PREOPERATIVE DIAGNOSIS: Healthy kidney donor.
POSTOPERATIVE DIAGNOSIS: Healthy kidney donor.
PROCEDURE PERFORMED: Laparoscopic ureteronephrectomy, left.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
BLOOD LOSS: 100 mL.
SPECIMENS: Left kidney for transplantation.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on the operating table. After adequate IV access and IV sedation, the patient was intubated and anesthetized. Venous catheterization was performed by Anesthesiology and a Foley catheter was placed by nursing staff aseptically. The patient was placed in the right lateral decubitus position and her left arm was placed under suspension armboard. All pressure points were padded and the patient was secured to the OR table with the OR beanbag. The kidney rest had been placed previously at maximal height and the bed flexed as well. The abdomen was prepped with Betadine solution and draped with sterile linen and sterile drapes. A midclavicular left subcostal incision was created and a 12 mm balloon port was placed by the Hasson technique. The abdomen was insufflated to 12 cm with CO2 gas and assessed. Multiple adhesions between the spleen and the omentum and the anterior abdominal wall were noted. These overlaid the kidney. A left lateral 5 mm and a left periumbilical 12 mm port were both placed under direct vision.
A hand port was placed in the left lower quadrant. Dissection began taking the left colon down at the white line of Toldt mobilizing medially and cephalad. The adhesions between the spleen, the omentum and anterior abdominal wall were taken down with Harmonic scalpel. The splenorenal ligament was divided with Harmonic scalpel. The adrenal gland was noted on the upper pole of the kidney and was followed down to the renal vein and the adrenal vein. The renal and adrenal veins were both dissected down the anterior surface. The adrenal vein was circumferentially dissected, ligated with clips x 4, and divided between ligatures. The adrenal gland was now taken off of the upper pole of the kidney with Harmonic scalpel. There was an upper pole vessel from the adrenal gland to the upper pole of the kidney, which did not communicate with the renal artery and was divided with the Harmonic scalpel creating a small dime-size area of ischemia. The rest of the upper of the kidney was mobilized and the kidney was retracted inferiorly. The renal vein was now dissected out lower surface. The gonadal vein was circumferentially dissected and was divided after ligated with clips x4. A very large lumbar vein was noted coming off of the renal vein on the posterior surface of the lobe of the gonadal vein. This vein was quite broad-based and immediately branched into 5 different vessels that were all large and engorged. The vein was circumferentially dissected down to the surface of renal vein and then was divided with endoreticulating vascular stapler.
The renal vein was now circumferentially mobilized down. With the renal vein elevated anteriorly, the takeoff of the renal artery was identified. The demarcation was developed with a Maryland dissector. All neurovascular tissues cephalad of the renal artery were then divided with the Harmonic scalpel inferiorly. The retroperitoneum was entered below the inferior pole of the kidney and above the gonadal vein. The tissues were then dissected sharply and bluntly, very carefully elevating the ureteral complex all the way down to the iliac vessels. The kidney was now brought out off of the retroperitoneum with Harmonic scalpel dividing the fibrous tissues on the back of the Gerota’s fascia. The posterior surface of the renal artery and renal vein were now cleared of neurolymphatic tissues. The kidney was placed back into the retroperitoneum, into its normal position.
The pneumoperitoneum was dissipated. The ureter was grasped, brought up through the hand port, was dissected down towards the bladder, was clamped below the iliac vessels, and divided leaving the ureter free to urinate within the peritoneum. The distal ureter was ligated with a 0 silk ligature. The kidney was now diuresed for 45 minutes with increased fluid management. The patient received 5 liters of fluid prior to excision of the kidney. With Dr. Doe now ready in the donor room, the abdomen was reinsufflated, the kidney was elevated, and the vessels were placed on mild tension and endoreticulating vascular stapler was placed across the artery at its junction with the aorta and deployed dividing the artery. The renal vein was divided with a serial load of the endoreticulating vascular stapler. Kidney was brought through the hand port and given to Dr. Doe under iced UW for preparation and the recipient on the back table.
The abdomen was reinsufflated. The abdomen was aspirated of as much urine as possible. The dissection bed and the peritoneum were irrigated with copious amounts of sterile saline and aspirated as dry as possible. The spleen and adrenal gland were identified at their dissection locations and had no injuries and were not bleeding. This staple line of the renal artery takeoff on the aorta was identified and it was not bleeding. The staple line of renal vein was also identified at the corner. The rest of it was below the aorta and was unable to be seen towards the vena cava. There was no blood welling up through this area and staple lines were intact. The distal dissection planes of the ureter were identified. There was some small clotted blood on the peritoneal surface in the retroperitoneum, this was cleared and aspirated from the peritoneum. There was no other bleeding noted. The distal tie on the distal ureter was intact and verified down towards the bladder. Iliac vessels were unharmed.
The abdomen was now desufflated and aspirated off all CO2 gas and liquid as much as possible. The 12 mm balloon ports were closed with figure-of-eight of 0 Vicryl suture incorporating the peritoneum and the fascia within the suture. Hand was placed to the hand port and the surface was palpated and found to have no bowel or omentum caught up with the sutures. The hand port was now closed. The peritoneum and posterior fascia were closed with a single running simple 0 PDS suture. An On-Q pain pump was now brought in 2 inches from the incision laterally and tunneled down underneath the oblique anterior fascia. The catheter was placed in the muscle layer between the anterior and posterior sheaths. The anterior sheath was now closed with another running 0 PDS suture in a simple running fashion. The subcutaneous tissues were irrigated with sterile saline and antibiotic solution. The pain pump catheter was pulled back gently to assure that it was not caught up within the sutures. It was then loaded with 15 mL, 1.25% Marcaine without epinephrine. The Scarpa’s layer and all incisions were brought together with 3-0 silk suture in an interrupted fashion. Skin incisions were brought together and reapproximated with 4-0 subcuticular Vicryl suture. All incisions were then covered with Dermabond tissue glue. The patient tolerated the procedure well and was taken to the recovery room in awake and stable condition.
