Laparoscopic nephrectomy in a patient with ankylosing spondylitis: surgical and anesthetic challenges

A 55-year-old man with ankylosing spondylitis was referred with left sided loin pain, loin mass, and painless macroscopic hematuria. Physical examination revealed a palpable loin mass, fixed flexion deformity of the lumbar and cervical spines, with severely restricted cervical movement and mouth opening. An ultrasound and computed tomography scan confirmed a 7-cm solid mass in the left kidney. Following a multidisciplinary meeting he elected to undergo radical laparoscopic nephrectomy. An anesthetic opinion was sought in view of the expected difficulties with intubation. Mouth opening was restricted to 3 fingers and he was Mallampati grade 3 on airway examination. As the degree of spinal flexion deformity and restricted spinal movement was significant, the patient was placed in a lateral decubitus position, and surgery was performed using a transperitoneal approach. A five-port technique was employed and was carried out successfully with no complication. Operative time was 240 minutes and estimated blood loss was 700 mL. His postoperative inpatient stay was 4.5 days. Surgical margins were clear and the patient was disease-free at 2-year follow-up. Laparoscopic nephrectomy in a patient with ankylosing spondylitis is technically challenging for both the surgeon and the anesthetist, however, with the right preoperative planning, potential morbidity can be limited to ensure a good outcome for the patient.