Hand-assisted laparoscopic right-donor nephrectomy in a patient with situs inversus.

Abstract

Because organ shortage remains a significant problem for patients with end-stage renal failure, it is essential to expand both the cadaveric and the live donor pools. We report, for the first time, the performance of laparoscopic donor nephrectomy in a patient with situs inversus. A 27-year-old male was evaluated as a live kidney donor for his 21-year-old human leukocyte antigen (HLA)-identical brother. Preoperative abdominal computed tomography revealed complete situs inversus, with the vena cava and liver on the left side and the aorta, spleen, stomach, ligament of Treitz, and heart on the right side (Fig. 1). Figure 1: Computed tomography demonstrating complete situs inversus in a live kidney donor. AO, aorta; COL, colon; IVC, inferior vena cava; PANC, pancreas; SPL, spleen; STOM, stomach.Laparoscopic nephrectomy was performed with the donor in the modified lateral decubitus position at a 60° angle with the left side down. The pneumoperitoneum was created with a Veress needle placed in the right upper quadrant. Ports were then placed as follows: a 12 mm working port in the midline below the xiphoid process, an 11 mm camera port in right lower quadrant in the midclavicular line, and a 5 mm retraction port above the right anterior superior iliac spine in the anterior axillary line. A peri-umbilical 7 cm midline incision was made for insertion of the hand-assist device (Pneumosleeve, Dexterity, Atlanta, GA). Hand-assisted laparoscopic right-donor nephrectomy was then performed using the standard approach for left nephrectomy. The kidney was removed through the peri-umbilical incision. The kidney was transplanted into the recipient’s right iliac fossa. Two widely separate renal arteries were individually anastomosed to the external iliac artery of the recipient in end-to-side fashion. The vein was anastomosed end-to-side on the external iliac vein. An extravesical Lich-Gregoir ureteral reimplantation was performed. The cold ischemic time was 52 minutes, and the warm ischemic time was 36 minutes. The recipient received a donor-specific blood transfusion on the day before transplant. He received induction immunosuppression with ATG at 1 mg/kg on days 0, 2, and 4. Maintenance immunosuppression consisted of mycophenolate at 500 mg twice daily and sirolimus at 3 mg once daily. Tacrolimus was started on postoperative day 14. He made urine in the operating room, and his creatinine trended from 15.7 mg/dL preoperatively to 1.3 mg/dL at discharge (postoperative day 5). The donor was advanced to a regular diet on the first postoperative day and discharged home the following day. Situs inversus totalis is a rare condition (prevalence 1 in 8,000) characterized by the complete inversion of all abdominal and thoracic organs. It is typically found incidentally during diagnostic imaging for unrelated conditions. Although open radical nephrectomy has been described before (1), we report the first laparoscopic donor nephrectomy in a patient with situs inversus. Laparoscopic donor nephrectomy has gained widespread acceptance and has contributed to the increase in numbers of living-related kidney transplants. The procedure is well established for the left kidney (2), and experience is growing with the management of the shorter renal vein on the right side (3). As laparoscopic techniques improve, the indications for their application can be broadened. More patients may benefit from the advantages of a minimally invasive procedure without a concomitant increase in risk. Laparoscopic donor nephrectomy should make more organs available for transplant. Peter C. Black James R. Porter Kevin P. Charpentier Ramasamy Bakthavatsalam Christopher L. Marsh