**4. Skin preparation and incision**

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.

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

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‐

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

So many factors impact the surgeon's decision on which site he could implant the kidney graft (table 2). These factors include: the graft size comparing with the recipient, the size, length and number of graft arteries, veins and/or ureters, previous surgeries (for example previous failed kidney transplantation, previous pelvic exploration for bladder reconstruction or anti-reflux surgeries), associated abdominal organ (liver, pancreas or small bowel) transplantation, lateral‐ ity of the donor kidney (left or right), anomalies of the donor graft (horseshoe kidney, double pelvis, double ureter, etc.), and at last the number of kidney grafts (double kidney from a pedia‐

reconstructions should be done in the back table prior to implantation.

zation of the recipient bladder or using of the recipient ureter is preferred.

the site of implantation is not necessary.

172 Current Issues and Future Direction in Kidney Transplantation

**3. Implantation site**

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 hair clippers immediately before surgery. We use scrub povidone iodine or any types of alcoholic or polyethylene glycol type solutions (e.g. Decocept®) for initial washing and then normal povidone iodine for 2 times for the final preparation. Also we use a sterile (Opsite®) drape for complete covering of the incision region. The standard skin incision is the traditional hockey-stick Gibson incision or an oblique Rutherford Morison in the right iliac fossa. Gibson incision starts at the tubercule of pubis and continued laterally transverse to inguinal ligament and then upward in a curvilinear manner in the lateral border of the rectus abdominis muscle till 1-2 cm above the level of umbilicus. In larger adults extension till the anterior superior iliac spine may be enough. The epigastric vessels and the round ligament in females usually need to be ligated and transected, but the spermatic cord simply retracted medially by releasing the border of inguinal canal. The surgeon should avoid entering the peritoneal space and any defect in the peritoneum should be repaired before continuing the incision.

All the dissections should be accompanied by strict hemostasis and avoiding extreme injury to the abdominal wall muscles to simplify the future abdominal wall repair at the end of the procedure. All the bleeding sites should be completely hemostatized during this time because at the end of the procedure hemostasis will be very difficult. Also most renal failure patients has bleeding tendency due to platelet dysfunction specially in the first 2 hours after the hemodialysis or in those patient who underwent preemptive renal transplantation. If hemo‐ stasis is not complete wound or peri-graft hematoma is inevitable which will lead to the other complications such as infection, dehiscence, hydronephrosis or kidney compartment syn‐ drome due to compression to the graft.

**Figure 2.** Denis-Browne retractor

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 175

**Figure 3.** Kirschner retractor

**Figure 4.** Bookwalter retractor

After entering the retroperitoneal space and revealing the anatomy of the iliac vessels and their suitability for transplantation, the iliac vein should be prepared first by ligating all lymphatics around it. It's better to avoid the first major deep iliac lymph node (Cloquet's node). Dissections around the external iliac artery should be limited and if the internal iliac artery has a good con‐ tour and length, it's better to use it as the arterial inflow. If this artery has atherosclerotic plaques an endarterectomy could be done. We use the external iliac artery only when the internal iliac ar‐ tery of the other side is used previously, or when a large size discrepancy is revealed or severe atherosclerosis reduce the arterial flow to a very low and crucial level. Using the internal iliac ar‐ tery slightly increases the postoperative lymphocele because of more dissections needed for its releasing, but if the surgeon ligate all the lymphatics it would not be a major problem.

Without a good exposure, transplantation is a very difficult procedure and using a, Denis-Browne (Figure 2), Kirschner(Figure 3) or Bookwalter-type (Figure 4) self retaining retractor is a critical step in the implantation procedure. Many manufacturers have invented more powerful retractors. Some of them like Thompson® retractor, although are very useful and unique for liv‐ er or kidney-pancreas transplantation, but their use for kidney transplantation alone is time consuming and is best limited to super-obese recipients. Some of them such as Henley or Dar‐ ling or Gosset abdominal retractor only are useful in pediatric or thin patients with a shallow pelvis. Balfour and Balfour-Baby, Collin and Baby Collin, Ricard and Sullivan- O'Connor have the same problem. Some of them such as Omni-Flex® (Omni-Tract® surgical, Minnesota Scien‐ tific, MN, USA) or SynFrame® retractor systems (Synthes® Spine Inc., PA, USA) are modifica‐ tions to the original Thompson retractor but their use may be more sophisticated.

**Figure 2.** Denis-Browne retractor

hair clippers immediately before surgery. We use scrub povidone iodine or any types of alcoholic or polyethylene glycol type solutions (e.g. Decocept®) for initial washing and then normal povidone iodine for 2 times for the final preparation. Also we use a sterile (Opsite®) drape for complete covering of the incision region. The standard skin incision is the traditional hockey-stick Gibson incision or an oblique Rutherford Morison in the right iliac fossa. Gibson incision starts at the tubercule of pubis and continued laterally transverse to inguinal ligament and then upward in a curvilinear manner in the lateral border of the rectus abdominis muscle till 1-2 cm above the level of umbilicus. In larger adults extension till the anterior superior iliac spine may be enough. The epigastric vessels and the round ligament in females usually need to be ligated and transected, but the spermatic cord simply retracted medially by releasing the border of inguinal canal. The surgeon should avoid entering the peritoneal space and any

All the dissections should be accompanied by strict hemostasis and avoiding extreme injury to the abdominal wall muscles to simplify the future abdominal wall repair at the end of the procedure. All the bleeding sites should be completely hemostatized during this time because at the end of the procedure hemostasis will be very difficult. Also most renal failure patients has bleeding tendency due to platelet dysfunction specially in the first 2 hours after the hemodialysis or in those patient who underwent preemptive renal transplantation. If hemo‐ stasis is not complete wound or peri-graft hematoma is inevitable which will lead to the other complications such as infection, dehiscence, hydronephrosis or kidney compartment syn‐

After entering the retroperitoneal space and revealing the anatomy of the iliac vessels and their suitability for transplantation, the iliac vein should be prepared first by ligating all lymphatics around it. It's better to avoid the first major deep iliac lymph node (Cloquet's node). Dissections around the external iliac artery should be limited and if the internal iliac artery has a good con‐ tour and length, it's better to use it as the arterial inflow. If this artery has atherosclerotic plaques an endarterectomy could be done. We use the external iliac artery only when the internal iliac ar‐ tery of the other side is used previously, or when a large size discrepancy is revealed or severe atherosclerosis reduce the arterial flow to a very low and crucial level. Using the internal iliac ar‐ tery slightly increases the postoperative lymphocele because of more dissections needed for its

releasing, but if the surgeon ligate all the lymphatics it would not be a major problem.

tions to the original Thompson retractor but their use may be more sophisticated.

Without a good exposure, transplantation is a very difficult procedure and using a, Denis-Browne (Figure 2), Kirschner(Figure 3) or Bookwalter-type (Figure 4) self retaining retractor is a critical step in the implantation procedure. Many manufacturers have invented more powerful retractors. Some of them like Thompson® retractor, although are very useful and unique for liv‐ er or kidney-pancreas transplantation, but their use for kidney transplantation alone is time consuming and is best limited to super-obese recipients. Some of them such as Henley or Dar‐ ling or Gosset abdominal retractor only are useful in pediatric or thin patients with a shallow pelvis. Balfour and Balfour-Baby, Collin and Baby Collin, Ricard and Sullivan- O'Connor have the same problem. Some of them such as Omni-Flex® (Omni-Tract® surgical, Minnesota Scien‐ tific, MN, USA) or SynFrame® retractor systems (Synthes® Spine Inc., PA, USA) are modifica‐

defect in the peritoneum should be repaired before continuing the incision.

drome due to compression to the graft.

174 Current Issues and Future Direction in Kidney Transplantation

**Figure 3.** Kirschner retractor

**Figure 4.** Bookwalter retractor
