Cadaveric Donor Nephrectomy: Isolated Renal Procurement Home
The donor is brought into the operating room and appropriate haemodynamic monitors are placed. Muscle relaxation is achieved with vecuronium or pancuronium. This is because spinal reflexes may still be present after brain death and it may be unpleasant for the operating room personnel.

Bilateral nephrectomy is accomplished through a long midline incision or a bilateral subcostal incision or a combination of both. The objective is to take both kidneys with the full length of the renal artery and vein, preferably on aortic and vena caval cuffs. This approach limits the possibility of injuring accessory vessels present in12-15% of normal kidneys. En bloc removal of both kidneys with an intact segment of aorta and inferior vena cava allows early in situ cooling of the kidneys. Besides, it reduces the time required for nephrectomy because the fine dissection necessary for the identification and isolation of the artery and vein can be performed after the kidneys are removed. Continuous perfusion of the kidneys for preservation could be provided via the aorta, thus avoiding direct renal artery cannulation and possibility of intimal injury. Lastly, multiple arteries can be left on a cuff of aorta, hence giving the transplant surgeon the option of using a single Carrel patch anastomosis for a simpler reimplantation procedure.

On entering the abdomen, rapid exploration is done to exclude the presence of unsuspected sepsis, neoplasia or other important pathology. The small bowel and mesentery are retracted to the right and the posterior parietal peritoneum is incised over the great vessels and through the ligament of Treitz. The peritoneal incision is extended around the ascending colon so that the bowel can be retracted upward and to the left.
The third and fourth portions of the duodenum are mobilised to expose the left renal vein. The duodenum and pancreas are retracted superiorly. The adrenal and gonadal branches of the left renal vein are ligated. The distal aorta is exposed and the inferior mesenteric artery ligated. The proximal aorta is freed to above the celiac axis. The celiac and superior mesenteric arteries are ligated and divided.
Incision of posterior parietal peritoneum1
 
Umbilical tapes are passed around the distal aorta and vena cava just above the iliac bifurcations. Because only the kidneys are removed, the proximal aorta is also encircled with an umbilical tape, enabling isolation of the renal circulation. After achieving proximal aortic, distal aortic and distal vena caval occlusion, preservation of the kidneys in situ is begun by perfusion with chilled Ringer’s lactate solution containing mannitol and heparin infused through sterile intravenous tubing that has been placed directly into the aorta. The perfusate is allowed to return to the donor circulation via the proximal vena cava.
Duodenum and pancreas retracted superiorly to obtain exposure of the proximal aorta and vena cava1
 
The kidneys are generally cool and pale after rapid infusion of 500 to 600 ml of perfusate, but the perfusion is continued at a slower rate throughout the remainder of the procedure. The final mobilisation of the kidneys from the retroperitoneum is undertaken within the plane of Gerota’s fascia in a more leisurely manner. The ureter is freed and sectioned as far down toward the bladder as possible and dissection within the renal hilus should be avoided. The distal aorta and vena cava are divided and the entire block is lifted anteriorly to expose the lumbar vessels posteriorly. These are divided after being doubly clamped with silver clips
Perfusion of the kidneys through the intravenous tubing that has been introduced into the distal aorta1  

Once these vessels are controlled and the proximal aorta and vena cava have been divided, the block consisting of both kidneys and ureters, aorta and inferior vena cava can be lifted out of the abdomen and placed immediately into a basin of cooled perfusion solution. A more complete dissection and assessment of the anatomy of the renal vessels can then be undertaken. Before closure of the abdominal incision, lymph nodes are taken from the small bowel mesentery and a piece of spleen is removed for tissue tying and crossmatching
Isolation of the kidney and ureter1