The laparoscopic approach is rapidly becoming the standard way to procure kidneys from living donors for transplantation. We will present our technique of laparoscopic left live donor nephrectomy.

The patient is positioned supine in a modified right lateral decubitus position with mild flexion of the operating table and the arms folded across the front of the chest over a pillow. The SKYTRON 6500 OR table allows for rotation of the donor's torso to the right or left as necessary. Three ports are used for access: 1) subumbilical 12 mm port for the laparoscope,2) a 12mm port at the margin of the rectus sheath level with the left anterior superior iliac spine and, 3) a 5 mm port two finger-breadths below the xiphoid process. A DeBakey-Crile grasper is passed via the 5 mm port; the sucker/endoscopic scissors is passed through the left lower quadrant port. The surgeon and the camera operator stand on the right side of the patient.

Pneumoperitoneum of 15 mm Hg is achieved with a Veress needle in the left lower quadrant. The left lower quadrant port is placed using a Visiport optical trocar. The infraumbilical 12mm and the sub-xiphoid 5 mm port are placed, under direct vision. The peritoneum is incised along the left paracolic gutter starting at the splenic flexure down to the sigmoid colon. Using the tip of the sucker, Gerota's fascia is identified. The Gerota's fascia is held up with the DeBakey-Crile. The splenic flexure,descending and sigmoid colon are reflected medially.

Next, a 5 cm long transverse skin incision is made 2 finger-breadths above the pubic bone. This incision is deepened to the level of the fascia. The fascia is incised in the midline till the peritoneum is exposed. A purse-string suture with 3-0 Maxon is taken, and the Endocatch assembly is placed through that into the peritoneal cavity.This acts as a retractor for the descending colon as the operation progresses. The ureter is identified by dissecting the colon and mesocolon away from the lower pole of the kidney and medial to the gonadal vein. Dissection medial to the gonadal vein and therefore medial to the ureter is performed to prevent devascularization of the ureter. Please note that the ureter is dissected off the psoas muscle.

The medial upper pole of the kidney is then dissected out, care being taken not to damage the kidney or a upper polar vessel. This dissection is done before the lower medial aspect of the kidney or the lateral and posterior aspects of the kidney are mobilized. This prevents torsion of the kidney on its pedicle. Dissection is done till the upper pole is mobile.

The Endocatch is used to retract the colon and mesocolon ,and the lower pole renal artery (in this instance) and the main renal vein are dissected out. Lumbar veins and the adrenal vein are isolated by careful dissection; care is taken not to avulse them in the process of clipping and division. The gonadal vein is isolated close to its upper end where it drains into the renal vein. It is divided here between hemoclips. The main renal artery is identified by dissection below the inferior margin of the renal vein. The video will show creation of space between the main renal artery and vein after division of a tributary of the main renal vein.