Technical aspects of Right laparoscopic Donor Nephrectomy

by Dr Devanshu Bansal, Santokba Durlabhji Memorial Hospital, Jaipur

Laparoscopic donor nephrectomy (LDN) is the current standard of care for live kidney donation.(1) The principle of selecting the left versus right kidney for donation is to leave the better functioning kidney with the donor. However, traditionally the left side has been favoured for retrieval even by the experienced surgeons because of the longer length of the renal vein (RV) with less complicated recipient surgery, and early reports of right donor nephrectomy showing an increased rate of graft vein thrombosis and graft loss. This might be related to the smaller length and the thin wall of the RV on the right side.(2,3) The retrocaval route of the right renal artery (RA) may also create a double graft artery in cases with early arterial branching. More recent reports from the high volume centers have confirmed the safety and optimal graft outcomes with right LDN.(1,4) The methods for RA control include application of two Hem-o-lok clips with or without an additional metal clip below them, or a vascular stapler. Although Hem-o-lok clip use has been advised against by the USFDA, other authors have reported several large series about their safety and ease of application.(5) On the other hand, there are various methods to obtain adequate RV length as detailed below (6)

1. Use of TA-30 stapler, which fires two staple lines without cutting. The vein is subsequently cut flush with staple line to gain extra length. 

2. Use of 15 mm Hem-o-lok clips with the applicator introduced parallel to inferior vena cava (IVC) to get maximum length of RV.

3. Use of laparoscopic Satinsky clamp to obtain vena cava cuff, with subsequent intracorporeal repair. 

4. Open incision for placement of Satinsky clamp to retrieve right RV with IVC cuff followed by open IVC repair.

Techniques to maximize vein length during anastomosis include the following (6) – 

1. Use of recipient’s saphenous vein to lengthen the RV. 

2. Complete mobilization of recipient iliac vein by dividing its posterior branches to bring it up in the wound for tension free anastomosis.

3. Placement of graft upside down for easier anastomosis.

With above techniques, an adequate RA and RV length can be obtained.