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

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,

### **Figure 3.**

*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.*

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