*4.3.2 Right-sided nephrectomy*

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

## **Figure 9.**

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

**Figure 10.** *Liver retracted through a 5-mm xiphoid trocar.*

**Figure 11.** *Laparoscopic view of right donor kidney with two veins (V) and one artery (A).*

the IVC. Duplication of renal vein is more common on the right side and is reported in as much as 15% of potential renal donors [54] (**Figure 11**). The adrenal vein, gonadal vein, and retroperitoneal veins (lumbar, ascending lumbar, and hemiazygos) may drain into the right renal vein in 30, 7, and 3% of cases, respectively [55]. The IVC must be well dissected below and above the renal vein to permit later easy positioning of the stapler device. In usual anatomy, the renal artery is classically found just behind the vein and the space between artery and vein is normally easily created. Retrocaval area is a difficult area to work at during LLDN; therefore, the exact location of the first segmental branch of right renal artery with respect to the IVC should be clearly identified in the pretransplant angio CT scan. In some cases, posterior release of the artery behind the IVC is necessary to reach the main trunk (Video 10 (https://youtu.be/DPGFtpAVar8)) especially if the artery is in an upper position to the vein (Video 11 (https://youtu.be/BfbPdO-U8zU)); or even rarely, access to the artery is done through the inter aorto caval space. Caval countertraction is applied just prior to firing the endovascular stapler, so that adequate venous length is obtained. The renal vein is usually 2–3 mm shorter compared with the open surgery. Operative time and warm ischemia time may be greater when performing a right-sided LLDN, but this does not result in delayed allograft function [56].
