Case 2: Dexon Mesh Repair
A 63-year old African-American female waiting five years for a deceased donor kidney transplant was transplanted with a kidney from a 54-year-old deceased donor. During bench preparation, a large separation of thin renal capsule on the posterior surface was noted. Upon revascularization, persistent bleeding occurred from the shredded capsule, exposing large areas of renal parenchyma.
Several attempts to control the bleeding with electrocautery, argon beam laser, and direct pressure were unsuccessful. As a rescue attempt to salvage the allograft, the posterior renal surface was covered with Floseal (Baxter, Deerfield, Ill.) and a 6 cm sheet of Fibrillar (Ethicon, Sommerville, N.J.). The entire kidney was wrapped with a sheet of Dexon (polyglycolic acid) Mesh (Covidien, Mansfield, Mass.), which was sutured closed at the level of the renal hilum with several 3-0 Vicryl sutures.
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Discussion
Capsular injury
Significant capsular injury of renal allografts most often occurs during procurement of the deceased donor or living donor allograft.3-4 Capsular disruption, when significant, may lead to non-acceptance and discard of the allograft by the transplant surgeon given the potential risk of major intraoperative and/or postoperative hemorrhage. Reinforcing the denuded capsule with Vicryl mesh with or without Evicel Fibrin sealant is a technique that can be used by the transplant surgeon to salvage the renal allograft and ultimately increase the available pool of kidney allografts for transplantation.
The authors are urologic surgeons at Cleveland Clinic’s Glickman Urological & Kidney Institute. Dr. Modlin is Associate Professor of Surgery and Dr. Flechner is Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr. Flechner also is Director of Clinical Research in the Section of Renal Transplantation.
The authors are urologic surgeons at Cleveland Clinic’s Glickman Urological & Kidney Institute. Dr. Modlin is Associate Professor of Surgery and Dr. Flechner is Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr. Flechner also is Director of Clinical Research in the Section of Renal Transplantation.
References
- 1. The 2008 annual report of the OPTN/SRTR: Kidney and Pancreas Transplantation. http://www.ustransplant.org
2. Sezhian N, Modlin CS Jr, Ghoneim I, et al. Renal allograft capsular repair surgical technique to reduce allograft discard rates of kidneys with capsular injury. J Natl Med Assoc 2012;104:199-201.
3. Hammer C, Hawasli A, Mequid A, Oh H. Degloving of renal capsule: a rare complication of laparoscopic live donor nephrectomy. J Laparoendosc Adv Surg Tech A 2006;16:362-364.4. Mohamed HK, Lin A, Savage SJ, et al. Parenchymal transection of the kidney inflicted by endocatch bag entrapment during a laparoscopic donor nephrectomy. Am J Transplant 2006;6:232-235.
