*4.3.1 Left-sided nephrectomy*

The ureter and its peri ureteral fat are lifted up to undertake an upper dissection along the genital vein until we reach the inferior border and the anterior aspect of the renal vein (Video 2 (https://youtu.be/Ms38M9mIV0Q)). Then, the spleen and tail of the pancreas are completely mobilized by cutting the splenorenal and splenophrenic ligaments (Video 3 (https://youtu.be/lKNHPx66Mgo)). Care is taken not to injure the pancreas, the splenic artery, and the stomach near the level of the crus of the diaphragm where dissection ends. By achieving this step, the space between the spleen and the kidney is usually widely opened and permits partial mobilization of the upper renal pole (**Figure 7**). We then proceed to adrenal dissection and separation starting very carefully from the upper border of the renal vein toward the upper pole of the kidney with division of the adrenal vein using LigaSure sealing without any clip placement and caring not to injure the anterior branch of the renal artery or small upper pole accessory

**31**

**Figure 5.**

**Figure 6.**

*Laparoscopic Live Donor Nephrectomy: Techniques and Results*

*Left renal aspect after colon dissection. Gerota's fascia is left intact.*

*Ureter with well-preserved periureteral fat and vasculature.*

arteries not detected on the preoperative renal angio CT scan (Video 4 (https://youtu.

The renal pedicle is now ready to be dissected. Before starting the hilar dissection, 12–25 mg of mannitol is administered. All lymphatics and autonomic nerve plexuses superior to the vein and around the renal artery are sealed and cut. Some small segments of these structures are sometimes difficult or possibly dangerous to access, and in such a case, they are quickly sealed and cut after the stapling of the renal pedicle. Very careful and minutious dissection is undertaken between the artery and vein to prepare a clear, precise, and secure positioning of the stapling device. The left renal artery is dissected at its aortic origin (Video 5 (https:// youtu.be/5wyqkJz7ick)). If vasospasm is noted, the renal artery can be bathed in a papaverine solution (30 mg/ml) [44]. In some cases, retroperitoneal veins (lumbar, ascending lumbar, and hemiazygos) join the left renal vein in up to 75% of individuals, and it must be sealed and cut [45]. Clips are avoided on all venous branches

be/WbgzAzZZprk)). This step will almost complete the upper pole release.

*DOI: http://dx.doi.org/10.5772/intechopen.80880*

**Figure 4.** *Left kidney suspended with a 2/0 silk suture on the parietal wall.*

*Basic Principles and Practice in Surgery*

**4.3 Surgical steps**

*4.3.1 Left-sided nephrectomy*

trocar placement is the same with an additional 5 mm one, inserted at the xiphoid for liver retraction. Additional ports can be used in some rare difficult cases and sometimes we do percutaneous kidney suspension using a 2/0 silk on a straight

As described in all transperitoneal approaches, we start by taking the colon off the kidney medially along the Toldt's fascia from the iliac vessels up to the colonic angle (splenic flexure on the left and hepatic flexure on the right). Gerota's fascia is left intact on the kidney (**Figure 5**). The lateral and parietal attachments of the kidney are left in place to prevent the kidney from slipping down and disturbing later the hilar dissection. We use from the start a LigaSure™ Maryland 5 mm (Covidien) sealing device. We then dissect and isolate the ureter inferiorly down to the iliac vessels with identification of the psoas muscle and the genital vessels. All periureteral and inferior renal pole fat must be well preserved to keep a wellvascularized ureter (**Figure 6**). Avoid any injury to the genitofemoral nerve and try to keep the psoas fascia in place. The gonadal vein can be divided proximally and distally and kept with the ureter in order to protect ureteric vascularity. This is thought to be the cause of postoperative ipsilateral orchialgia, which occurs in 6.2–9.6% of male donors [40, 41]. Large studies, however, have demonstrated that leaving the gonadal vein in situ does not lead to increased ureteric complications in

The ureter and its peri ureteral fat are lifted up to undertake an upper dissection along the genital vein until we reach the inferior border and the anterior aspect of the renal vein (Video 2 (https://youtu.be/Ms38M9mIV0Q)). Then, the spleen and tail of the pancreas are completely mobilized by cutting the splenorenal and splenophrenic ligaments (Video 3 (https://youtu.be/lKNHPx66Mgo)). Care is taken not to injure the pancreas, the splenic artery, and the stomach near the level of the crus of the diaphragm where dissection ends. By achieving this step, the space between the spleen and the kidney is usually widely opened and permits partial mobilization of the upper renal pole (**Figure 7**). We then proceed to adrenal dissection and separation starting very carefully from the upper border of the renal vein toward the upper pole of the kidney with division of the adrenal vein using LigaSure sealing without any clip placement and caring not to injure the anterior branch of the renal artery or small upper pole accessory

needle through Gerota's fascia and perirenal fat (**Figure 4**).

the transplant recipient [42] and prevents orchialgia [40, 43].

**30**

**Figure 4.**

*Left kidney suspended with a 2/0 silk suture on the parietal wall.*

**Figure 5.** *Left renal aspect after colon dissection. Gerota's fascia is left intact.*

**Figure 6.** *Ureter with well-preserved periureteral fat and vasculature.*

arteries not detected on the preoperative renal angio CT scan (Video 4 (https://youtu. be/WbgzAzZZprk)). This step will almost complete the upper pole release.

The renal pedicle is now ready to be dissected. Before starting the hilar dissection, 12–25 mg of mannitol is administered. All lymphatics and autonomic nerve plexuses superior to the vein and around the renal artery are sealed and cut. Some small segments of these structures are sometimes difficult or possibly dangerous to access, and in such a case, they are quickly sealed and cut after the stapling of the renal pedicle. Very careful and minutious dissection is undertaken between the artery and vein to prepare a clear, precise, and secure positioning of the stapling device. The left renal artery is dissected at its aortic origin (Video 5 (https:// youtu.be/5wyqkJz7ick)). If vasospasm is noted, the renal artery can be bathed in a papaverine solution (30 mg/ml) [44]. In some cases, retroperitoneal veins (lumbar, ascending lumbar, and hemiazygos) join the left renal vein in up to 75% of individuals, and it must be sealed and cut [45]. Clips are avoided on all venous branches
