Modified J-shaped incision for combined pediatric liver-kidney transplants (CLKT): Focusing on the urological outcomes.

Objectives: Combined liver-kidney transplants (CLKT) are performed through two separate incisions. Our aim was to describe our initial experience using a modified J-shaped incision to perform a single-access CLKT and evaluate the results focusing on the urological outcomes and complications.

Methods: We performed a retrospective analysis of all pediatric liver-kidney transplants (LKT) performed at our center between January 2000-December 2022 using the modified single J-shaped incision. The modified J-shaped incision is a midline incision that extends from the xiphoid process down to a centimeter above the umbilicus and continues laterally, reaching the right posterior axillary line. This incision grants access to the upper and lower right quadrants, which allows for the orthotopic implantation of the hepatic graft and the heterotopic intraperitoneal implantation of the renal graft on the right side.

Results: Out of 20 CLKT, 7 (3 females/4 males) were performed using this approach. Mean age and weight were 9.4 ± 4.4 years and 35.3 ± 14.1 kg, respectively. Primary disease was autosomal polycystic kidney disease (4), NEK8 gene mutation (1), primary hyperoxaluria type 1 (1) and methylmalonic acidemia (1). All but one patient were first-time kidney graft recipients. All grafts were implanted intraperitoneally and on the right side. The iliac vessels were employed in all but one arterial and venous anastomosis. Ureteral reimplantation was performed using the Lich-Gregoir (LG) technique in five patients and an end-to-end uretero-ureteral (UU) anastomosis in the remaining two patients. There were no intraoperative complications. We observed postoperative complications in 2 patients: 2 urinary leaks (one LG reimplantation and another UU reimplantation) of which one required reintervention. One patient developed a small incisional hernia. With a mean follow-up of 20.9 months all grafts are functional.

Conclusions: Single-access CLKT through a modified J-shaped incision provides safe access to both upper and lower right quadrants without compromising surgical exposure. Concurrently, this enables to reduce operative and renal allograft cold ischemia time. Vascular anastomoses can be performed to the iliac vessels just-as-good as with the classical retroperitoneal approach. Despite it may hinder ureteral reimplantation to the bladder especially in grafts with short ureters or older recipients with deep-set pelvic bladders, this should not affect the outcomes.