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

*Basic Principles and Practice in Surgery*

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

**Figure 10.**

**Figure 11.**

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

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

right-sided LLDN, but this does not result in delayed allograft function [56].

The early postoperative period after laparoscopic donor nephrectomy is a particular moment in the management of kidney donors. Extubation is done after

**34**

**5. Postoperative care**

normothermic state. Orogastric tube is removed prior to extubation. Hemoglobin measurement is realized every 6 h postsurgery, and if normal, it will be repeated the next morning with serum creatinine and electrolytes. Urine output is monitored. Shoulder tip discomfort and pain is a major complaint after LLDN perhaps from residual pneumoperitoneum. Epidural analgesia is ineffective for shoulder pain. There has been collective belief to aggressively minimize pain postoperatively in this special category of patients who are usually narcotics naïve. IV "patient-controlled analgesia" (PCA; fentanyl or morphine less commonly) was considered to be the modality of choice to achieve that. If PCA is not available, pain control is achieved with IV paracetamol and if needed ketoprofen or ketorolac over the first 24 h [57]. To reduce the risk of nephrotoxicity, the patient should be kept well hydrated. Opiates also have an effective role for breakthrough pain when opiate-sparing strategies have not been effective. Clear liquids are started on the day of surgery with increase of diet later. The emergence of enhanced recovery after surgery (ERAS) brought major changes to the traditional standard of care. Many centers across the USA have adopted the enhanced recovery programs that include intraoperative fluid restriction to 3 ml/ kg/h preventing excessive third spacing and bowel edema, urine output of 0.5 ml/ kg/h, use of local subfascial bupivacaine or other anesthetics as well as a postoperative narcotic-free pain control regimen, i.e., acetaminophen, ketorolac, etc. [58]. Novelties in this management were associated with reduced length of hospital stay, better pain control, and increased patient satisfaction. It has become evident that ERAS would potentially enhance the benefits of laparoscopic surgery for kidney donors [59].

Foley catheter is removed on the morning of day 1 and ambulation started as soon as possible either during the evening of day 0 or the next morning. Living kidney donors are classified as "medium risk" patients for deep venous thrombosis (DVT) and pulmonary embolism [4]. All living donors must have intra- and postoperative compression stockings and should receive adequate thromboprophylaxis with low-molecular weight-heparin and continuing for at least 1 week. Patient is discharged most frequently on day 2 and seen back 10 days later with a follow-up at 6 months, 1 year, and 2 years after donation. Donors must resume a normal lifestyle as soon as possible with regular surveillance of their blood pressure and their weight. They should be warned about avoiding nephrotoxic medications.
