A Modified Single Mercedes Incision Surgical Technique for Simultaneous Liver Kidney Transplant: A Case Series Report

The traditional approach in simultaneous liver-kidney transplantation (SLKT) involves two separate and sequential incisions. We describe modification of the classic Mercedes incision which limits the operation to a single incision yet provides and maintains adequate exposure enabling safe dual-allograft transplantation.

Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4-finger-breadths below the rib-edge with a midline, cephalad incision, and inferior±medial, ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis.

Five consecutive patients (3 women/2 men; mean age, 49 years; median BMI, 29.8 kg/m2) underwent SLKT for end-stage liver disease and progressive hepatorenal syndrome via modified Mercedes incision approach (at a median MELD of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the five patients experienced post-op wound complications, including one with delayed wound healing and superficial dehiscence in a diabetic patient. All patients have normal dual-allograft function with four out of five beyond six months and one at two months post-transplantation.

Modified Mercedes incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation, respectively. Further studies are needed to prove the theoretical benefits of this technique.