**Figure 7.** *Spleen separated from the left renal upper pole.*

to prevent their later insertion between the jaws of the stapling device leading to misfire and serious malfunction [46].

The ureter and its periureteral fat are again lifted up at the level of the iliac vessels and posterior dissection will start from here and go up to the whole posterior surface of the kidney. The ureter is isolated with a generous periureteric fat. After completing this posterior release, the kidney is completely lying medially and we can free the posterior aspect of the renal artery (**Figure 8**; Video 6 (https://youtu. be/xQswiMds4Nc)). Now the kidney is supposed to hold only on the artery, vein, and ureter and is ready to be harvested. The patient is given another dose of mannitol. An Endocatch bag 15 mm (Covidien) is inserted through the LapCap. The distal ureter is clipped and sectioned. A good flow of urine should be noticed before pedicle clamping. A number of vascular transfixing stapling devices are available for surgeons to secure the renal vessels. The choice of which device to use is down to surgeon preference. Recently, we rely on two stapling devices: Endo-TA 30 stapler (30-mm length, 2.5-mm staples-Covidien) if maximum length is needed because this device delivers three rows of staplers without a cutting knife and no articulation; and vessels are cut with cold scissors; and Echelon Flex™ Powered Vascular Stapler 35 mm (Ethicon) with manual articulation for more precise placement, a narrow curved blunt tip, and reduction in tip movement during firing; this device delivers four rows of staples (instead of six) in a staggered pattern and gives a very secure vascular control and less loss in vessel length with nonbloody surgical field because of the absent backflow. Stapling starts on the renal artery and then quickly on the vein, and the kidney is rapidly placed in the Endo bag and extracted through the LapCap (Videos 7 (https://youtu.be/RfIGOjtqpD8) and 8 (https://youtu.be/ dGUKd3R23Yo)). We do not give intravenous heparin prior to vascular occlusion.

**33**

**Figure 9.**

*vascular stapling.*

*Laparoscopic Live Donor Nephrectomy: Techniques and Results*

Warm ischemia time is usually around 3–5 min before the kidney is flushed out on

Before ending the surgery, latero aortic and inter aorto caval lymphatics are clipped (Hem-o-lok clips) to prevent chylous leakage (Video 9 (https://youtu.be/\_ c4rjTtvlTw)). Meticulous and extensive clipping remains the safest way of securing lymphatic channels along the dissection area despite being usually burned with energy-based sealing devices. It has been shown that bipolar cautery can effectively ligate and control lymph leakage as also other laparoscopic dissection devices using bipolar and ultrasonic energy but monopolar scissors were unreliable with respect to sealing lymphatic channels [52, 53]. Last view of the whole surgical field is done with particular inspection of the vascular stumps (**Figure 9**). Pneumoperitoneum is exsufflated. No drainage is usually needed. Port and extraction sites are closed.

In some patients, the right side seems to be easier than the left. Steps are almost the same. Trocar placement has the same distribution as on the left except for an additional 5 mm trocar inserted at the xiphoid for liver retraction (**Figure 10**). Less right colon dissection is needed and careful duodenal displacement is performed to expose the inferior vena cava (IVC). Genital vein is usually kept in place. The renal upper pole is carefully separated from the adrenal as on the left side starting from the upper border of the right vein. Renal vessels are also approached from below after isolation of the ureter and periureteral fat and identification of the psoas muscle and lifting up the kidney. The right renal vein is exposed at its insertion into

*Left renal artery and vein stumps after stapling and kidney harvesting. Clips on lymphatics are placed after* 

Originally, the artery was secured using locking polymer clips that are much cheaper than staples. On April 2006, the manufacturer of Weck Hem-o-lok ligating clips, Teleflex Medical, added a contraindication to the use of these clips on renal vessels in laparoscopic live donor nephrectomy, after receiving 15 medical device reports of 12 injuries and 3 deaths, all of which occurred between November 19, 2001 and March 20, 2005. All reports were associated with using the clips for ligation of the renal artery during LLDN [47, 48]. Clip dislodgement may occur several hours following the procedure resulting in fatal hemorrhage on the ward [49]. US Food and Drug Administration (FDA) issued on May 2011 a warning to healthcare providers that Weck Hem-o-Lok ligating clips should not be used for the ligation of the renal artery during LLDN because of serious risks and potential life-threatening complications to the donor [50]. On the other hand, surgeons must be aware that reported failure rates for staplers are 3.0% [51]. Stapler misfire rates can be reduced by avoiding the use of titanium and other clips around the hilar structures before securing the renal pedicle [46].

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

ice with the preservation solution.

*4.3.2 Right-sided nephrectomy*

**Figure 8.** *Laparoscopic view after posterior left renal dissection.*
