Special Surgical Procedures II
LESSON 3: Procedures in Genitourinary Surgery
Section Iii: operations on the kidney, ureter, and adrenal glands
3-19
3-19. KIDNEY TRANSPLANT
a. General.
(1) This procedure involves the removal of a donor kidney by means of a nephrectomy and ureterectomy with transplant of the donor's kidney in the recipient's iliac fossa. This is done in an effort to restore kidney function and thus maintain life in a patient who is succumbing to renal failure.
(2) The patient selected for kidney transplant is usually young, well advanced in irreversible uremia, free of other significant disease or infection, and free of obstruction in the lower urinary tract.
(3) A kidney replacement may be chosen from a living donor or from a cadaver that is without disease and of the same blood group as the recipient. The ideal living donor is an identical twin, although family members or other volunteers may be selected.
(4) It is important that the time lapse between donor nephrectomy and trans-plantation of the organ to the recipient be kept to a minimum. In living donors, hypothermia may be used to reduce the oxygen requirements of the kidney.
b. Preparation. Two adjacent operating rooms are prepared for the surgery, and the operations on donor and recipient proceed simultaneously. On a cadaver donor, the supine position is used, and a disposable drape with a large fenestration is used to provide adequate exposure for bilateral nephrectomies. For a living donor, either the lateral or supine position may be used. The recipient lies in the supine position.
c. Donor Operation.
(1) In living donors, angiography assists in selection of the preferred donor kidney.
(2) The donor nephrectomy is done much as the procedure already described in paragraph 3-14, but the surgeon will do a delicate dissection to prevent trauma to the renal vessels and ureter.
(3) The patient may be given intravenous mannitol before the kidney is excised, and the surgeon may inject 1percent lidocaine (Xylocaine®) about the renal pedicle before its dissection to prevent vasoconstriction. The scrubbed nursing team member should have sterile iced normal saline available to cool the kidney immediately after it is removed.
(4) If the donor kidney is cooled by intraarterial perfusion, cold (15˜C), sterile, lactated Ringer's solution to which heparin and procaine have been added will be introduced into the vessels by means of small polyethylene catheters under strict aseptic conditions. The sterile basins and donor kidney should be covered with a sterile drape and taken to the recipient operation by the surgeon.
d. Recipient Operation.
(1) The incisional approach is carried out.
(2) The donor kidney is placed in the contralateral iliac fossa of the patient and rotated 180 degrees so that the posterior surface is anterior in the patient. Placing the organ extraperitoneally may prevent peritonitis if an infection develops.
(3) The renal artery is anastomosed to a branch of the hypogastric artery and the renal vein to the external iliac vein.
(4) The ureter, depending on its length, may be implanted into the bladder directly by a tunneling technique, or it may be anastomosed to the recipient ureter. A cystostomy tube may be inserted into the bladder.
NOTE: Bilateral nephrectomies and splenectomy may be performed on the recipient
at the time of transplant or at another time, depending on the patient's general
condition and the surgeon's program of management. This is done to prevent
hypertension or urinary tract infection.
