**5. Vascular anastomosis**

After preparation of the place of the implantation, the surgeon should transfer the graft to its position transiently for better evaluation of the anastomoses sites. Some authors suggest that slush ice should put in the bed of the graft in the recipient, but we abso‐ lutely disagree with this opinion, because the total vascular reconstruction time is usual‐ ly less than 20 minutes and adding ice only increase the risk of local hypothermic injury. The surgeon should do his best efforts to reduce the total arterial and venous clamping time. First the site of each anastomosis and the position of the graft should be specified accurately according to the size and length of the vessels and also the length of the ure‐ ter and position of the recipient bladder or ureter and the final position of the implanted kidney. As described previously, we prefer to use the internal iliac artery and external iliac vein for vascular anastomoses. For reducing the vein clamping time (with subse‐ quent risk of deep vein thrombosis), we perform the arterial anastomosis first. But when the vein is shorter than usual or when the left iliac fossa is used for implantation, or when the abdominal cavity and aorta and inferior vena cava or the external iliac artery are used for implantation, it's better to perform the venous anastomosis first.

the upper corner and the internal iliac artery should be spatulated in the direction of the opposite lower corner (in other words in the direction the deep part of the artery). Renal vein

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 177

An endarterectomy should be done with extreme caution after cutting the internal iliac artery or entering the external iliac artery. No intimal flaps in the opposite direction of the blood flow should be remained at the end of endarterectomy. If such flap is remained, then the surgeon should decide to change the arterial anastomosis site, if possible, or at least the flap must

Special attention should be paid to the length of the right artery and left renal vein of the de‐ ceased donor. They are both too long for anastomosis and if not trimmed or shortened, kinking will be inevitable which will result in postoperative renal dysfunction and hypertension.

Arterial anastomosis is started by two corner stitch in each side of the vessel as described first by Carrel in 1902. Care is taken to include equal bites of all layers of the arterial wall in each passage of the needle and the adventitia remained outside. For this purpose we perform a 1 mm adventi‐ tiectomy of both arteries and use microvascular forceps, scissors and needle holders for arterial anastomosis and also recommend using a 4.5-6X loop for magnification and surgical headlights for better illumination. It's so important that the posterior layer suturing of the arterial anasto‐ mosis is done first and from outside. The needle should move from inside to outside of the more diseased artery (usually the recipient artery) to tag the intima to the media of the artery and pre‐ venting from creating an intimal flap which will be a good trigger point for future thrombosis. The upper suture is tied but the lower is maintained untied till the end of the anastomosis. The posterior layer is sutured first and then anterior layer anastomosis is started from both corners. In the children or for small arteries at least one half of the anastomosis should be done by sepa‐ rate sutures. In all other continuous anastomoses (artery or vein), we tie the last suture loosely and preserve a "Growth factor" or "expansion factor" to prevent purse-string effect of the con‐ tinuous suture on constricting the anastomosis as first described by Starzl in the portal anasto‐

mosis of liver transplantation (Starzl TE, 1984, Zomorrodi, et al, 2012) [7, 8]) [7].

For vein anastomosis we use a somewhat different technique. After inserting the two corner stitches, an anchoring or stay suture is used in the midpoint of the anterior layer of the venotomy site of the external iliac vein to maintain the orifice of the anastomosis site totally exposed and prevent from inadvertent catching of the posterior suture line in the anterior suture line. All the anastomosis is performed circumferentially by a single stitch that used as the proximal corner stitch. Then the surgeon should be cautious when tying this suture that the two remaining part are in the same length. The anastomosis is started from the proximal part by entering tying the corner stitch. Then the needle is entered from the posterior layer of the internal iliac vein into its lumen. Then a four-point technique is used for approximating the two intimal layers of the renal vein and external iliac vein. After completing the posterior layer then the anastomosis is continued from distal and proximal corner to the anterior layer and the anchoring stitch is removed. Again a "Growth factor" is necessary to prevent the purse string effect and also in the pediatric group, the anterior layer stitches should be in separate manner for make future growth possible. If the venotomy site is larger than the orifice of the

completely secured to the arterial wall with a tagging U-stitch.

usually needs no spatulation.

The principles of vascular anastomosis are not different from any standard vascular surgery. The best suture size is usually 5-0 and 6-0 Prolene® sutures for venous and arterial anasto‐ mosis. The size of the needles depends of the location of the anastomosis but in most cases the needle should be taper-point or taper-cutting-tip round-bodied 3/8 circle with 11 – 13 mm length for better performance. For smaller arteries 7-0 or 8-0, 1/2 circle, 7-9.3 mm needles may be more suitable. For severe atherosclerotic arteries use of special visible Ethicon Visi-Black® Everpoint®, or Tapercut® needles with spatulated heads which is more firm and crashresistant is needed.

After confirming the exact length and position of the anastomosis site to prevent kinking or rotation, vascular clamps are applied to the first vessel. We prefer to use Bulldog clamps to the internal iliac artery and iliac veins and Satinsky clamps for side-clamping of external iliac and common iliac artery or aorta or inferior vena cava. We discourage systemic heparinization before clamping because of bleeding tendency in chronic renal failure patients, but other authors recommend this. Heparinized saline is enough for irrigation of the vessels during the anastomosis.

For end-to-side anastomoses a patch from the vessel should be removed for preventing future constriction. This patch is removed from the arteries by No. 3, 4 or 5 aortic punches depending on the arterial size and by special Metzenbaum or Potts scissors from the veins. Also we should avoid the venous valve site in the external iliac vein, if possible. The wall of the vein is very thin proximal to the venous valves (sinuses of Valsalva) and may be ruptured during the anastomosis.

For end-to side anastomosis of a renal artery to the external iliac or common iliac or aorta, the graft artery should be spatulated in the direction of its lower corner. For end-to-end anasto‐ mosis of the renal artery to the internal iliac artery, the renal artery should be spatulated from the upper corner and the internal iliac artery should be spatulated in the direction of the opposite lower corner (in other words in the direction the deep part of the artery). Renal vein usually needs no spatulation.

**5. Vascular anastomosis**

176 Current Issues and Future Direction in Kidney Transplantation

resistant is needed.

anastomosis.

anastomosis.

After preparation of the place of the implantation, the surgeon should transfer the graft to its position transiently for better evaluation of the anastomoses sites. Some authors suggest that slush ice should put in the bed of the graft in the recipient, but we abso‐ lutely disagree with this opinion, because the total vascular reconstruction time is usual‐ ly less than 20 minutes and adding ice only increase the risk of local hypothermic injury. The surgeon should do his best efforts to reduce the total arterial and venous clamping time. First the site of each anastomosis and the position of the graft should be specified accurately according to the size and length of the vessels and also the length of the ure‐ ter and position of the recipient bladder or ureter and the final position of the implanted kidney. As described previously, we prefer to use the internal iliac artery and external iliac vein for vascular anastomoses. For reducing the vein clamping time (with subse‐ quent risk of deep vein thrombosis), we perform the arterial anastomosis first. But when the vein is shorter than usual or when the left iliac fossa is used for implantation, or when the abdominal cavity and aorta and inferior vena cava or the external iliac artery

are used for implantation, it's better to perform the venous anastomosis first.

The principles of vascular anastomosis are not different from any standard vascular surgery. The best suture size is usually 5-0 and 6-0 Prolene® sutures for venous and arterial anasto‐ mosis. The size of the needles depends of the location of the anastomosis but in most cases the needle should be taper-point or taper-cutting-tip round-bodied 3/8 circle with 11 – 13 mm length for better performance. For smaller arteries 7-0 or 8-0, 1/2 circle, 7-9.3 mm needles may be more suitable. For severe atherosclerotic arteries use of special visible Ethicon Visi-Black® Everpoint®, or Tapercut® needles with spatulated heads which is more firm and crash-

After confirming the exact length and position of the anastomosis site to prevent kinking or rotation, vascular clamps are applied to the first vessel. We prefer to use Bulldog clamps to the internal iliac artery and iliac veins and Satinsky clamps for side-clamping of external iliac and common iliac artery or aorta or inferior vena cava. We discourage systemic heparinization before clamping because of bleeding tendency in chronic renal failure patients, but other authors recommend this. Heparinized saline is enough for irrigation of the vessels during the

For end-to-side anastomoses a patch from the vessel should be removed for preventing future constriction. This patch is removed from the arteries by No. 3, 4 or 5 aortic punches depending on the arterial size and by special Metzenbaum or Potts scissors from the veins. Also we should avoid the venous valve site in the external iliac vein, if possible. The wall of the vein is very thin proximal to the venous valves (sinuses of Valsalva) and may be ruptured during the

For end-to side anastomosis of a renal artery to the external iliac or common iliac or aorta, the graft artery should be spatulated in the direction of its lower corner. For end-to-end anasto‐ mosis of the renal artery to the internal iliac artery, the renal artery should be spatulated from An endarterectomy should be done with extreme caution after cutting the internal iliac artery or entering the external iliac artery. No intimal flaps in the opposite direction of the blood flow should be remained at the end of endarterectomy. If such flap is remained, then the surgeon should decide to change the arterial anastomosis site, if possible, or at least the flap must completely secured to the arterial wall with a tagging U-stitch.

Special attention should be paid to the length of the right artery and left renal vein of the de‐ ceased donor. They are both too long for anastomosis and if not trimmed or shortened, kinking will be inevitable which will result in postoperative renal dysfunction and hypertension.

Arterial anastomosis is started by two corner stitch in each side of the vessel as described first by Carrel in 1902. Care is taken to include equal bites of all layers of the arterial wall in each passage of the needle and the adventitia remained outside. For this purpose we perform a 1 mm adventi‐ tiectomy of both arteries and use microvascular forceps, scissors and needle holders for arterial anastomosis and also recommend using a 4.5-6X loop for magnification and surgical headlights for better illumination. It's so important that the posterior layer suturing of the arterial anasto‐ mosis is done first and from outside. The needle should move from inside to outside of the more diseased artery (usually the recipient artery) to tag the intima to the media of the artery and pre‐ venting from creating an intimal flap which will be a good trigger point for future thrombosis. The upper suture is tied but the lower is maintained untied till the end of the anastomosis. The posterior layer is sutured first and then anterior layer anastomosis is started from both corners. In the children or for small arteries at least one half of the anastomosis should be done by sepa‐ rate sutures. In all other continuous anastomoses (artery or vein), we tie the last suture loosely and preserve a "Growth factor" or "expansion factor" to prevent purse-string effect of the con‐ tinuous suture on constricting the anastomosis as first described by Starzl in the portal anasto‐ mosis of liver transplantation (Starzl TE, 1984, Zomorrodi, et al, 2012) [7, 8]) [7].

For vein anastomosis we use a somewhat different technique. After inserting the two corner stitches, an anchoring or stay suture is used in the midpoint of the anterior layer of the venotomy site of the external iliac vein to maintain the orifice of the anastomosis site totally exposed and prevent from inadvertent catching of the posterior suture line in the anterior suture line. All the anastomosis is performed circumferentially by a single stitch that used as the proximal corner stitch. Then the surgeon should be cautious when tying this suture that the two remaining part are in the same length. The anastomosis is started from the proximal part by entering tying the corner stitch. Then the needle is entered from the posterior layer of the internal iliac vein into its lumen. Then a four-point technique is used for approximating the two intimal layers of the renal vein and external iliac vein. After completing the posterior layer then the anastomosis is continued from distal and proximal corner to the anterior layer and the anchoring stitch is removed. Again a "Growth factor" is necessary to prevent the purse string effect and also in the pediatric group, the anterior layer stitches should be in separate manner for make future growth possible. If the venotomy site is larger than the orifice of the renal vein, then after completing the posterior layer, the excessive part should be repaired before starting the anterior layer, preferably by another suture line.

Kidney transplantation may be accompanied by pancreas, liver (Nadim MK, et al, 2012)[9], heart (Florman S, Kim-Schluger L.,2012) [10], lung (Rana RK, et al, 2011) [11] or multiorgan transplantation. In such situations usually the more important transplantation (heart, lung, liver, pancreas or small bowel) is done first. And after stability of the recipient, kidney transplantation is performed. Even when the abdomen is entered during the first procedure, it's better to use the retroperitoneal iliac fossa for the second transplant by the same incision. This will reduce the complications associated with urine leakage. In case of simultaneous kidney –pancreas transplantation the kidney transplant is done first in the left iliac fossa and during the time of this procedure, the other team prepares the pancreas graft by ex vivo surgery for the second transplantation which is usually use the right common or external iliac artery as the inflow. The kidney transplantation combined with multivisceral transplantation is usually is an en-bloc transplantation. This means that the kidney is not separated from the donor aorta and inferior vena cava (IVC). All major vascular anastomoses are done by aorta as the inflow artery and IVC and/or portal vein as the venous outflow. The urinary recon‐

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 179

After completing the vascular anastomoses, the opposite corner stay sutures remained untied until reperfusion. The recipient systolic blood pressure should be at least 120 mmHg and the central venous pressure between 10 to 14 cm H2O. The use of vasopressors such as dopamine for increasing the blood pressure is controversial. Immunosuppressant is best infused before declamping according to the protocols of each transplant ward. Some authors suggests some over-hydration, infusing Furosemide and Mannitol and correction of acid-base imbalance according to the last arterial blood gas base deficit before declamping to prevent the so called "reperfusion syndrome". Unlike liver or small bowel transplantation, in most cases reperfu‐ sion syndrome will not be a problematic issue, because the kidney graft is relatively small, except when using an adult kidney for a pediatric recipient or in cases of a long implantation time with complete aortic or common or external iliac artery clamping time. In such cases the cause of "reperfusion syndrome" is transient ischemia of the lower limbs. The anesthesiologist should prepare sodium bicarbonate, calcium gluconate, and insulin with 50% Glucose before declamping for managing this complication and obtain an arterial blood gas before and after the declamping for estimating the severity of acidosis and monitor the electrocardiogram for

Arterial declamping is done first and after complete filling of the graft, veins are also opened. In this phase brisk bleeding is a rule, especially when we applied "growth factors" to the last ties. Most of the bleeding will be stopped spontaneously after complete dilatation of the anastomotic lines. Small bleeding sites may be covered by small parts of any hemostatic agent such as Surgicel®, N-butyl cyanoacrylate glues, Tachosil® or similar agents (Sageshima J, et al, 2011) [13]. All the other larger bleeding sites should be transligated or repaired by fine Prolene® sutures especially near the hilum, but extreme caution should be paid not to include

struction is performed after complete reperfusion of all abdominal organs.

**7. Declamping and reperfusion**

diagnosis of hyperkalemia.

the delicate hilar arterial branches in the sutures.
