Living donor hand-assisted laparoscopic nephrectomy in a healthy individual with situs inversus totalis: no need to turn down the donor

Abstract

A 70-year-old healthy male individual offered to undergo a living donor hand-assisted laparoscopic nephrectomy to enable kidney transplantation for a close relative. As required for all living transplant donor candidates, extensive screening was performed to exclude potential contraindications for donation. Tests revealed a situs inversus totalis, meaning a complete transposition of the thoracic and abdominal organs in the sagittal plane. As other contraindications for living kidney donation were absent, the feasibility of this procedure was determined multidisciplinary. A successful donation procedure was performed without surgical complications for the donor and good short-term transplant outcomes. In line with current developments that have resulted in more liberal criteria for potential living kidney donors, major anatomical deviations should not automatically be a contraindication. With multidisciplinary efforts and thorough surgical preparation at a high-volume transplant centre, this procedure is feasible and safe.

Background

Living kidney donation could be considered to be in disagreement with the general medical principle of doing no harm, and elaborate screening of living transplant donor candidates is pivotal.^{1 2} Standard living donor nephrectomy has proven to be without major risk, with 2.6% postsurgical complications and a perioperative mortality of 3.1 per 10 000 donors.^3–5 Laparoscopic (hand-assisted) nephrectomy is standard practice in most centres, showing similarly low complication rates even for more challenging cases.⁶ While 25% of donors experience chronic pain after hand-assisted laparoscopic nephrectomy, the postdonation quality of life is reported as equal or better than that of the general population.^{7 8} A worldwide estimated total of 27 000 living donor transplantations are performed each year (2006), showing that 39% of all kidney transplantations are enabled by living donation.⁹ For the recipient, receiving a transplant from a living donor comes with the advantage of a shorter period on the waiting list and better long-term survival compared with deceased donor transplantation.¹⁰ While the literature on potential donor candidate refusal is scarce, a single-centre descriptive study shows that over half of potential donors do not pass the initial health screening and 10% is refused based on anatomical information obtained by contrast-enhanced CT.¹¹ Donor safety is of utmost importance in any living donation programme, therefore a thorough predonation screening is required. With the ongoing long times on waiting lists and the increasing demand for donor organs, more liberal selection criteria for potential living kidney donors, such as donors with anatomical deviations, have become common practice.^{2 12 13} Several reports describe the potential harms of refusing to allow living donation, showing the emotional consequences of turning down a potential donor candidate.^{14 15}

Case presentation

A 70-year-old healthy male individual was considered fit to donate his left kidney to a close relative. Medical history showed no prior abdominal surgical procedures and no history of renal insufficiency or other medical conditions, with the exception of controlled hypertension. In-depth psychological assessment did not show contraindications for donation, confirming good motives, commitment and understanding of the balance between the procedure’s risk and potential benefits for the recipient. Standard predonation screening included chest X-ray and contrast-enhanced CT, revealing situs inversus totalis (figures 1 and 2). This situs inversus totalis was not accompanied by Kartagener syndrome, the underlying condition of primary ciliary dyskinesia seen in 25% of these individuals.¹⁶ There were no additional anatomical deviations (eg, no vascular abnormalities) or suspicion for malignancy; the donor candidate had a body mass index of 30.2 kg/m² (figure 3).

Figure 1.

Chest X-ray prior to living donor hand-assisted laparoscopic nephrectomy.

Figure 2.

Contrast-enhanced CT, showing a transversal and frontal image of the abdomen prior to living donor hand-assisted laparoscopic nephrectomy.

Figure 3.

Intraoperative image showing the renal vasculature during living donor hand-assisted laparoscopic nephrectomy.

Investigations

In line with the current guidelines for screening of living transplant donor candidates, this patient underwent a chest X-ray (figure 1) and contrast-enhanced CT (figure 2). The chest X-ray shows the cardiac apex pointing to the right and a right-sided aortic arch, indicating dextrocardia, and free air under the right-side of the diaphragm, indicating a right-sided stomach. The contrast-enhanced CT shows complete transposition of the abdominal organs in the sagittal plane. Assessment of the kidneys showed a small cystic lesion on the right kidney, with an accessory renal artery. Signs of a focal parenchymal lesion were seen on the left kidney, possibly due to calcification and/or ischaemic damage.

Outcome and follow-up

Hand-assisted laparoscopic donor nephrectomy using a transperitoneal approach is standard practice in our centre. The procedure was performed with the patient in right-sided position and a suprapubic transverse incision was made to provide hand access. The first trocar (10 mm) was placed in the left iliac fossa, the second trocar (10 mm) periumbilically as a video port and the third trocar (5 mm) subcostally. After successful nephrectomy of the left kidney, the suprapubic fascia was closed with running absorbable suture.⁷ To assess the success of the donation procedure there was a 30-day follow-up. The donor had a procedure-related complication during this follow-up period, a seroma at the incision site. This surgical complication was classified as Clavien-Dindo Grade I, not requiring a medical intervention.¹⁷ The donor did not experience other complications in this period, although he did have pain at the surgical wound site in the first days after donation. Postoperative pain scores were assessed by a Visual Analogue Scale (VAS) score. Postoperative VAS was 3/10 at rest and he was discharged on the third postoperative day. At 2 weeks follow-up VAS score was 0/10 at rest and 1–2/10 during mild exercise, with some remaining irritation at the suprapubic wound site. At 30-day follow-up the donor reported a VAS score of 0/10 at rest and 1/10 during mild exercise. His creatinine was 72 μmol/L preoperatively, 119 μmol/ on the second postoperative day and 69 μmol/L on the sixth postoperative day.

Discussion

Situs inversus totalis is the total reversal of both thoracic and abdominal organs in the sagittal plane, and was first described by Leonardo da Vinci in the 15th century. It is seen in about 1 person in 10 000.¹⁸ This anatomical deviation complicates surgical procedures, as it requires a complete shift of the team’s anatomical perspective. However, in the current report we describe a case of a successful living donor hand-assisted laparoscopic nephrectomy on a 70-year-old man with situs inversus totalis, showing that this major anatomical deviation does not pose an increased threat to the donor’s safety.

Living kidney donors are extremely motivated to undergo a donor nephrectomy procedure enabling kidney transplantation for a family member or friend in need. Not being able to donate due to anatomical deviations discovered during predonation screening is a tremendous disappointment for these potential donors. Although previous case reports have been published on living donor nephrectomy in a donor with situs inversus totalis, the perspective of the potential donor has been underexposed. Qualitative research on emotional status after screening for living kidney donation revealed negative emotional consequences in a subgroup of candidates who were turned down for donation.¹⁵ This is in line with the viewpoint article written by Allen and colleagues, addressing the expanded view of risks and benefits for potential living kidney donor candidates. Their systematic analysis of risks and benefits in living kidney donation describes an underestimation of the harms of being turned down for donation.¹⁴

We conducted a systematic search to identify similar cases in the literature (PubMed search (“transplant* nephrectomy” OR “donor nephrectomy”) AND “situs inversus”) and found six earlier case reports. Even when combining the experience gained in these six performed procedures, the data on donation procedures in situs inversus donors remains limited. While most case reports discuss the transplant outcomes, five out of six did not report data on donor follow-up.^19–23 The case report addressing donor outcomes reports creatinine levels within normal range and fast recovery without need for additional pain medication.²⁴

In line with current developments, namely more liberal criteria for potential living kidney donors, major anatomical deviations should not automatically be a contraindication. Multidisciplinary teamwork is currently the cornerstone of these kind of procedures, and this, together with thorough surgical preparation, should enable high-volume transplant centres to perform living donor hand-assisted laparoscopic nephrectomy in a safe and feasible way for donors with situs inversus totalis. This would enable centres to lower their refusal rates for potential donors based on their anatomical deviations, without additional hazards for the donor.

Patient’s perspective.

To provide an insight into the impact of situs inversus totalis on a living transplant donor candidate, the donor was interviewed: ‘I heard that a close relative had kidney failure and that she was in need of a transplant donor. I knew that I had the opportunity to help here, although this would be an impactful decision for myself. In my opinion, providing the needed transplant for this close relative outweighed the possible negative impact it might have on myself. Furthermore, I found it important that this close relative would not be dependent on lifelong dialysis. Prior to the screening process I was aware that my anatomy somewhat deviated from normal, yet I was unaware of its extent and whether it had implications for my own health or for my ability to donate. Had I been turned down for donation, with this deviating anatomy as the sole reason, I would have been very disappointed. In that case I would have asked for a second opinion. If the reason for being turned down for donation was related to a health problem, it would have been more acceptable to me. At the time point of the donation procedure I had no remaining concerns regarding my own health in relation to undergoing a surgical procedure with situs inversus totalis, thanks to the thorough explanation and reassurance by the surgical team. Shortly after donating I felt satisfied and my recovery was going well, even though the swelling at the incision site caused some mild discomfort. My emotional status was positively affected by the good short-term outcomes for the recipient.’

Learning points.

• Living donor hand-assisted laparoscopic nephrectomy is a feasible and safe procedure in candidates with situs inversus totalis.

• This procedure should only be performed after multidisciplinary assessment of the potential risks.

• As an anatomical deviation could pose an attributable risk, the procedure should be performed by an experienced transplant surgeon at a high-volume centre.

• The more liberal criteria for acceptance of living donor candidates should include candidates with situs inversus totalis, after thorough surgical preparation.