Renal Transplant Surgery

Transcription

1 Renal Transplant Surgery Mr Somaiah Aroori MS MD EBS in HPB FRCS Consultant HPB & Renal Transplant Surgeon SWTC, Derriford Hospital, Plymouth

2 Over next few minutes Aim to cover Details of Transplant procedure Work up of kidney donor Work up of kidney recipient Complications associated with transplant

3 Kidney Donors Cadaveric Donation after brain death Donation after cardiac death Live Related Unrelated Altrustic

4 Kidney Transplant Site- Usually extra peritoneal Cadaveric renal artery is usually on aortic patch Live kidneys no arterial patch Venous anastomosis- end of renal vein to side of external iliac vein Arterial anastomosis end of renal artery to side of external iliac artery Ureteric drainage- spatulated end of ureter to dome of bladder over stent

5 Steps involved in Kidney Transplant 1 st stage is to choose the side and site of transplant Previous abdominal operations Previous transplants/pd catheter site/anatomy of iliac vessels Whether or not it is isolated kidney transplant

6 Site and number of kidney transplants

7 Steps of Kidney transplant Steps of the operation Exposure of iliac vessels Clamping of external iliac vein End-to-side renal vein to external iliac vein anastomosis Clamp external iliac artery End-to-side renal artery to external iliac artery anastomosis Filling of bladder to identify the site of anastomosis End-to-side uretero-cystostomy over double J- ureteric anastomosis Haemostasis and drain insertion Doppler probe attached to renal artery Closure

8 Renal vein Renal artery Kidney

9 Kidney Hilum of the kidney Ureter Renal vein Renal artery

10 Arterial anastomosis Which artery to be used- renal arteries are end arteries External iliac artery Internal iliac Common iliac Inferior epigastric Number of arteries Cadaveric kidney Live kidney

11 Arterial Anastomosis

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13 Venous anastomosis End to side renal vein to external or common iliac vein Rarely onto the inferior vena cava

14 Renal vein Renal to external iliac vein an Renal to internal iliac artery anastom

15 Doppler Probe

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18 IMPD Study results

19 Exploration findings

20 What was done after re-exploration

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22 ICG Clearance image

23 Surgeon s Wish list

24 Donor Side Differential function Anatomy Arterial Venous Ureter

25 Donor Arterial anatomy Number of renal arteries Branching pattern Distance from origin to division Origin of renal arteries Atherosclerosis If it is cadaveric arteries on a patch or not

26 Renal arterial anatomy Renal arteries are end arteries Accessory arteries occurrence 30% of population Common on left side 1-6 arteries, common - 2 Early branching (or prehilar branching) - occurs in ~10% of the population occurs within cm of origin in the left renal artery or in the retrocaval segment of the right renal artery MRA grafts were associated with a higher risk of complication and delayed graft function but had comparable long-term outcomes for graft and patient survival.

27 Arterial anatomy

28 Venous anatomy Branches Number Recipient- anatomy of IVC, Common iliac and external iliac vein Any signs of previous DVT

29 Recipient Arterial anatomy - Calcification - Stenosis - Branching pattern - Diameter of both external and internal iliac artery Venous anatomy Thrombosis Signs of previous DVT Previous operations

30 What to expect post-op? US in recovery if there is a concern with perfusion US transplant kidney 24 hrs after surgery (baseline) Abdominal drain 3-4 days (if no urine or lymph leak) Doppler probe 2-3 days Urinary catheter 5 days Ureteric stent 3-4 weeks

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32 Surgical Complications Vascular complications (1-2%) Bleeding Arterial thrombosis Venous thrombosis Infarction Renal arterial stenosis Pseudoanerysm AV-fistulas

33 Non- vascular complications Urinary complications Urine leak (5%) Ureteric obstruction Post-op collections Hematoma Abscess Lymphocele Urine leak

34 Year old live related kidney transplant from a relative. Donor had two arteries which were joined together before implantation. 6 hours post-op urine output dropped. Nephrologists worried about renal artery/vein thrombosis. US- patchy perfusion of kidney.

35 A young patient 24 hours post DBD kidney transplant with hematuria and significant drop in urine output. Baseline US-reverse diastolic flow.

36 Renal transplant 6 days ago. New large collection inferior to graft with compression of bladder?infected haematoma? Active extravasation

37 50 year old male DBD transplant a week ago. Kidney is still not working. Post renal biopsy - significant amount of pain and drop hemoglobin CT within 24 hrs post biopsy CT following repeat biopsy a week later

38 35 year old female 6 weeks post kidney transplant with slowly increasing creatinine. US hydronephrotic kidney

39 9 weeks post live transplant with significant arterial stenosis

40 2 weeks post renal transplant with pyrexia, high white cell count and graft pain.

41 Questions?