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Anatomic Diversity Encountered During Laparoscopic Hand-Assisted Transperitoneal Donor Nephrectomy: A Case Report of Complete Caval Duplication
Anatomic Diversity Encountered During Laparoscopic Hand-Assisted Transperitoneal Donor Nephrectomy: A Case Report of Complete Caval Duplication S.L. Kireccia, M. Demirb, M. Ilgia,*, M. Battalc, A.I. Dokucub, and A. Unsald a Organ Transplantation and Urology Clinic, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey; bPediatric Surgery and Organ Transplantation Clinic, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey; cGeneral Surgery Clinic, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey; dNephrology Clinic, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey
ABSTRACT Introduction. Laparoscopic donor nephrectomy is widely used to retrieve a kidney for transplantation. Preoperative evaluation of the donor is of crucial importance to the recipient. In particular, vascular anatomy should be assessed with the help of modern imaging modalities. We present a hand-assisted laparoscopic nephrectomy of a kidney donor with a complete duplex vena cava. Case Report. A 40-year-old male patient was admitted to our clinic as a kidney donor for his 20-year-old son. After the preliminary tests, further imaging with the use of computerized tomographic angiography showed a complete duplex vena cava. He had no morbidities or previous surgeries. A hand-assisted transperitoneal laparoscopic left nephrectomy was performed as the kidney removal technique commonly used in our center. There was minimal blood loss, and the warm ischemia time was 66 minutes. Operation time was 265 minutes. After transplantation had been performed, graft functions were good with normal urine output. Blood sample tests were in normal ranges. The live donor was discharged on the 7th day after the procedure without any complications. Conclusions. Although renal vascular anomalies are rarely seen, they have a significant impact on the outcomes of the renal transplantation. Knowing the vascular anatomy minimizes the complications risk and increases the success rate. Laparoscopic live-donor nephrectomy can be performed safely, even in patients with vascular anomalies.
T
HE MINIMAL invasive surgical approach has been highly developed for 20 years. Likewise, laparoscopic donor nephrectomy is the common kidney removal technique for transplantation. This procedure had become applicable on the different centers after Ratner et al performed the first laparoscopic live-donor nephrectomy [1]. Laparoscopic live-donor nephrectomy is a technically challenging procedure which requires prompt extraction of the kidney to avoid warm ischemia and dissection of the main vascular structures [2]. With appropriate patient selection and operative experience, laparoscopic livingdonor nephrectomy is a safe procedure associated with low morbidity [3].
ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 613e615 (2017)
Primary principles of laparoscopic live-donor nephrectomy are to minimize the warm ischemia and blood loss and to extract the kidney promptly. Developmental malformations can be seen in the donors. Anomalies of the vena cava are rare and have no clinical significance. They have an incidence of 0.5%-3% and are discovered incidentally [2,4]. The purpose of the present report indicates the handassisted laparoscopic donor nephrectomy is a safe procedure in the case of a complete duplex vena cava. *Address correspondence to Dr Musab Ilgi, Sisli Hamidiye Etfal Research and Training Hospital, Urology Clinic, Sisli, Istanbul 34371, Turkey. E-mail: [email protected] 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.01.038
613
614
KIRECCI, DEMIR, ILGI ET AL
Fig 1. Computerized tomographic angiography shows the caval duplication in the coronal plane.
CASE REPORT A 40-year-old man wished to donate a kidney to his 20-year-old son. He had no previous medical disease or operation history. A complete duplex inferior vena cava was detected on preoperative computerized tomographic (CT) angiography (Figs 1 and 2). A paramedian abdominal incision adjacent to the umbilicus to place the hand-assisted device was then performed with the transperitoneal approach. Pneumoperitoneum was created to accommodate the hand-port, and the operation was started with the placement the additional trocar. The descending colon was mobilized, and the Gerota fascia was incised to expose the renal vessels. Complete caval duplication was clearly identified, and the vascular pedicles were dissected to the aorta. The ureter was dissected to the level of pelvic brim. With minimal blood loss and warm ischemia time of 66 minutes, a left nephrectomy was done successfully. Operative time was 265 minutes. Preoperative and postoperative complications were not encountered. Preoperative and postoperative creatinine levels were 0.99 and 1.19 mg/dL, respectively. Table 1 presents the recipient outcomes, which were good with normal urine output. The donor was discharged on the 7th day after surgery with no complications and good urine output.
DISCUSSION
Live-donor nephrectomy is performed on healthy individuals, so it must be as safe as possible to protect the health of the donor as well as the graft [5]. Vascular anomalies are rarely seen and are usually detected during surgery, making the nephrectomy more complicated. The presence of abnormal vasculature can be a challenge [2,4]. Preoperative CT angiography is an appropriate detection method for both arterial and venous anomalies. It can be our guide during the procedure. Mandal et al reported 50 left nephrectomies with vascular anomalies in a series of 210, and 1 of them had a duplicated inferior vena cava. They demonstrated that the vascular abnormalities of the left kidney are not contraindications to the use of the left kidney. Moreover, preoperative assessment of the donor renal vasculature has tremendous importance for operation safety [6].
In our patient, after the careful dissection of perivascular bodies, the complete duplex inferior vena cava was exposed and the nephrectomy was performed safely. There were no complications due to the vascular anomaly. Previously published cases reported transplantations carried out on incomplete inferior vena cava duplication noted below the left renal vein and with the left renal vein draining into the main vena cava. However, in our case, the vena cava was completely duplicated to the diaphragm and the left renal vein was directly draining into the left vena cava; thus the left renal vein length was short, like a right renal vein. Laparoscopic hand-assisted donor nephrectomy with complete caval duplication has not been reported in the literature; this case report is unique. In conclusion, live donor patients should be evaluated meticulously for determination of the vascular abnormalities before surgery. Vascular malformations can increase the complications, operative time, and ischemia time and reduce the success rate of the procedure. However, handassisted laparoscopic donor nephrectomy can be performed safely and efficiently by adequately experienced surgeons even if patients have vascular anomalies.
Fig 2. Computerized tomographic angiography shows the caval duplication in the axial plane.
CASE REPORT OF COMPLETE CAVAL DUPLICATION
615
Table 1. Recipient Outcomes Postoperative Day
1 7 14 30
Urine Output (mL)
Creatinine Level (mg/dL)
eGFR (ml/min/1.73 m2)
Intake (mL)
6,110 10,300 7,300 6,120
5.09 1.66 1.47 1.38
15.48 56.42 64.91 69.82
8,240 11,900 8,400 8,240
Note. Age, 20 y; height, 1.74 cm; weight, 56 kg; body mass index, 18.5 kg/m2; preoperative creatinine, 6.44 mg/dL; preoperative urine output, 800 mL. Abbreviation: eGFR, estimated glomerular filtration rate (Modification of Diet in Renal Disease formula).
REFERENCES [1] Ratner LE, Ciseck L, Moore RG, Cigarroa F, Kaufman HS, Kavoussi L. Laparoscopic live donor nephrectomy. Transplantation 1995;60:1047e9. [2] Wu C-T, Chiang Y-J, Liu K-L, Chu S-H. Laparoscopic live donor nephrectomy in a patient with duplex inferior vena cava. Transplant Proc 2004;36:1912e3. [3] Harper J, Breda A, Leppert J, Veale J, Gritsch H, Schulam P. Experience with 750 consecutive laparoscopic donor nephrectomiesdis it time to use a standardized classification of complications? J Urol 2010;183:1941e6.
[4] Brener BJ, Darling RC, Frederick PL, Linton RR. Major venous anomalies complicating abdominal aortic surgery. Arch Surg 1974;108:159e65. [5] Fabián J, Mancilla E, Aburto J, Kasep J, Lopez J, Almaguer F, et al., editors. Hand-assisted laparoscopic nephrectomy for live donor kidney transplantation. Transplant Proc 2016;48:568e71. [6] Mandal AK, Cohen C, Montgomery RA, Kavoussi LR, Ratner LE. Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindication to laparoscopic left donor nephrectomy. Transplantation 2001;71:660e4.
ABSTRACT Introduction. Laparoscopic donor nephrectomy is widely used to retrieve a kidney for transplantation. Preoperative evaluation of the donor is of crucial importance to the recipient. In particular, vascular anatomy should be assessed with the help of modern imaging modalities. We present a hand-assisted laparoscopic nephrectomy of a kidney donor with a complete duplex vena cava. Case Report. A 40-year-old male patient was admitted to our clinic as a kidney donor for his 20-year-old son. After the preliminary tests, further imaging with the use of computerized tomographic angiography showed a complete duplex vena cava. He had no morbidities or previous surgeries. A hand-assisted transperitoneal laparoscopic left nephrectomy was performed as the kidney removal technique commonly used in our center. There was minimal blood loss, and the warm ischemia time was 66 minutes. Operation time was 265 minutes. After transplantation had been performed, graft functions were good with normal urine output. Blood sample tests were in normal ranges. The live donor was discharged on the 7th day after the procedure without any complications. Conclusions. Although renal vascular anomalies are rarely seen, they have a significant impact on the outcomes of the renal transplantation. Knowing the vascular anatomy minimizes the complications risk and increases the success rate. Laparoscopic live-donor nephrectomy can be performed safely, even in patients with vascular anomalies.
T
HE MINIMAL invasive surgical approach has been highly developed for 20 years. Likewise, laparoscopic donor nephrectomy is the common kidney removal technique for transplantation. This procedure had become applicable on the different centers after Ratner et al performed the first laparoscopic live-donor nephrectomy [1]. Laparoscopic live-donor nephrectomy is a technically challenging procedure which requires prompt extraction of the kidney to avoid warm ischemia and dissection of the main vascular structures [2]. With appropriate patient selection and operative experience, laparoscopic livingdonor nephrectomy is a safe procedure associated with low morbidity [3].
ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 613e615 (2017)
Primary principles of laparoscopic live-donor nephrectomy are to minimize the warm ischemia and blood loss and to extract the kidney promptly. Developmental malformations can be seen in the donors. Anomalies of the vena cava are rare and have no clinical significance. They have an incidence of 0.5%-3% and are discovered incidentally [2,4]. The purpose of the present report indicates the handassisted laparoscopic donor nephrectomy is a safe procedure in the case of a complete duplex vena cava. *Address correspondence to Dr Musab Ilgi, Sisli Hamidiye Etfal Research and Training Hospital, Urology Clinic, Sisli, Istanbul 34371, Turkey. E-mail: [email protected] 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.01.038
613
614
KIRECCI, DEMIR, ILGI ET AL
Fig 1. Computerized tomographic angiography shows the caval duplication in the coronal plane.
CASE REPORT A 40-year-old man wished to donate a kidney to his 20-year-old son. He had no previous medical disease or operation history. A complete duplex inferior vena cava was detected on preoperative computerized tomographic (CT) angiography (Figs 1 and 2). A paramedian abdominal incision adjacent to the umbilicus to place the hand-assisted device was then performed with the transperitoneal approach. Pneumoperitoneum was created to accommodate the hand-port, and the operation was started with the placement the additional trocar. The descending colon was mobilized, and the Gerota fascia was incised to expose the renal vessels. Complete caval duplication was clearly identified, and the vascular pedicles were dissected to the aorta. The ureter was dissected to the level of pelvic brim. With minimal blood loss and warm ischemia time of 66 minutes, a left nephrectomy was done successfully. Operative time was 265 minutes. Preoperative and postoperative complications were not encountered. Preoperative and postoperative creatinine levels were 0.99 and 1.19 mg/dL, respectively. Table 1 presents the recipient outcomes, which were good with normal urine output. The donor was discharged on the 7th day after surgery with no complications and good urine output.
DISCUSSION
Live-donor nephrectomy is performed on healthy individuals, so it must be as safe as possible to protect the health of the donor as well as the graft [5]. Vascular anomalies are rarely seen and are usually detected during surgery, making the nephrectomy more complicated. The presence of abnormal vasculature can be a challenge [2,4]. Preoperative CT angiography is an appropriate detection method for both arterial and venous anomalies. It can be our guide during the procedure. Mandal et al reported 50 left nephrectomies with vascular anomalies in a series of 210, and 1 of them had a duplicated inferior vena cava. They demonstrated that the vascular abnormalities of the left kidney are not contraindications to the use of the left kidney. Moreover, preoperative assessment of the donor renal vasculature has tremendous importance for operation safety [6].
In our patient, after the careful dissection of perivascular bodies, the complete duplex inferior vena cava was exposed and the nephrectomy was performed safely. There were no complications due to the vascular anomaly. Previously published cases reported transplantations carried out on incomplete inferior vena cava duplication noted below the left renal vein and with the left renal vein draining into the main vena cava. However, in our case, the vena cava was completely duplicated to the diaphragm and the left renal vein was directly draining into the left vena cava; thus the left renal vein length was short, like a right renal vein. Laparoscopic hand-assisted donor nephrectomy with complete caval duplication has not been reported in the literature; this case report is unique. In conclusion, live donor patients should be evaluated meticulously for determination of the vascular abnormalities before surgery. Vascular malformations can increase the complications, operative time, and ischemia time and reduce the success rate of the procedure. However, handassisted laparoscopic donor nephrectomy can be performed safely and efficiently by adequately experienced surgeons even if patients have vascular anomalies.
Fig 2. Computerized tomographic angiography shows the caval duplication in the axial plane.
CASE REPORT OF COMPLETE CAVAL DUPLICATION
615
Table 1. Recipient Outcomes Postoperative Day
1 7 14 30
Urine Output (mL)
Creatinine Level (mg/dL)
eGFR (ml/min/1.73 m2)
Intake (mL)
6,110 10,300 7,300 6,120
5.09 1.66 1.47 1.38
15.48 56.42 64.91 69.82
8,240 11,900 8,400 8,240
Note. Age, 20 y; height, 1.74 cm; weight, 56 kg; body mass index, 18.5 kg/m2; preoperative creatinine, 6.44 mg/dL; preoperative urine output, 800 mL. Abbreviation: eGFR, estimated glomerular filtration rate (Modification of Diet in Renal Disease formula).
REFERENCES [1] Ratner LE, Ciseck L, Moore RG, Cigarroa F, Kaufman HS, Kavoussi L. Laparoscopic live donor nephrectomy. Transplantation 1995;60:1047e9. [2] Wu C-T, Chiang Y-J, Liu K-L, Chu S-H. Laparoscopic live donor nephrectomy in a patient with duplex inferior vena cava. Transplant Proc 2004;36:1912e3. [3] Harper J, Breda A, Leppert J, Veale J, Gritsch H, Schulam P. Experience with 750 consecutive laparoscopic donor nephrectomiesdis it time to use a standardized classification of complications? J Urol 2010;183:1941e6.
[4] Brener BJ, Darling RC, Frederick PL, Linton RR. Major venous anomalies complicating abdominal aortic surgery. Arch Surg 1974;108:159e65. [5] Fabián J, Mancilla E, Aburto J, Kasep J, Lopez J, Almaguer F, et al., editors. Hand-assisted laparoscopic nephrectomy for live donor kidney transplantation. Transplant Proc 2016;48:568e71. [6] Mandal AK, Cohen C, Montgomery RA, Kavoussi LR, Ratner LE. Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindication to laparoscopic left donor nephrectomy. Transplantation 2001;71:660e4.