Evolution of laparoscopic donor nephrectomy has lead to our final approach as followings:
1. Entry: We always use open access. This has eliminated access complications in our department, (with training fellows involved).
2. We leave Gerota's fascia and perinephric fat on the kidney intact except small area in upper pole. (like radical nephrectomy), making nephrectomy faster, while kidney and ureter is better preserved.
3. We have combined bioclip with a titanium non automatic clip placed by hand force, so we do not use Endo GIA stapler which is costly and less safe. By adding metallic clip we increase the safety of Hom-o-lok that recently has been under question.
4. We use bipolar cautery to control lumbar, adrenal and other veins need to be divided, therefore avoiding clips as much as possible.
5. Gonadal vein is preserved with ureter leading to longer renal vein with no dissection around. ureter
6. Fourth trocar: we always have the assistant hand (camera holder) by a 5mm forth trocar retracting the bowel, holding the kidney when necessary and helping the surgeon dissecting renal pedicle.
7. Less or no manipulations on adrenal gland to prevent arrhythmia. We use hem-o-lok clip to control adrenal arteries during removal phase of the kidney.
8. We always hand extract the kidney from suprapubic incision which makes more cost effective and cosmetic.
9. We use no heparin, preventing bleeding tendency in donors. We observed no adverse effect in this regard.
10. Long term graft survival with above measures has been 93.8%.