Ex Vivo”
				Reconstruction “In Vivo”
				Common Ostium, Common Outlet, “Side to Side” Anastomosis: The Conjoined Technique is Possible Only When the Vessels Are of Sufficient Length and Similar Size
				Introduction and Surgical Technique
				Advantages and Disadvantages of Common Ostium Between Two Arteries (Pantaloon—Side to Side Anastomosis)
		3.10.3 Reconstruction of the Renal Upper Pole Accessory Artery Cut Close to the Capsule During Organ Procurement
		3.10.4 Preparation for Transplantation: Right Kidney with Four Arteries, One Renal Vein Procured with the IVC and One Ureter—Steps (From Author’s Own Collection)
	3.11 Conclusion
	References
	Further Reading
4 Kidney Transplant Surgery Techniques
	4.1 Patient Position on the Operating Table
		4.1.1 The Position of the Patient on the Operating Table and “Time Out”
		4.1.2 General Anesthesia and the Last Time the Patient Is Repositioned on the Operating Table (Depending on the Surgeon)
	4.2 Urinary Bladder Catheter Placement and Its Availability During the Operation
	4.3 Cleaning and Sterile Draping of the Operating Field
		4.3.1 Patient Preparation Before Operation
		4.3.2 Skin: Operating Room
		4.3.3 Draping: Operating Room
	4.4 Choice of Surgical Access for Kidney Transplantation (Most Common Incisions)
		4.4.1 Hockey Stick Incision
		4.4.2 Oblique Incision (Gibson Incision—Gibson Cut)
		4.4.3 Horizontal Incision Lengths of 10–12 cm for Use in Young Slim Recipients
		4.4.4 Classic Incision: Rutherford Morison Incision
		4.4.5 Midline Incision
	4.5 Installation of a Professional Abdominal Retractor
		4.5.1 Introduction
		4.5.2 Installation Step by Step
		4.5.3 My Personal Settings of Retractors and Blades on the Wishbone Frame
		4.5.4 Iliac Vessel Preparation
	4.6 Kidney Inspected, Packed and Taken to Operating Theatre
	4.7 Biopsy of the Renal Allograft and of the Transplanted Kidney
		4.7.1 Introduction
		4.7.2 Open Biopsy
		4.7.3 Deep Needle Biopsy
	4.8 Determination of the Best Position of the Kidney in the Retroperitoneal Space, Determination of the Length of the Renal Vessels and the Ureter, and the Location of Their Anastomosis
		4.8.1 Confrontation with a Short Ureter; A Kidney You May Receive for Transplantation; Some Tips and Tricks
	4.9 Kidney Transplantation on the Right Side of the Retroperitoneal Space
		4.9.1 Introduction
		4.9.2 How Long Does the Renal Vein Have to Be in a Renal Allograft just Before the Anastomosis?
		4.9.3 Surgical Technique for Kidney Transplantation on the Right Side of the Pelvic Girdle
			4.9.3.1 Prepare the Right Iliac Vessels
			4.9.3.2 Preparing for Renal Vein Anastomosis
			4.9.3.3 Iliac Vein Clamping
		4.9.4 Arterial Anastomosis: The Renal Artery with the Iliac Artery End to Side
			4.9.4.1 Introduction
			4.9.4.2 Renal Artery Anastomosis with the One-suture, one-knot, Parachute Technique Is Also Preferred by the Author: Detailed Description of the Best Technique for the Artery
		4.9.5 Ureter Implantation into the Wall of the Urinary Bladder: Own Modified Lich-Gregoir (LG) Technique
			4.9.5.1 Introduction
			4.9.5.2 The Ureter Implantation LG Own Modified Technique: A Detailed Description (Fig. 4.52)
			4.9.5.3 Ureterovesical Anastomosis and Urinary System Decompression With or Without Decompression (Splint)?
			4.9.5.4 Urinary Diversion in Kidney Transplantation
				4.9.5.4.1 Introduction
				4.9.5.4.2 Surgical Performance Techniques of Ileal Conduit and Ureter Conduit Connections
				4.9.5.4.3 Complications
				4.9.5.4.4 The Most Important Steps in Kidney Transplantation
				4.9.5.4.5 Results
			4.9.5.5 Completion of the Operation (Which Is Worth Remembering)
				4.9.5.5.1 Perfect Hemostasis
				4.9.5.5.2 Drains
				4.9.5.5.3 Wound Closing
	4.10 Kidney Transplantation on the Left Side
		4.10.1 Introduction
		4.10.2 Differences in the Position of the Iliac Vessels on the Right and Left
		4.10.3 Method of Shortening the Distance Between the Short Renal Vein and the Iliac Veins
	4.11 Author’s Own Experiences: Difficult Cases of Kidney Transplantation
		4.11.1 Introduction
		4.11.2 First Case: Third Kidney Transplantation With the Simultaneous Removal of One of the Previously Transplanted, Failing Kidneys
			4.11.2.1 Introduction
			4.11.2.2 Case Raport
		4.11.3 Second Case: Kidney Retransplantation With End-to-end Anastomosis Between the New Renal Artery and Old Renal Artery
			4.11.3.1 Introduction
			4.11.3.2 Case Report
		4.11.4 Case 3: Kidney Transplantation. Renal Artery Anastomosis with a Vascular Prosthesis (Patient with Renal Failure after Aorto-bifemoral Vascular Reconstruction)
			4.11.4.1 Introduction
			4.11.4.2 Transplantation Procedure
		4.11.5 Kidney Transplantation with Two Ureters
			4.11.5.1 Introduction
			4.11.5.2 Surgical Technique
		4.11.6 Transplantation of Two Kidneys from One Donor
			4.11.6.1 Introduction
			4.11.6.2 Surgical Techniques
			4.11.6.3 Stimulation of Diuresis after Kidney Transplantation
	References
5 Methods of Treatment of Surgical Complications After Kidney Transplantation
	5.1 Bleeding: Surgical Side Bleeding
		5.1.1 Indications for Emergency Surgery
		5.1.2 Indications for Intensive Monitoring of a Patient with Suspected Bleeding into the Transplanted Kidney Area or into the Abdomen
		5.1.3 Management of Early Sub-renal Capsule Hemorrhage Occurring Immediately During or Sometimes Shortly After Renal Reperfusion. May Occur After any Form of Kidney Donation by Both Deceased and Living DonorsPerform a quick opening of the kidney capsule at the site of the bleeding. It is usually a vessel that is bleeding under the kidney capsule, because of the earlier contact with the retroperitoneal space in the donor’s body. A small vessel under the kidney capsule may not have been ligated or coagulated during or after retrieval and kidney benching. In many cases this small vessel has moved under the kidney capsule. A bleeding vessel can be very dangerous because, after a kidney reperfusion, it can bleed very intensely under the kidney capsule and detach it and cause a giant subcapsular hematoma which finally can destroy the kidney. If you are confronted with a subcapsular bleeding during kidney retrieval, procure the kidney and preserve it with cold preservation solution. Then open the renal capsule, find the bleeding vessel and sew up or ligate it and—if possible—suture the kidney capsule. In some cases, one of the contact hemostatic agents may be left under and/or on the kidney capsule before suturing it, and then the capsule may be sutured over it. In the event of subcapsular bleeding after kidney transplantation, the capsule should be opened, the vessel sewn up or coagulated, and then one of the hemostatic agents should be applied and the capsule should be sutured (if possible).A procured and flushed kidney reduces its volume. This means that the kidney parenchyma surface becomes smaller compared to the surface of the kidney capsule. The suturing of the kidney capsule is performed after the kidney has been flushed and before the implantation when the volume of the parenchyma is smaller than the volume of the capsule. After transplantation the volume of the kidney parenchyma increases rapidly. If the defect of the kidney capsule is very big, we do not sew it up but we coagulate the parenchyma of the transplanted kidney capsule which usually bleeds.
		5.1.4 Delayed Hemorrhage in Kidney Transplantation: A Life-threatening Condition
	5.2 Renal Allograft Rupture and Surgical Treatment
		5.2.1 Introduction
		5.2.2 Treatment
	5.3 Renal Artery Thrombosis
	5.4 Transplant Renal Artery Stenosis or Renal Artery Stenosis of the Transplanted Kidney
		5.4.1 Introduction
		5.4.2 Etiology
		5.4.3 Diagnostics
		5.4.4 Treatment
	5.5 Renal Vein Thrombosis
		5.5.1 Introduction
		5.5.2 Manifestation, Detection and Thrombolytic Therapy
		5.5.3 Surgical Treatment
			5.5.3.1 Introduction
			5.5.3.2 Surgical Thrombectomy of the Complete Thrombosed Renal Vein Soon After Transplantation: The Most Important Surgical Steps
	5.6 Urine Fistula/Urinary Leakage
		5.6.1 Introduction
		5.6.2 Unusual Description of Two Cases with Urinary Leakage (Author’s Own Experience)
			5.6.2.1 First Patient
			5.6.2.2 Second Patient
			5.6.2.3 The Most Common Causes of Pathological Changes Occurring During Organ Procurement, Benching and After Transplantation in the Ureter of the Transplanted Kidney [46–50]
		5.6.3 Symptoms of Urinary Leakage
		5.6.4 Treatment of Urinary Leakage
			5.6.4.1 Conservative
			5.6.4.2 Surgical Treatment
	5.7 Ureteral Stricture After Kidney Transplantation
		5.7.1 Introduction
		5.7.2 Causes of Obstruction or Complete Closure of the Ureter in a Renal Transplant Patient
		5.7.3 Symptoms
		5.7.4 Diagnostics
		5.7.5 Treatment
		5.7.6 An Unusual Patient as an Example of Ureteral Stenosis (Author’s Own Experience) [64]
			5.7.6.1 Discussion
	5.8 Lymphocele
		5.8.1 Introduction
		5.8.2 Incidence, Risk Factors, Prevention
		5.8.3 Symptoms
		5.8.4 Diagnostics
		5.8.5 Treatment
			5.8.5.1 Drainage with the Use of a Tenckhoff Catheter [82]
			5.8.5.2 Laparoscopic Fenestration [76]
			5.8.5.3 Surgical Fenestration
			5.8.5.4 Personal Experience of the Author
	5.9 Wound Infection in Renal Transplant Patients
		5.9.1 Introduction
		5.9.2 Signs and Symptoms of Wound Infection
			5.9.2.1 Superficial Incisional SSI Wound Infection: Treatment [84–90]
			5.9.2.2 Deep Incisional SSI Wound Infection: Treatment [84–90]
	5.10 Infection or Recurrent Infection of the Urinary Tract After Kidney Transplantation Due to Urethra-Bladder Anastomosis Decompression with a JJ Catheter
	5.11 Wound Dehiscence
		5.11.1 Introduction
		5.11.2 Symptoms of Dehisced Surgical Wounds
		5.11.3 Risk Factors of Dehisced Surgical Wounds
		5.11.4 Treatment of Dehisced Surgical Wounds
	References
6 Surgical Technique to Remove a Transplanted Kidney: Graftectomy or Transplantectomy
	6.1 Introduction
	6.2 Early Graftectomy or Graft Loss During One Year
	6.3 Late Graftectomy or Graft Loss
		6.3.1 Introduction
		6.3.2 Surgical Preparation for Late Graftectomy in Steps:
		6.3.3 Author’s Own Experience: How Dangerous Can Be?
		6.3.4 Own Modified Surgical Technique for Late Transplantectomy Step-by-step
	6.4 Conclusion
	References
7 The Most Important Issues in Qualifying a Patient for a Kidney Transplant by a Surgeon
	References
8 What a Safe and Successful Kidney Transplant Program Depends on?
	8.1 Introduction
	8.2 First Do no Harm—Primum Non Nocere—The Hippocratic Oath
	8.3 Conclusion
	References
Index