What are the anaesthetic considerations for living donor nephrectomy?

Anaesthetic Considerations in Living Donor Nephrectomy

The optimal anaesthetic approach for living donor nephrectomy should prioritize donor safety while providing effective pain management through multimodal analgesia techniques, with laparoscopic hand-assisted or mini-open approaches being the preferred surgical methods to minimize postoperative morbidity. 1

Preoperative Considerations

Imaging and Surgical Planning

• Computed tomographic angiography (CT) is the preferred imaging modality to assess renal anatomy before nephrectomy 1
• The radiologist must understand the laparoscopic procedure to convey critical information to the surgeon 1
• Left kidney procurement is generally preferred due to the longer venous pedicle, unless specific anatomical considerations indicate right kidney donation 1

Surgical Approach Selection

• Hand-assisted laparoscopy or "mini-open" laparoscopy should be the primary surgical approaches 1
• Open nephrectomy may be acceptable in specific circumstances:
  • Donors with extensive previous surgery/adhesions
  • Centers where laparoscopy is not routinely performed 1
• Robotic, single-port, and natural orifice transluminal nephrectomy should generally be avoided due to limited evidence supporting their safety and efficacy 1

Intraoperative Management

Antibiotic Prophylaxis

• Administer antibiotic prophylaxis (e.g., cefazolin) within 60 minutes before surgical incision 1
• Extended postoperative antibiotics provide no additional benefit 1

Skin Preparation

• Chlorhexidine-alcoholic solution is strongly recommended over povidone-iodine solution to reduce surgical site infections 1

Analgesia Options

Neuraxial Techniques

• Thoracic epidural analgesia (TEA) can modify stress response and provide effective pain control but carries risks of:

  • Hypotension due to sympathectomy
  • Complications with fluid therapy
  • Potential need for vasopressors
  • Timing issues for catheter removal due to postoperative coagulation changes 1

• Intrathecal opiates (spinal anesthesia) can be considered as an alternative to TEA:

  • Reduces postoperative opioid requirements
  • Avoids need for continuous infusions
  • Similar efficacy to TEA with lower risk of complications 1
  • However, spinal anesthesia with hyperbaric bupivacaine and diamorphine showed no significant benefit over rectus sheath block in time-to-discharge readiness 2

Regional Techniques

• Rectus sheath block (RSB) with levobupivacaine provides similar analgesia to spinal anesthesia with fewer side effects 2
• Consider local anesthetic infiltration at laparoscopic port sites and Pfannenstiel incision 3

Multimodal Approaches

• Acetazolamide-based multimodal analgesia:

  • Combination of orogastric acetazolamide
  • Intraperitoneal saline irrigation
  • Bupivacaine instillation in the renal fossa and incision sites
  • Significantly reduces postoperative pain and analgesic requirements 3

• Ketorolac-based analgesia:

  • Reduces postoperative narcotic requirements by up to 58%
  • Shortens hospital stay (3.7 to 3.1 days)
  • Improves oral intake and return to regular diet
  • No long-term negative impact on renal function 4, 5

Postoperative Management

Pain Management

• Implement multimodal analgesia to minimize opioid requirements:
  • NSAIDs (ketorolac) when not contraindicated
  • Acetaminophen/paracetamol
  • Local anesthetic techniques
  • Limited opioids for breakthrough pain 3, 4

Shoulder Tip Pain Prevention

• Shoulder tip pain is a common complaint after laparoscopic nephrectomy
• Preventive measures include:
  • Intraperitoneal saline irrigation
  • Acetazolamide administration
  • Complete evacuation of pneumoperitoneum 3

Early Recovery

• Fast-track pathways significantly shorten hospital stay and accelerate oral intake 5
• Early mobilization and resumption of oral intake should be encouraged
• Monitor for potential complications:
  • Bleeding
  • Urinary retention (more common with spinal anesthesia) 2
  • Nausea and vomiting

Special Considerations

Vascular Concerns

• Careful ligation of renal artery is critical:
  • Avoid nontransfixing clips (e.g., Weck Hem-O-lok)
  • Use suture ligature or anchor staple within the vessel wall 1
  • Prevent potential catastrophic hemorrhage

Complex Anatomy

• Procurement of kidneys with 3 or more arteries should only be undertaken by surgeons with adequate experience 1
• Donors with atherosclerotic renal artery disease or fibromuscular dysplasia involving both renal artery orifices should not donate 1

Psychosocial Support

• Recognize the psychological impact of donation
• Provide appropriate pre and postoperative psychological support 1

By implementing these anaesthetic considerations, donor safety can be maximized while providing optimal conditions for kidney procurement and minimizing postoperative morbidity.