**9. Wound closure**

Wound closure is the final step of the procedure. Closing is done by 2-layer repair of the abdominal muscles (first transverse and internal oblique as one layer and then the external oblique muscle), by a No. 0 loop Nylon suture. Using any drain before closure is controversial but if used it should be a closed suction drain such as a Jackson-Pratt drain and every effort should be used that the drain has no compression effect on the renal vasculature and the ureter. The exit site also should be assessed for bleeding. Every bleeding site should be assessed and repaired before closure to prevent postoperative hematoma. Diffuse oozing at the end of operation may be the result of platelet dysfunction or heparin overdose and should be managed accordingly by desmopressin and protamine sulfate, respectively. Excess perirenal fat should be removed, and the graft should be placed in a retroperitoneally created pouch parallel with the psoas muscle, to prevent compression of the kidney between the abdominal wall and the pelvic bones. If the kidney volume is greater than this space, or the renal vascu‐ lature or ureter is shorter than usual, then "compartment syndrome" is inevitable is the abdominal muscles repaired in the usual manner. In such situation, the renal artery inflow is good but the outflow will be disturbed because of pressure of the abdominal wall on the renal vein. Renal venous pressure increase and then the graft will be congested and the urine flow will decreased. If remained unmanaged, this will eventually lead to decreasing renal artery flow and finally to renal artery thrombosis and graft loss. If the surgeon could not reposition the graft in to the supravesical area and anchor it to the abdominal wall without vascular kinking, many other options should be tried. One option is to incise the rectus sheath after closing the muscles. Another option is to close the abdominal wall from distal and proximal and let the part which is covering the kidney remains unclosed or closed by an artificial mesh which is used for hernia repair. The last option is to let abdominal musculature remained completely opened and only covered by the skin. The resultant incisional hernia will be repaired in the future, usually 3 months after the transplantation. The best treatment of such conditions is "prevention" by matching the size of the donor and recipient and special attention to the length of the graft vasculature and ureter and also creating the pouch as the first step during the procedure.
