**2. Graft preparation**

Preservation of the viability of the graft during the time between explantation and implantation is vital for early and late graft function after transplantation. Most kidney transplant teams consist of at least two separate groups. One group prepares the donor and the other team is doing the recipient operation at the same time or with some delay depending on the duration needs for transferring the graft from the donor operating room to the recipient operation theatre. In many countries such as the United States or in the Euro Zone the kidney grafts from the deceased donors are transferred between hospitals, cities or even countries according to the Human Leukocyte Antigen (HLA) matching or other important criteria for attributing the graft to a preferred recipient. In such conditions it's better to use every effort to improve the graft longevity. Using better preservation solutions or automatic machine perfusion systems are among the routine measurements in such conditions which are discussed in other chapters of this book. The surgeons and coordinators should shorten the ischemic time of the graft as long as possible and during all of this period the temperature of the graft should be maintained between 1-4° centigrade to decrease the injury to the graft.

Simple hypothermia is not enough for preserving the viability of the graft and evacuation of the graft blood and replacing it with a preservation solution is a mandatory step in the graft prepa‐ ration. Graft cold irrigation in the deceased donors is done during the harvesting operation by irrigation of the clamped aorta and the solution used for this irrigation may be any of the preprepared solutions such as Belzer University of Wisconsin's (UW), Histidine-Tryptophan-Ke‐ toglutarate (HTK, Bretschneider or Custodiol), Euro-Collins, Celsior or other newer solutions such as Biolasol® (Dolińska B, et al, 2012)[1]. Table 1 shows the compositions of some of these solutions. All of the blood should be evacuated from the graft during this phase. In the living do‐ nor, all of the irrigation is done after removing the graft the donor body in an iced cold basin. In the countries that the living donor still forms over 75% of the donor pool such as China or India, irrigation of the living donor graft is done by more simple solutions such as lactated Ringer's solution and many studies shows that when the total ischemic time is less than 60 minutes (as in most living donor programs) the long-term graft survival is not impacted significantly by using these simple solutions comparing with more complex solutions (Prasad GS, et al, 2007)[2]. In our center we add lidocaine (100 mg/liter), sodium bicarbonate (10 meq/liter) and heparin (5000 IU/liter) to this simple solution. Also, we use intravenous Mannitol and Furosemide in the do‐ nor just before the arterial clamping for better diuresis before nephrectomy.


**Table 1.** Composition of the more common organ preservation solutions.

In this chapter we will review basic steps of the standard approach to recipient's procedure from preparing the graft, then the skin incision till the skin closure with special attention to basic vascular and urinary tract re-establishment techniques and also intraoperative care of the patient. Then we proceed to the special and unusual situations including: complex vascular and ureteral reconstruction techniques, using kidneys with congenital and other anatomical anomalies, en bloc double kidney transplantation, using other vasculature for transplanting the kidney in different intraperitoneal spaces, and kidney transplantation conjoint with other

Preservation of the viability of the graft during the time between explantation and implantation is vital for early and late graft function after transplantation. Most kidney transplant teams consist of at least two separate groups. One group prepares the donor and the other team is doing the recipient operation at the same time or with some delay depending on the duration needs for transferring the graft from the donor operating room to the recipient operation theatre. In many countries such as the United States or in the Euro Zone the kidney grafts from the deceased donors are transferred between hospitals, cities or even countries according to the Human Leukocyte Antigen (HLA) matching or other important criteria for attributing the graft to a preferred recipient. In such conditions it's better to use every effort to improve the graft longevity. Using better preservation solutions or automatic machine perfusion systems are among the routine measurements in such conditions which are discussed in other chapters of this book. The surgeons and coordinators should shorten the ischemic time of the graft as long as possible and during all of this period the temperature of the graft should be maintained

Simple hypothermia is not enough for preserving the viability of the graft and evacuation of the graft blood and replacing it with a preservation solution is a mandatory step in the graft prepa‐ ration. Graft cold irrigation in the deceased donors is done during the harvesting operation by irrigation of the clamped aorta and the solution used for this irrigation may be any of the preprepared solutions such as Belzer University of Wisconsin's (UW), Histidine-Tryptophan-Ke‐ toglutarate (HTK, Bretschneider or Custodiol), Euro-Collins, Celsior or other newer solutions such as Biolasol® (Dolińska B, et al, 2012)[1]. Table 1 shows the compositions of some of these solutions. All of the blood should be evacuated from the graft during this phase. In the living do‐ nor, all of the irrigation is done after removing the graft the donor body in an iced cold basin. In the countries that the living donor still forms over 75% of the donor pool such as China or India, irrigation of the living donor graft is done by more simple solutions such as lactated Ringer's solution and many studies shows that when the total ischemic time is less than 60 minutes (as in most living donor programs) the long-term graft survival is not impacted significantly by using these simple solutions comparing with more complex solutions (Prasad GS, et al, 2007)[2]. In our center we add lidocaine (100 mg/liter), sodium bicarbonate (10 meq/liter) and heparin (5000 IU/liter) to this simple solution. Also, we use intravenous Mannitol and Furosemide in the do‐

between 1-4° centigrade to decrease the injury to the graft.

nor just before the arterial clamping for better diuresis before nephrectomy.

abdominal organs.

**2. Graft preparation**

168 Current Issues and Future Direction in Kidney Transplantation

When possible, the donor team should report the detailed graft anatomy (including number of arteries, veins and ureters and any anatomical anomaly or inadvertent injury to the graft during the donor operation) to the recipient team, especially when the graft is transferred from another hospital locally or regionally. It is very important to prevent any more injury to the graft and its capsule, vessels or ureter during the back table procedure, especially in case of deceased donor grafts which usually accompanied with other abdominal organs or at least covered by the peritoneum or peri-renal fats or other non-important tissues. Direct contact of the ice with the graft should be prevented by inserting the graft in a separate basin or organ bag filled with a cold solution and then inserting this bag in another iced filled basin.

First of all, for irrigation of the living donor graft, the surgeon should find the artery and canulate it with an atraumatic olive-headed heparin irrigation needle as shown in figure 1. Using other devices such as Angiocath©, Baranule© or any types of intravenous needles for irrigation should be discouraged because of risk of intimal injury induced by such cannulas. In many cases, it may be difficult to find the artery first because it is hidden by other hilar tissues or retracted to the deeper hilar areas of the graft. In such conditions the irrigation may be started by canulation the more accessible renal vein, till the surgeon finds the artery. All the dissections should better be done after complete irrigation. At this point all of the renal parenchyma will appear in yellow-pink color. All of the dissections should be done delicately by using atraumatic or microvascular instruments, without any more injury to the vessels intima or their major branches and any more unusual traction of the vessel wall.

suggest that all of the major lymphatic vessels should be ligated to prevent future lymphocele, however, the most important measurement for preventing the lymphocele is avoiding exces‐

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 171

The best approach for prevention of arterial branch injury is to start with dissection of the renal vein and follow its wall through the hilum until sufficient length is achieved by ligating the minor veins. We suture-ligate the accessory minor vein branches and also the major lumbar veins by 6-0 Prolene suture for prevention of postoperative bleeding from hilar vessels.

If the graft has more than one artery, vein or ureter, the surgeon should decide which type of re‐ construction is suitable according to the condition of the graft and the recipient. In the deceased donor it's better to use a Carrel patch of aorta and inferior vena cava in line with the graft ves‐ sels. But this has two major impacts on future graft implantation. First, this results in a longer than usual artery (especially in the right side) or vein (especially in the left side) which may be results in kinking (and future thrombosis or hypertension) after the anastomosis. And second, it will results in a large Carrel patch in some cases. The surgeon has to remove a large patch from the recipient's vessels for a good anastomosis. If complicated by graft non-function, then future removal of the graft will result in a large defect of the recipient vessels which will be dangerous or even limb life threatening. Also, the Carrel patch of the aorta may be severely atherosclerotic and could not be used for a safe anastomosis. Any reconstruction will elongate the total ische‐ mic time of the graft, and we should do every effort to prevent this by postponing unnecessary

dissections and reconstructions to the time after at least partial reperfusion of the graft.

mosis if possible to prevent ischemia of the ureter.

According to these important issues, when possible, we prefer to use no reconstruction prior to implantation to decrease the ischemic time. Every transplant surgeon should be fully trained and familiar with microvascular techniques in such conditions. Every arterial branch should be anastomosed separately. The major artery is anastomosed first usually to the internal iliac artery, which provides a longer arterial conduit and allow more free movements of the graft for venous anastomosis. Smaller arteries are anastomosed after reperfusion of the graft to the external iliac artery or even to the smaller arteries such as inferior epigastric artery (El-Sherbiny M, et al, 2008)[3]. When all arterial branches have the same size, then reperfusion is postponed till the end of anastomosis of all of the arterial branches usually to the external iliac artery but if the kidney has a large artery and some other smaller arteries then reperfusion is started after completion of the large artery anastomosis. Arteries less than 1 mm could be ligated specially in the upper pole. Also ligation of the arteries with resultant ischemic area of less than 15% of the upper or middle pole is acceptable and by reducing the total operation duration will reduce the complications in the recipient comparing with adding a long microvascular anastomosis to the operation. Arteries larger than 1 mm in the lower pole should be reperfused by anasto‐

If the surgeon decides to reconstruct the arteries before implantation then multiple varieties of techniques could be used: side to side anastomosis of the same size arteries or end to side anastomosis of a small artery to a larger artery. Using microvascular techniques with a good illumination and at least 4.5X magnification and 7-0 or 8-0 Prolene sutures, all of the ties should be placed out of the intimal surface and the lumen should be protected by a smooth metal probe to prevent inadvertent back-wall suturing. In the deceased donor, the surgeon can use

sive dissections around the iliac artery during the preparing the implantation site.

**Figure 1.** Special olive-headed needles for irrigation (Courtesy of GEISTER Medizintechnik GmbH, Tuttlingen/ Germany)

When using the left kidney of the living donor the adrenal and gonadal vein should be on the graft in order to have a longer vein for future anastomosis. In both right or left kidneys or living donor or deceased donor grafts, the surgeon should make every effort to preserve the con‐ nective tissues between the ureter and the gonadal vein to prevent ischemic injury to the delicate collateral vessels of the ureter. Always the ureter should be accompanied by at least one centimeter of the peri-ureteral tissues and also the hilar inferior triangle (e.g. the window between the inferior pole of the graft and the ureteral origin from the renal pelvis) should be maintained intact. Removing peri-renal fat or other tissues should be postponed till complete renal revascularization. These tissues are protective for handling of the graft and might be used for graft covering or anchoring during or after revascularization.

The window between the renal artery and vein in the renal hilum is full of accessory branches and lymphatic vessel. All of the major arterial branches especially of the inferior pole should be maintained intact. Any injury to this branches leads to regional ischemia or necrosis of the kid‐ ney or ureter which may lead to future graft dysfunction or ischemia – induced hypertension in the donor or ureteral necrosis, ureteral anastomosis disruption or urine leakage. Some surgeons suggest that all of the major lymphatic vessels should be ligated to prevent future lymphocele, however, the most important measurement for preventing the lymphocele is avoiding exces‐ sive dissections around the iliac artery during the preparing the implantation site.

irrigation should be discouraged because of risk of intimal injury induced by such cannulas. In many cases, it may be difficult to find the artery first because it is hidden by other hilar tissues or retracted to the deeper hilar areas of the graft. In such conditions the irrigation may be started by canulation the more accessible renal vein, till the surgeon finds the artery. All the dissections should better be done after complete irrigation. At this point all of the renal parenchyma will appear in yellow-pink color. All of the dissections should be done delicately by using atraumatic or microvascular instruments, without any more injury to the vessels

**Figure 1.** Special olive-headed needles for irrigation (Courtesy of GEISTER Medizintechnik GmbH, Tuttlingen/ Germany)

When using the left kidney of the living donor the adrenal and gonadal vein should be on the graft in order to have a longer vein for future anastomosis. In both right or left kidneys or living donor or deceased donor grafts, the surgeon should make every effort to preserve the con‐ nective tissues between the ureter and the gonadal vein to prevent ischemic injury to the delicate collateral vessels of the ureter. Always the ureter should be accompanied by at least one centimeter of the peri-ureteral tissues and also the hilar inferior triangle (e.g. the window between the inferior pole of the graft and the ureteral origin from the renal pelvis) should be maintained intact. Removing peri-renal fat or other tissues should be postponed till complete renal revascularization. These tissues are protective for handling of the graft and might be used

The window between the renal artery and vein in the renal hilum is full of accessory branches and lymphatic vessel. All of the major arterial branches especially of the inferior pole should be maintained intact. Any injury to this branches leads to regional ischemia or necrosis of the kid‐ ney or ureter which may lead to future graft dysfunction or ischemia – induced hypertension in the donor or ureteral necrosis, ureteral anastomosis disruption or urine leakage. Some surgeons

for graft covering or anchoring during or after revascularization.

intima or their major branches and any more unusual traction of the vessel wall.

170 Current Issues and Future Direction in Kidney Transplantation

The best approach for prevention of arterial branch injury is to start with dissection of the renal vein and follow its wall through the hilum until sufficient length is achieved by ligating the minor veins. We suture-ligate the accessory minor vein branches and also the major lumbar veins by 6-0 Prolene suture for prevention of postoperative bleeding from hilar vessels.

If the graft has more than one artery, vein or ureter, the surgeon should decide which type of re‐ construction is suitable according to the condition of the graft and the recipient. In the deceased donor it's better to use a Carrel patch of aorta and inferior vena cava in line with the graft ves‐ sels. But this has two major impacts on future graft implantation. First, this results in a longer than usual artery (especially in the right side) or vein (especially in the left side) which may be results in kinking (and future thrombosis or hypertension) after the anastomosis. And second, it will results in a large Carrel patch in some cases. The surgeon has to remove a large patch from the recipient's vessels for a good anastomosis. If complicated by graft non-function, then future removal of the graft will result in a large defect of the recipient vessels which will be dangerous or even limb life threatening. Also, the Carrel patch of the aorta may be severely atherosclerotic and could not be used for a safe anastomosis. Any reconstruction will elongate the total ische‐ mic time of the graft, and we should do every effort to prevent this by postponing unnecessary dissections and reconstructions to the time after at least partial reperfusion of the graft.

According to these important issues, when possible, we prefer to use no reconstruction prior to implantation to decrease the ischemic time. Every transplant surgeon should be fully trained and familiar with microvascular techniques in such conditions. Every arterial branch should be anastomosed separately. The major artery is anastomosed first usually to the internal iliac artery, which provides a longer arterial conduit and allow more free movements of the graft for venous anastomosis. Smaller arteries are anastomosed after reperfusion of the graft to the external iliac artery or even to the smaller arteries such as inferior epigastric artery (El-Sherbiny M, et al, 2008)[3]. When all arterial branches have the same size, then reperfusion is postponed till the end of anastomosis of all of the arterial branches usually to the external iliac artery but if the kidney has a large artery and some other smaller arteries then reperfusion is started after completion of the large artery anastomosis. Arteries less than 1 mm could be ligated specially in the upper pole. Also ligation of the arteries with resultant ischemic area of less than 15% of the upper or middle pole is acceptable and by reducing the total operation duration will reduce the complications in the recipient comparing with adding a long microvascular anastomosis to the operation. Arteries larger than 1 mm in the lower pole should be reperfused by anasto‐ mosis if possible to prevent ischemia of the ureter.

If the surgeon decides to reconstruct the arteries before implantation then multiple varieties of techniques could be used: side to side anastomosis of the same size arteries or end to side anastomosis of a small artery to a larger artery. Using microvascular techniques with a good illumination and at least 4.5X magnification and 7-0 or 8-0 Prolene sutures, all of the ties should be placed out of the intimal surface and the lumen should be protected by a smooth metal probe to prevent inadvertent back-wall suturing. In the deceased donor, the surgeon can use freely every small bifurcated or trifurcated donor artery (such as the celiac artery) for these delicate reconstructions. In such complex situations such as severe atherosclerosis of the renal artery orifice when eversion endarterectomy is not possible (Nghiem DD, Choi SS, 1992) [4] or results in a damaged artery, the best approach for salvage of the graft is transecting the diseased part of the renal artery and using a small branch of the donor artery such as the left gastric or splenic artery as an elongation conduit of the renal artery. In the case of living donors, a short segment of the recipient saphenous vein may be a good choice for this purpose but it has a real risk of future aneurismal transformation in the future (Sharma A, et al, 2010) [5]. Sometimes we could use a combination of these techniques. For example when the graft has 2 large-size and 1 small-size artery, the best option is to perform an anastomosis between the small-size artery and one of the larger size branches and then perform two separate anasto‐ moses in the recipient. This action will reduce the total operative time of the recipient.

tric or old age or marginal donor). Traditionally the right iliac fossa is the standard fossa for a kidney transplantation procedure and the left iliac fossa is the preferred site for simultaneous kidney-pancreas transplantation. In the pediatric recipient when the graft is larger than usual we should use the main abdominal fossa for implantation. The most important limiting factor for each of these procedures is the length of the renal vein and also the length of the donor ureter and mobility of the recipient urinary bladder. In most instances when the recipient internal iliac artery is used as the arterial inflow, it provides a good length for mobilization and would not be a limiting factor. The right iliac fossa is the preferred site because of the more superficial posi‐ tion of the external iliac vein. The deep branches of the iliac vein can be suture ligated and cut if more superficialization is needed. If the recipient ureter is not diseased it can be used for urinary

**Factor Preferred Site Rationale**

Prevention of kidney compartment

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 173

Prevention of urine leakage or ureteral

prevention of lymphocele, shorter

Prevention of adding the complications of each graft on the other graft

Some authors use the opposite side because of position of the transplanted graft for future percutaneous interventions on the urinary system

If the iliac arteries are not large enough it's better to use the abdominal aorta

Enough space for the graft and enough stations for vascular anastomosis

and inferior vena cava

cavity and postoperative ileus

syndrome

stricture

operative time

Iliac fossa is preferred Prevention of entering to the abdominal

It's better to use right iliac fossa More superficial position of iliac vein

outflow reconstruction if the donor ureter is short.

The size, length and number of graft arteries and veins

Laterality of

the donor kidney (left or right)

Graft size comparing with the recipient Abdominal fossa if the graft is very

The size, length and number of ureters Iliac fossa is preferred if the recipient

Associated abdominal organ transplantation Left iliac fossa and in the

The number of kidney grafts Retroperitoneal space of right iliac

Anomalies of the donor graft Abdominal cavity if the graft is large,

**Table 2.** Factors influencing the choice of implantation site

**4. Skin preparation and incision**

fossa

large

ureter is not diseased. Retrovesical area if the ureters are short but vessels are long enough

retroperitoneal space Abdominal cavity for en bloc or

composite grafts

Previous surgeries Opposite iliac fossa Prevention of vessel or visceral injury,

if the graft is small iliac fossa is better.

Skin preparation and drape is not so different from other clean abdominal operations. The patient should bathe before entering the operation theatre. Hair removal is better done with

Approach to the vein branches is a little different because of intra-parenchymal communica‐ tions between the vein branches. We could ligate non-major venous branches, but when the vein branches are in the same size we should reconstruct them before venous anastomosis. Some surgeons prefer to mobilize the external iliac vein by ligating the internal iliac vein or superior gluteal vein or other side branches of this vein, but usually these maneuvers are futile in providing better window for venous anastomosis especially when we use the right kidney from a living donor. In such conditions we prefer to perform the venous anastomosis first or placing the graft in an upside down direction (ureter in the upper part) (Webb J et al, 2003) [6]. In the deceased donor, using a part of the donor external iliac, internal jugular or inferior vena cava as an extension graft is more preferable for adding the length of the vein graft. Such reconstructions should be done in the back table prior to implantation.

In our opinion, ureteral reconstruction also should be discouraged in case of multiple graft ureters. When the ureters have insufficient length, or denuded in their entire length, mobili‐ zation of the recipient bladder or using of the recipient ureter is preferred.

At the end of graft preparation some authors suggest that the graft should be wrapped in iced or cold saline soaked surgical gauzes or cloth stockinet or surgical glove to remain cold throughout the implantation procedure. In our opinion this is a time consuming and fruitless maneuver when the surgeons could do the anastomoses rapidly. Also using the ice packets in the site of implantation is not necessary.
