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 minimally invasive surgical techniques (laparoscopic or hand-assisted laparoscopic) combined with multimodal analgesia to ensure donor safety, rapid recovery, and minimal postoperative pain. 1

Surgical Approach Considerations

Recommended Surgical Techniques

• Hand-assisted laparoscopy or "mini-open" laparoscopy is the preferred surgical approach for donor nephrectomy 1
• Traditional open nephrectomy may be acceptable only in specific circumstances:
  • Donors with extensive previous surgery/adhesions
  • Centers where laparoscopy is not routinely performed 1

Surgical Technique Contraindications

• Robotic, single-port, and natural orifice transluminal nephrectomy are generally not recommended for donor nephrectomy due to lack of evidence supporting their safety and efficacy 1
• Nontransfixing clips (e.g., Weck Hem-O-lok) should not be used to ligate the renal artery; instead, renal artery transfixation by suture ligature or anchor staple should be used 1

Kidney Selection

• Left kidney is preferred for laparoscopic donor nephrectomy due to the longer venous pedicle, which facilitates the procedure 1
• Right kidney procurement may be performed if the surgeon has adequate training and experience 1
• Procurement of kidneys with complex vascular anatomy (≥3 arteries) should only be undertaken by surgeons with adequate experience 1

Preoperative Anaesthetic Considerations

Preoperative Assessment

• Thorough evaluation of renal function and anatomy
• Computed tomographic angiography is mandatory to assess renal anatomy before nephrectomy 1
• Screening for cardiovascular and respiratory comorbidities
• Assessment of coagulation profile

Antibiotic Prophylaxis

• Administer antibiotic prophylaxis (such as cefazolin) within 60 minutes before surgical incision 1
• No benefit to extending antibiotics into the postoperative period 1

Skin Preparation

• Chlorhexidine-alcoholic solution is recommended for skin preparation as it is associated with lower rates of surgical site infections compared to povidone-iodine solution 1

Intraoperative Anaesthetic Management

Anaesthetic Technique

• General anaesthesia is the mainstay for donor nephrectomy
• Consider combining with regional techniques for enhanced recovery:
  • Thoracic epidural analgesia (TEA) can modify stress response and provide superior pain control but may cause hypotension and complicate fluid therapy 1
  • Intrathecal opiates can reduce postoperative opioid requirements when combined with multimodal analgesia 1
  • Rectus sheath block (RSB) provides similar analgesia to spinal anaesthesia with fewer side effects 2

Fluid Management

• Maintain adequate hydration to optimize renal perfusion
• Cautious use of vasopressors if needed, especially with epidural analgesia 1
• Monitor urine output closely

Postoperative Pain Management

Multimodal Analgesia Options

• Ketorolac-based analgesia has been shown to reduce postoperative stay (from 3.7 to 3.1 days), decrease narcotic requirements by 58%, and improve oral intake without affecting long-term renal function 3
• Acetazolamide-based multimodal approach combined with intraperitoneal saline irrigation and bupivacaine instillation at surgical sites can significantly reduce postoperative pain and shoulder tip pain 4
• Thoracic epidural analgesia provides better pain control and reduces opioid use compared to IV patient-controlled analgesia (PCA) 1
• Rectus sheath block with levobupivacaine (2 mg/kg) provides similar analgesia to spinal anaesthesia with fewer side effects such as urinary retention 2

Fast-Track Protocols

• Fast-track pathways using ketorolac (with or without morphine spinal) significantly shorten hospital stay compared to traditional patient-controlled analgesia (median 2 days vs 3 days) 5
• Improved oral intake: only 6% of patients on ketorolac-based protocols experienced delayed oral intake compared to 83% with PCA 5
• Cost containment: mean global cost was significantly lower with ketorolac-based protocols ($9,394) compared to PCA ($11,601) 5

Special Considerations

Minimizing Donor Morbidity

• Prioritize techniques that reduce postoperative pain and facilitate early mobilization
• Monitor for potential complications specific to laparoscopic approach:
  • Shoulder tip pain due to residual pneumoperitoneum
  • Positioning-related complications
  • Pneumothorax

Monitoring Renal Function

• While ketorolac may cause a slight decrease in immediate postoperative creatinine clearance (66% vs 72% of preoperative values), long-term renal function is not affected 3
• Close monitoring of fluid status and urine output is essential

Conclusion Points

• Laparoscopic approach by experienced surgeons is strongly recommended for donor nephrectomy 1
• Multimodal analgesia incorporating regional techniques and NSAIDs (when not contraindicated) provides optimal pain control
• Fast-track protocols significantly reduce hospital stay and improve recovery without compromising donor safety
• The primary goal is to minimize donor morbidity while ensuring optimal conditions for kidney retrieval