**4. Surgical technique**

*Basic Principles and Practice in Surgery*

surgical past history, risk factors like alcohol intake and smoking, family history (mainly renal disease, hypertension, and diabetes), renal, liver, and cardiopulmonary function. They should have no active malignancy or infection. The waiting period before transplant in recipients with a history of malignancy depends on the type, TNM stage and grade of the tumor, and recipient's age and general health. Recipients with tumors that have a low recurrence rate can be considered for immediate transplantation after successful treatment. Active HBV and HCV are usually contraindications to living donor kidney donation; and HIV infection is an absolute contraindication. Screening of serum prostate-specific antigen (PSA) is mandatory in males above 54 years as also mammograms in women. A urine albumin/creatinine ratio done on a spot urine sample is a recommended screening test and it should be <30 mg/mmol. The presence of persistent microhematuria (two or more positive urine analysis) or recently called "persistent nonvisible hematuria," with no evident explanation like stones, neoplasms, and infection, should be investigated with cystoscopy and renal biopsy. Assessment of renal function is based on serum creatinine and calculation of creatinine clearance. Differential kidney function, using DMSA isotope scanning, is recommended when there is >10% variation in kidney size or abnormal renal anatomy [4]. Donors with mild and well-controlled hypertension, on one or two antihypertensive drugs, and with no evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria), might be accepted [20]. Data regarding long-term safety of nephrectomy in hypertensive donors are modest; but small studies with short-term follow-up suggest no increase in the incidence of kidney disease or worsening of the control of hypertension in donors with a history of mild well-controlled hypertension [21]. The Amsterdam Forum consensus guidelines in 2004 stated that some patients (age > 50, GFR >80, and with low urine albumin excretion of <30 mg/d) with easily controlled hypertension can represent a low-risk group for the development of kidney disease but might be considered as donors [22]. A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional who can be a psychologist or a psychiatrist. This assessment also evaluates whether the decision to donate is free of constraint and other undue pressures. Donor age is suggested to be between 22 and 75 years; but the upper age limit can be beyond if the donor is in good health and with a normal range of age-related change in kidney function (e.g., advisory thresh-

old GFR levels considered acceptable at age 80 years is 58 ml/min/1.73 m2

on the safety of kidney donation in the very obese (BMI >35 kg/m2

function is one that leaves sufficient function after donation to maintain the donor in normal status without affecting lifespan [4]. Old donors (> 60 years) should be aware of a greater risk of pre- and postoperative complications. We are very cautious about young donors who are less than 30 years old because their absolute risk over a lifetime, particularly with additional risk factors for end-stage renal disease (like hypertension, obesity, and diabetes), is likely to be more significant [4]. Living donors should ideally have a body mass index (BMI) that is less than 30 kg/m2

donation should be discouraged. Morbid obesity increases the risk of hypertension, dyslipidemia, insulin resistance and diabetes, heart disease, stroke, sleep apnea, and certain cancers [23]. On the other hand, data suggest that laparoscopic living-donor nephrectomy (LLDN) is an increasingly safe procedure in the otherwise healthy obese kidney donor and does not result in a high rate of major perioperative complications [24, 25]. Also, transplantation from an old or obese donor is most probably better than dialysis or transplantation from a deceased donor [26]. Computed tomography and tomographic angiography are used to assess renal vascular anatomy (presence of accessory vessels, intervessel distance, distance from ostium to the first division, presence of atherosclerotic disease), renal dimensions, presence of

for females). A safe threshold level of predonation kidney

for males

. Data

) are limited and

**26**

and 49 ml/min/1.73 m2

Multiple techniques have been described to harvest a kidney from a living donor. The old classic open surgery performed through a lumbar or subcostal incision is nowadays much less popular compared to mini-invasive approaches using laparoscopic extra corporeal manipulation and magnified ultrahigh definition view of the surgical field. But regardless of how minimally invasive laparoscopy can be, living donor nephrectomy remains a maximally invasive surgery because we are dealing with major vessels and consequently very serious and sometimes lethal hemorrhagic complications might occur. Highly qualified, competent, and well-trained surgeons are allowed to perform such techniques within a very well-equipped environment and with experienced surgical staff. A living donor program should undertake at least 30 cases per year to maintain adequate experience. Today, laparoscopy is by far the preferred procedure for kidney removal in live donors, offering a quick recovery, less pain, and a shorter hospital stay; and it will be the technique detailed in this chapter. A well-informed consent is obtained prior to surgery. The surgeon performing living donor nephrectomy has a particular responsibility to ensure that the donor fully understands the potential risks and long-term effects of the operation. Surgery must offer to the donor safety, low morbidity, and fast recovery; and must obtain a graft with adequate vessel length, short warm ischemia time, and well-preserved ureteral blood supply. A donor kidney with a single renal artery should, whenever possible, be chosen for transplantation to minimize the risk of vascular complications in the recipient procedure; similarly, single renal veins are usually preferred. Many transplant centers prefer the left kidney for LLDN because of the longer vein and perhaps an easier surgery on the left side; but with increasing experience, kidney side was not a real obstacle [30] although for some authors the right kidney was the only risk factor for early graft thrombosis [31, 32]. The answer to which kidney to take when facing a donor with two arteries on the left and a single artery on the right is based on the surgeon's experience of laparoscopic right nephrectomy and his skills in reconstructing the vasculature of the graft. The presence of a retroaortic renal vein is of no problem with no increased complications; and it is even an easier case because of the large distance between the artery and the retroaortic vein which is in an inferior position (**Figure 2**). The most important criterion regarding the side to be chosen for retrieval is to keep the better kidney for the living donor.

There is variability among different centers on the choice of laparoscopic technique between only pure laparoscopy (transperitoneal versus retroperitoneal), only hand-assisted laparoscopy or a combination of both. Laparoendoscopic single-site

**Figure 2.** *Retroaortic vein (V). See the distance between the artery (A) and the vein (V). U = ureter.*

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 laparoscopic approach which will be detailed in this chapter.
