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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 341-344
Deceased donor kidney recovery procedure: Safe and simple in situ separation protects vascular anatomy

Section of Renal Transplant Surgery, Department of Nephrology, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia

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Date of Web Publication18-Mar-2011

How to cite this article:
Khan T, Baig A. Deceased donor kidney recovery procedure: Safe and simple in situ separation protects vascular anatomy. Saudi J Kidney Dis Transpl 2011;22:341-4

How to cite this URL:
Khan T, Baig A. Deceased donor kidney recovery procedure: Safe and simple in situ separation protects vascular anatomy. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 Jan 27];22:341-4. Available from: https://www.sjkdt.org/text.asp?2011/22/2/341/77628
To the Editor,

There is a universal shortage of organs for transplantation, and the kidneys are no excep­tion. Deceased donor kidneys are a precious gift and all efforts must be made to prevent damage to their vasculature during the reco­very procedure. Generally, in the Middle East, this procedure is not standardized as different surgeons have varied training backgrounds with differing methods of kidney recovery. We describe a simple in situ technique to separate kidneys during the recovery procedure that virtually eliminates technical errors irrespec­tive of vascular anatomy. In the last eight years, no kidneys recovered by us using this tech­nique have been reported to the organ procure­ment organizations in the US, UK and Saudi Arabia for vascular damage.

The technique is similar for all deceased do­nor kidney recovery, whether in multiorgan or kidneys-only procedures. It is described from the time (a) when the liver/pancreas has been recovered during a multiorgan donor and (b) end of perfusion in a kidney-only donor. During multiorgan donor, the kidney recovery team must be scrubbed at the time of division of the infrahepatic cava to ensure that the individual renal veins draining into the cava are safeguar­ded.

The principle of the procedure is separation of the kidneys by in situ division of the vascu­lar and ureteric attachments in a manner that preserves their vessels and ureters for safe and successful implantation in the recipient.

In the kidney-only procedure, aortic cannu­lation, perfusion and division of the IVC be­low the liver is carried out by the kidney team and, because the liver is not being recovered, a generous length of infrahepatic cava is avai­lable that safeguards both renal veins. In mul­tiorgan recovery, the liver teams generally di­vide the cava flush with the renal veins that can sometimes encroach upon the renal vein territory [Figure 1]. After the infrahepatic cava has been divided, the first step in kidney reco­very is the division of the left renal vein (LRV) where it enters the IVC [Figure 2]. This step will separate the venous systems of the two kidneys and leave the entire segment of the cavacava attached to the right renal vein (RRV). The division of the LRV exposes the anterior surface of the aorta from the superior mesen­teric artery (SMA) to its bifurcation. The base of the SMA is opened with a knife and the aorta is circumferentially divided in a cephalad direction with scissors. This is to avoid damage to the renal arteries, which may be originating at this level, especially in shorter donors. The anterior surface of the aorta is then cleared of all neurolymphatic tissue and the aortic cannula that was placed above the bifurcation is re­moved by dividing the aorta at this point. Star­ting here, the anterior wall is split in the mid­line up to the SMA [Figure 3]. Staying in the midline protects all renal arteries arising from the lateral wall of the aorta. Next, the posterior wall is also split in the midline and the division proceeds between numerous lumbar arteries. This step completely separates the two kidneys with their respective arteries and veins. Only after this step do the arterial orifices become clearly visible [Figure 4] and the number of arteries to each kidney can be appreciated. As a last step, the IVC is divided above the union of the iliac veins to disconnect the right kidney from the lower cava [Figure 5]. Next, each kid­ney is removed individually beginning with the division of the ureter and dissecting it from the surrounding tissue. Once each kidney is dissected free, only the aortic segment remains attached to the spinal muscles. By lifting the kidney along with the ureter, the arteries straighten and assume a vertical position and, at this time, all paravertebral muscular and ten­doninous tissue is divided on the spine, pos­terior to the aorta. A lot of extra tissue accom­panies each kidney and is easily removed at the back table, but is essential to protect the arterial anatomy.
Figure 1: Mulitorgan recovery. Divided end of the IVC encroaches on the renal veins (white arrow head), RRV (long arrow) and LRV (short arrow). The orifice of the SMA is visible above the left renal vein (white arrow).

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Figure 2: The LRV is about to be divided at its entry into the cava (small arrow) and the RRV is visible (arrowhead). The cut-edge of the cava and the orifice of SMA (white arrow) are in the foreground.

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Figure 3: The anterior wall of the aorta is being split cephalad up to SMA. The cut-edge of IVC (white arrow) and RRV are visible (black arrow).

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Figure 4: The posterior aortic wall is being split down the middle. Both renal artery (short arrows) and lumbar artery orifices (white arrow) are visible and the stump of the SMA is also marked (long arrow).

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Figure 5: The cava is divided above the union of the iliac veins inferiorly (chevron), a distance from the RRV (arrow). The superior stump of the cava (double arrow) in this instance is also long.

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In our experience, multiorgan recovery teams do not pay enough attention to detail when re­covering kidneys because they may not be the end users. Recovery teams use techniques that best serve their needs, which may at times dis­regard the genuine needs of others. There is a pressing need to standardize the kidney reco­very procedure to reduce instances of needless vascular damage, which, at times, is irrepara­ble and makes the allograft unusable. The pre­sence of a cuff of IVC instead of an entire seg­ment of IVC with the right kidney is undesi­rable and needs to be emphasized.

There are other techniques of deceased donor kidney recovery in the literature [1],[2],[3],[4] that include en bloc removal of both kidneys and separa­ting them at the back table. There are other authors who also feel that removal of a seg­ment of cava with the right kidney is advan­tageous, especially in cases where the RRV is short or the recipient is obese. [5],[6] Santangelo et al [7] recommend an in situ elongation patch of the cava at the time of cold perfusion, and the advantage of this procedure remains unclear. We prefer to separate them in situ because the vessels are supported and attached to the surrounding tissue, which prevents rotation and maintains them in the anatomical position. Also, during back table separation, there can be loss of orientation as the kidneys are afloat in the basin and their vessels remain at risk of rotation. One theoretical objection to in situ removal can be that it takes a longer time, but we would like to reiterate that in situ separation does not prolong the extraction time of the kidneys when compared with en bloc removal. We briefly describe the procedure for recovery of deceased donor kidneys because, in our opinion, this procedure is not standar­dized and continues to be operator-dependent. The most common error is seen in the reco­vered right kidneys, where the vital IVC seg­ment in continuity with the RRV is absent. It should be emphasized that the LRV is in itself sufficient and does not require a caval cuff be­cause, if this is provided, it will take away part of the caval segment that may be required for RRV augmentation. Arterial damage is usually seen when multiple arteries are present and when attention is not paid to the origin of the main renal arteries at the time of division of the aorta at the level of the SMA. In short donors, the origins of SMA and the renal arteries is likely to be at the same level and division of the aorta must be in a cephalad direction to protect the renal arteries [Figure 1]. When we split the aorta in the midline ante­riorly, the orifices of the main and any acces­sory renal arteries can be visualized and pro­tected, especially when the aorta is divided cephalad. We briefly describe a simple, quick and foolproof technique for safe recovery of kidneys from deceased donors that we have used and taught for several years. We tend to recover our own kidneys or communicate with the recovery surgeon to ensure that the right kidney comes with the IVC.

   References Top

1. Taylor RJ, Hakala TR, Rosenthal JT. Use of vena cava to extend the right renal vein in cadaveric transplants. Surg Gynecol Obstet 1985;160:279-80.  Back to cited text no. 1
2.Chopin DK, Popov Z, Abbou CC, Auvert JM. Use of vena cava to obtain additional length for the right renal vein during transplantation of cadaveric kidneys. J Urol 1989;141:1143-4.  Back to cited text no. 2
3.European Association of Urology - Guidelines on renal transplantation-2010- http://www.uroweb.org/files/uploaded_files/gunoneidelines/renaltransplant .  Back to cited text no. 3
4.Janschek EC, Rothe AU, Holzenbein TJ, et al. Anatomic basis of right renal vein extension for cadaveric kidney transplantation. Urology 2004;63(4):660-4.  Back to cited text no. 4
5.Benedetti E, Fryer J, Matas AJ, et al. Kidney transplant outcome with and without right renal vein extension. Clin Transplant 1994;8 (4):416-7.  Back to cited text no. 5
6.Chopin DK, Popov Z, Abbou CC, Auvert JM. Use of vena cava to obtain additional length for the right renal vein during transplantation of cadaveric kidneys. J Urol 1989;141(5): 1143-4.  Back to cited text no. 6
7.Santangelo M, Spinosa G, Grassia S, et al. In situ elongation patch in right kidney transplan-tation. Transplant Proc 2008;40(6):1871-2.  Back to cited text no. 7

Correspondence Address:
Taqi Khan
Section of Renal Transplant Surgery, Department of Nephrology, Riyadh Military Hospital, Riyadh
Kingdom of Saudi Arabia
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PMID: 21422640

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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