The patient is put under general anaesthesia. Immunosuppressant drugs are administered in the ward preoperatively. The bladder is catheterised, any urine drained and the bladder filled with an antibiotic solution (cefuroxime 750 mg in 50 ml of saline), following which the catheter is spigoted.
The abdomen is prepped and draped, some surgeons apply an adherent iodine impregnated translucent drape. The surgeon stands on the side of the incision. A `Reisberg' incision is made from anterior axillary line above the umbilicus to just above the pubic tubercle. The external oblique aponeurois and anterior rectus sheaths are divided in the line of the skin incision. The rectus abdominus muscle is retracted medially and the transversalis fascia at the lateral aspect of the rectus sheath divided, care must be taken not to enter the peritoneal cavity at this point. The extra peritoneal fat is identified and the inferior epigastric vessels located. If the inferior epigastric artery is not needed for anastomosis to a separate polar artery, the epigastric vessels are ligated and divided. The extra peritoneal fat is pushed towards the midline and the muscles of the lateral abdominal wall and iliac fossa are identified. The dissection proceeds in this fashion until the iliac vessels are identified. If the iliac artery is of poor quality, for example heavily calcified or with a poor pulse then it may be necessary to choose another site for implantation of the donor kidney.
First the external iliac artery is dissected. It is necessary to divide the fascia and lymphatics over the external iliac artery to mobilise it. Anything that looks like it may contain lymphatic channels is best ligated to reduce the risk of subsequent lymphocoele formation. The lympatics are excised where needed and these are sent to the histopathological laboratory for examination. The external iliac artery is looped and a good length is mobilised, enough so that the vessel may be clamped and the arterial anastomosis performed without undue difficulty. Next the external iliac vein is dissected. Dissection is commenced distally where it may be necessary to divide the deep circumflex iliac vein and /or the inferior epigastric veins (often a common trunk). The vein is looped and the vessel mobilised to the necessary extent. A `Brookman' retractor is inserted, this is a retractor with a large metal ring. The retractor is attached to the table on the opposite side of the table, this gives a metal post to which a side-bar is attached. The metal ring is then attached to the side-bar. Positioning the ring is important as it may get in the way. It is best placed first with the incision in the center, then the ring is moved a fraction towards the midline. The ring is inclined so that the ring is lowest on the surgeon's side. Retractors are attached to the ring to keep the abdominal contents retracted, usually two are placed on the medial side. Large silk sutures are placed through the lateral abdominal wall and tied to the ring. If deep retractors are being placed, ensure that they are not pressing on the lumbo-sacral plexus or the recipient may suffer severe pain in the post operative period.
The donor kidney is taken from the back table in the tray of iced solution to the operating table. The tray is placed upon a folded drape, which keeps the tray steady and prevents damage to the recipients legs from the tray. Wet swabs are placed over the ring to prevent entanglement of the sutures used for the anastomosis. Anastomosis of the vein and artery of the donor kidney to the recipients vessels should be performed without delay as the kidney will start to warm up once it it taken off ice.
The recipient external iliac vein is clamped. No heparin is given. a longitudinal venotomy is made with a no. 15 or 11 blade scalpel. The scalpel blade is just used to open the vein, a rush of venous blood confirms entry, this stops when the blood in the vein empties if it continues it means that the clamps are not placed fully across the vein, they are not tight enough or a branch has been missed. The venotomy is lengthened with the `Potts' scissors to match the length of the donor vein. The kidney is taken off ice and the time noted. Two double ended prolene sutures (5/0 or 6/0) are inserted through the ends of the side to end veno-venous anastomosis. The deepest one is ligated, and the donor and recipient veins are sutured together on one side at least half way along. Then the distal prolene suture is tied and that side of the anastomosis completed from superficial to deep. The kidney is rotated so that the suture line may be inspected from the inside to ensure that the far wall has not been picked up. The the other side of the anastomosis is similarly completed starting form deep and moving up to at least half way, then coming down from superficial to deep. A straight clamp is placed across the donor vein and flow in the recipient vein restored by removal of the clamps. The suture line is inspected for bleeding. If there is heavy bleeding this is arrested with a suture, care being taken not to narrow the anastomosis. Next attention is turned to the arterial anastomosis.
The site of arterial anastomosis is selected. The donor artery is controlled with vascular clamps. Care should be taken not to apply the clamps too hard or they may transect the inner aspect of the artery, when the blood flow is restored the inner aspect of the artery may separate as an intimal flap which may occlude the blood flow to the donor kidney and/or the recipients lower limb. If the artery is very calcified then it may not be possible to clamp, in which case it may be controlled by an occlusion balloon `Fogarty' catheter. These heavily calcified arteries are difficult or impossible to stitch. An arteriotomy is made with a no. 15 or 11 blade scalpel. The arteriotomy is enlarged with a `Potts' scissors. There should be no bleeding once the blood in the controlled section of artery has emptied. If there is continuous bleeding this means that the clamps are misplaced, the clamps are not tight enough, a branch has been missed or the artery is so diseased that it may not be clamped. When the artery has been controlled two double ended prolene sutures are inserted, one at each end of the side to end arterio-arterial anastomosis. The deepest one is ligated, one side of the anastomosis is formed by suturing the donor and recipient arteries together from the deep aspect to superficial. The suturing along this side is continued for more than half way along the side, then the superficial suture is tied and that side of the anastomosis completed. The suture line is inspected from the inside to ensure that the far-wall has not been included. Then the other side of the anastomosis is formed starting from deep and proceeding to superficial for at least half way and then completing the suture line by proceeding from superficial to deep. The donor artery is pinched and the lower limb reperfused washing any clots down into the lower limb. Then the donor kidney is reperfused and the time noted. The kidney should rapidly pink up and fill with blood. After a minute or two some urine should be seen in the ureter. There may be some bleeding from the kidney or the vascular pedicle this must be carefully controlled.
The donor ureter is next anastomosed to the bladder. The bladder is identifed and is pulled cephalad with an `Allis' clamp. A transverse incision is made in the muscle of the bladder until the bladder mucosa is seen to bulge through the incision. The donor ureter is spatulated and brought deep to the vas (to stop it being pinched). The ureter is anastomsed to the bladder using 3/0 Maxon or Monacryl. One suture is placed in the bladder to invaginate the uretero-cystostomy.
The incision is closed in layers, the fascia is re-approximated with 1 Maxon and the skin closed with clips.