The first stage of the operation is on the donor kidney on the back table. This can be done by a single surgeon and one cirulating assistant. The surgeon sits on a chair at convenient height with good light (eg a small sattelite light will do nicely). An assistant cuts open the outer bag of the donor kidney and the surgeon removes the inner bag and places it on a tray of crushed ice. A bag is wrapped around the tray to keep the water in and a swab is put over the bag and ice to stop frostbite on the donor kidney. The surgeon first inspects the kidney for damage and to orientate the organ. The dissection is similar for the right and left organs apart for their anatomical peculiarities. Silk sutures are placed at the corners of the cava and aorta, these act to straighten out the vessels and make dissection easier. The dissection proceeds in an orderly manner, first the vein is dissected, then the artery, the supra renal gland and fat over the top and sides of the kidney are removed and finally the ureter is dissected.
When dissecting the vessels, any fascia that looks like it may contain lymphatics should be ligated. This is to reduce the chances of lymphocoele formation in the post-operative period. In addition, any small vessels that are not being retained should be carefully ligated. The vein is dissected first. It is separated from adherent fat and fascia as far as the renal pelvis. It is not necessary to clean the vein all the way into the kidney as this may damage the vein. On the left kidney the adrenal and gonadal veins enter the left renal vein and should be divided and ligated. Next the artery is dissected. Care must be taken to avoid damage to any of the smaller arteries. All major arteries supplying the kidney must be preserved. The arteries are dissected free of fat and fascia up to the renal pelvis. The suprarenal gland and the fat/fascia over the superior, anterior, lateral and posterior aspects of the kidney are removed. Finally attentention is turned to the ureter. A golden triangle of fat/fascia carrying blood to the proximal urter is said to exist between the lower pole of the kidney and the ureter, this should be preserved.
A special step that must be taken when preparing the right donor kidney is to form a venous extension from the vena cava. The cava is trimmed just above the site where the right renal vein enters the cava. The trim line is brought across below where the left renal vein was cut from the cava. This new deffect in the cava is repaired with prolene so that the donor vein is now longer than the artery. The anastamotic site will be where the cava has been cut inferiorly.
Each of the arteries supplying the kidney are cannulated with a Tips cannula and the kidney is irrigated with cold saline. It is important to use saline as the university of Wisconsonin solution has a high potassium content and must be washed out prior to reperfusion. A bag of cold saline is hung on a drip stand and the sterile giving set is connected to the Tips cannula. The effluent in the vein makes any holes obvious, these are repaired with prolene. It is also helpful to gently irrigate the vein with the Tips to check for further holes. Syringe pressure on a Tips is not used as the high pressure damages the vessels endothelium and may increase the risk of subsequant intimal hyperplasia and anastamotic stenosis.
Finally a Carrel patch of the donor vessels is trimmed to facilitate rapid and safe vasular anastamosis.