**4.1 Anesthesia**

Laparoscopic donor nephrectomy has had a big impact on anesthesia and recovery of this special category of patients. Intraoperative anesthesia for laparoscopic live donors follows the rules of laparoscopic kidney surgery as far as sedation and muscle relaxation but the concept of protection of the donor kidney is mandatory throughout the case, one among many disparities compared to other kidney surgeries [33]. Nowadays, two large-bore IV catheters are considered more than enough as far as vascular access and risk of bleeding. Arterial lines are not recommended and noninvasive blood pressure monitoring is a reasonable option [34]. After induction of anesthesia, classically with propofol and a neuromuscular blocking agent, maintenance of anesthesia has been the subject of many studies to evaluate the nephrotoxicity of various agents. While isoflurane and desflurane were considered safe and with the least toxicity on the kidney, this was not the case with sevoflurane that is associated with production of compound A in the circulation; a direct nephrotoxic substance [35]. Despite many works, the type of anesthetic agent was not shown to impact serum creatinine or GFR in transplanted grafts and it was concluded that toxicity, if any, was minimal. Nitrous oxide is one agent preferably avoided in laparoscopic surgery as it can cause bowel distention in more than 50% of cases and subsequent compromise of insufflation or surgical field exposure in near 25% of laparoscopic donor nephrectomy, increasing the need even more for neuromuscular blocking agents [36]. Mechanical ventilation settings are not different from other laparoscopic procedures. Special considerations for donor nephrectomy would include tolerance of mild hypercapnia to 45 mmHg since it helps better tissue perfusion and circulation in light of pneumoperitoneum. Positive-end expiratory pressure (PEEP) at 5–10 mmHg, a 20–30% increase in minute ventilation reflecting an increased respiratory rate with constant volumes, is similar to other laparoscopic procedures. The effects of pneumoperitoneum were explored by studies on rats demonstrating that abdominal insufflation with CO2 during laparoscopy in subjects with chronic renal function impairment should not be a contraindication to surgery [37]. Additionally, if insufflation had a substantial negative effect on kidney function, we would have expected this to have a great impact on kidney donors out of concern on the retained kidney, which has not been

**29**

**Figure 3.**

*Laparoscopic Live Donor Nephrectomy: Techniques and Results*

**4.2 Antibiotics, patient position, and trocar placement**

born out in the literature. IV hydration holds a crucial place in counteracting the notorious effects of pneumoperitoneum on tissue perfusion and renal plasma flow caused by an increased intraperitoneal pressure sometimes near 15 mmHg. Some studies emphasized the great effects of hydration on mean arterial pressure preservation and ensuring hemodynamic stability [38]. Whether this is realized by giving donors colloid boluses preoperatively or during surgery is based on institutional protocols and the team preferences. In general, a patient undergoing laparoscopic donor nephrectomy should get 4–6 L during the procedure to maintain at least a urine output >50 mL/h [38]. This will help avoid the use of any vasopressors or inotrope agents because of the associated deleterious renal vasoconstriction. If they become really needed, ephedrine is the best agent to start with, giving small boluses in order to attain the desired effects. IV fluids should be warmed and full measures should be taken to prevent hypothermia. There is a mounting evidence to suggest that 0.9% normal saline can be detrimental to patient outcome, and may indeed contribute to renal dysfunction, and therefore, the use of this solution in donors cannot be recommended; Ringer's lactate solution is the intravenous fluid of choice [4]. The administration of mannitol 12–25 g once or twice, or furosemide at small doses during the case, is another example of common practice depending on departmental protocols, but they lack any definite data or evidence to support it.

We routinely give antibiotic prophylaxis based on one single shot of cefazolin. After placement of a Foley catheter, the patient is put in a complete lateral decubitus position almost 90° to the table without any flexure or kidney rest; the belly being on the external border of the table. Arms and legs are well secured with pillows and gel pads to prevent any vascular or nerve compression. We start by doing the extraction site as a small transverse supra pubic incision 6–8 cm width, depending on donor kidney size, with opening of the peritoneum and insertion of a LapCap device (Applied Medical-Alexis Laparoscopic System with Kii® Fios® First Entry) (**Figure 3** and Video 1 (https://youtu.be/LBWXDCD2Upk)). Pneumoperitoneum induction is made through this device. Intraabdominal CO2 pressure is fixed at 12 mm Hg. The use of low-pressure pneumoperitoneum with deep neuromuscular block did not seem to reduce postoperative pain scores or improve the overall quality of recovery after surgery [39]. After complete insufflation, we insert all trocars under direct vision. On the left side, the first is a 10 mm placed umbilical or para umbilical depending on obesity status; the second is a 5 mm placed subcostal on the level of the anterior axillary line, and the third one is a 12 mm trocar (which comes in the LapCap package) placed in the left iliac fossa (**Figure 3**). On the right side,

*Left side: position of patient and 3 trocar placement: 5 mm subcostal, 10 mm umbilical or para umbilical (yellow dot) depending on obesity, and 12 mm left iliac fossa. LapCap device shown on the right.*

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

*Laparoscopic Live Donor Nephrectomy: Techniques and Results DOI: http://dx.doi.org/10.5772/intechopen.80880*

*Basic Principles and Practice in Surgery*

**4.1 Anesthesia**

**Figure 2.**

surgery (LESS), natural orifice transluminal endoscopic surgery (NOTES), and robotic-assisted are other interesting techniques that still need to be evaluated. In our experience, we started our first 10 cases with hand assistance, given the increased security that it provides, and then switched to pure transperitoneal

*Retroaortic vein (V). See the distance between the artery (A) and the vein (V). U = ureter.*

Laparoscopic donor nephrectomy has had a big impact on anesthesia and recovery of this special category of patients. Intraoperative anesthesia for laparoscopic live donors follows the rules of laparoscopic kidney surgery as far as sedation and muscle relaxation but the concept of protection of the donor kidney is mandatory throughout the case, one among many disparities compared to other kidney surgeries [33]. Nowadays, two large-bore IV catheters are considered more than enough as far as vascular access and risk of bleeding. Arterial lines are not recommended and noninvasive blood pressure monitoring is a reasonable option [34]. After induction of anesthesia, classically with propofol and a neuromuscular blocking agent, maintenance of anesthesia has been the subject of many studies to evaluate the nephrotoxicity of various agents. While isoflurane and desflurane were considered safe and with the least toxicity on the kidney, this was not the case with sevoflurane that is associated with production of compound A in the circulation; a direct nephrotoxic substance [35]. Despite many works, the type of anesthetic agent was not shown to impact serum creatinine or GFR in transplanted grafts and it was concluded that toxicity, if any, was minimal. Nitrous oxide is one agent preferably avoided in laparoscopic surgery as it can cause bowel distention in more than 50% of cases and subsequent compromise of insufflation or surgical field exposure in near 25% of laparoscopic donor nephrectomy, increasing the need even more for neuromuscular blocking agents [36]. Mechanical ventilation settings are not different from other laparoscopic procedures. Special considerations for donor nephrectomy would include tolerance of mild hypercapnia to 45 mmHg since it helps better tissue perfusion and circulation in light of pneumoperitoneum. Positive-end expiratory pressure (PEEP) at 5–10 mmHg, a 20–30% increase in minute ventilation reflecting an increased respiratory rate with constant volumes, is similar to other laparoscopic procedures. The effects of pneumoperitoneum were explored by studies on rats demonstrating that abdominal insufflation with CO2 during laparoscopy in subjects with chronic renal function impairment should not be a contraindication to surgery [37]. Additionally, if insufflation had a substantial negative effect on kidney function, we would have expected this to have a great impact on kidney donors out of concern on the retained kidney, which has not been

laparoscopic approach which will be detailed in this chapter.

**28**

born out in the literature. IV hydration holds a crucial place in counteracting the notorious effects of pneumoperitoneum on tissue perfusion and renal plasma flow caused by an increased intraperitoneal pressure sometimes near 15 mmHg. Some studies emphasized the great effects of hydration on mean arterial pressure preservation and ensuring hemodynamic stability [38]. Whether this is realized by giving donors colloid boluses preoperatively or during surgery is based on institutional protocols and the team preferences. In general, a patient undergoing laparoscopic donor nephrectomy should get 4–6 L during the procedure to maintain at least a urine output >50 mL/h [38]. This will help avoid the use of any vasopressors or inotrope agents because of the associated deleterious renal vasoconstriction. If they become really needed, ephedrine is the best agent to start with, giving small boluses in order to attain the desired effects. IV fluids should be warmed and full measures should be taken to prevent hypothermia. There is a mounting evidence to suggest that 0.9% normal saline can be detrimental to patient outcome, and may indeed contribute to renal dysfunction, and therefore, the use of this solution in donors cannot be recommended; Ringer's lactate solution is the intravenous fluid of choice [4]. The administration of mannitol 12–25 g once or twice, or furosemide at small doses during the case, is another example of common practice depending on departmental protocols, but they lack any definite data or evidence to support it.
