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Modified Mercedes Single Incision for Combined Liver Kidney Transplant: A Case Series Report. Transplant Proc 2022; 54:2248-2253. [PMID: 36167595 DOI: 10.1016/j.transproceed.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/04/2022] [Accepted: 08/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The traditional approach in combined liver-kidney transplantation involves 2 separate and sequential incisions. We describe a modification of the standard Mercedes incision that allows a single-incision operation while providing and maintaining adequate exposure to enable safe dual-allograft transplantation. METHODS Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4 fingerbreadths below the rib edge with a midline, cephalad incision and inferior ± medial ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. RESULTS Five consecutive patients (3 women/2 men; mean age, 49 years; median body mass index, 29.8 kg/m2) underwent combined liver-kidney transplantation for end-stage liver disease and progressive hepatorenal syndrome via a modified Mercedes single-incision approach (at a median Model for End-stage Liver Disease of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the 5 patients experienced postoperative wound complications, including 1 with delayed wound healing and 1 with superficial dehiscence. All patients have normal dual-allograft function at or beyond 6 months posttransplantation. CONCLUSIONS The modified Mercedes single-incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation. Further studies are needed to prove the theoretical benefits of this technique.
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Simultaneous right-sided nephrectomy with orthotopic liver and kidney transplantation-An alternative method for patients with autosomal dominant polycystic liver and kidney disease. Langenbecks Arch Surg 2021; 406:2107-2115. [PMID: 34036408 PMCID: PMC8481182 DOI: 10.1007/s00423-021-02206-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/16/2021] [Indexed: 11/15/2022]
Abstract
Purpose In patients suffering from autosomal dominant polycystic liver and kidney disease (ADPLKD), combined organ transplantation often poses a technical challenge due to the large volume of both organs. To simplify the transplantation procedure by improving the exposure of anatomical structures, we introduce a novel surgical technique of orthotopic liver and kidney transplantation. Methods The modified simultaneous liver and kidney transplantation technique via a right-sided L-incision included three steps: (1) right-sided nephrectomy in the recipient followed by (2) orthotopic liver transplantation in cava replacement technique and (3) the orthotopic kidney transplantation with arterial reconstruction to the right common iliac artery. Results In total, seven patients with ADPLKD were transplanted by using the modified transplantation technique. The mean operation time was 342.43 min (±68.77). Postoperative patients were treated for 6.28 days (±2.50) in the intensive care unit and were discharged from the surgical ward approximately 28 days (±5.66) after the operation with normal graft function. Complications associated with the use of the modified technique, such as bleeding, anastomotic stenosis, biloma, or urinoma, did not occur. Conclusion Modified simultaneous liver and kidney transplantation is a safe alternative for patients with ADPLKD. By combining right-sided nephrectomy and orthotopic graft transplantation, the approach optimizes the exposure of anatomical structures and simplifies the transplantation procedure. Additionally, the modified transplantation technique does not require a particular organ explantation procedure and can be applied for all liver and kidney grafts.
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Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Silski LS, Quillin RC, Cuffy MC, Jones CR, Diwan TS, Shah SA. Outcomes of en bloc simultaneous liver-kidney transplantation compared to the traditional technique. Am J Transplant 2020; 20:1181-1187. [PMID: 31605561 DOI: 10.1111/ajt.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Latifa S Silski
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph C Quillin
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madison C Cuffy
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Nguyen MC, Black S, Washburn K, El-Hinnawi A. En bloc liver-kidney transplantation with renal artery variation using donor splenic artery and left gastric artery as inflow to the kidney: Case report. Int J Surg Case Rep 2018; 53:13-16. [PMID: 30366170 PMCID: PMC6203241 DOI: 10.1016/j.ijscr.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/10/2018] [Accepted: 10/01/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION En bloc liver-kidney transplantation can be difficult with renal artery variations for which the risk of multiple anastomoses can outweigh the benefits. PRESENTATION OF CASE This report is the first to describe an en bloc liver-kidney transplantation using a donor kidney with double renal arteries. The indication for a combined liver-kidney transplant was non-alcoholic steatohepatitis (NASH) cirrhosis with chronic kidney disease secondary to hypertension and diabetes compounded by hepato-renal syndrome. The explant pathology was consistent with steatohepatitis, but did have PAS/D-positive intracytoplastic globules which suggest an additional component of alpha-1-antitrypsin deficiency. DISCUSSION Diminished arterial inflow to the inferior renal pole was noted intraoperatively, requiring re-anastomosis of the inferior renal polar artery to the donor left gastric artery. The post-operative course was uncomplicated with patient discharge on post-operative day six. CONCLUSION With increasing numbers of simultaneous liver-kidney transplants being performed, kidneys with multiple renal arteries can successfully be transplanted en-bloc without compromising ischemia time.
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Affiliation(s)
- Michelle C Nguyen
- Division of Transplantation, The Ohio State University Wexner Center, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Sylvester Black
- Division of Transplantation, The Ohio State University Wexner Center, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Ken Washburn
- Division of Transplantation, The Ohio State University Wexner Center, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Ashraf El-Hinnawi
- Division of Transplantation, The Ohio State University Wexner Center, 395 W 12th Avenue, Columbus, OH, 43210, USA.
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