Dr Vikas Jain, Fortis Hospital, Shalimar Bagh and Vasant Kunj (New Delhi)
Presence of multiple renal arteries (MRAs) is the most common anatomical variation found in kidneys and are seen in 20-30% of individuals; double renal arteries (DRAs) being the most common.(1) Double barrel anastomosis (also known as Conjoined side-to-side or “pantaloon” anastomosis) is the preferred approach in case of renal arteries of similar length & comparable lumen, especially when they are close to each other.
In this type of reconstruction, a single arterial lumen is created on bench (ex-vivo reconstruction), which is then anastomosed to either internal iliac artery (IIA) or external iliac artery (EIA).
Description of Technique
On bench (under cold ischemia), the fat from the all over the graft is removed and hilar dissection is performed to adequately expose the renal vessels. All the vessels are dissected free and at this point, decision is finally taken on the type of reconstruction. As mentioned, the anatomical configuration of the arteries (length, calibre and proximity to each other) dictate the type of anastomosis. So, if the arteries are far apart, a pantaloon reconstruction may not be preferred as it may put tension on suture line (figure 1).
Figure 1: Bench photograph of prepared graft showing two renal arteries far-apart
However, for arteries close to each other (figure 2a), a pantaloon is simple to create. In this method, a single lumen is created by spatulating the two arteries medially and suturing them together in a side-to-side manner (figure 2c).
Figure 2: Steps in Double-barrel reconstruction of two renal arteries
Step 1: Both the arteries are spatulated medially to an equal distance (figure 2b).
Step 2: Using 7-0 prolene, posterior layer is sutured first in continuous manner, followed by anterior layer. As a result, a single inflow channel is created. One must make sure that both the lumens are patent by passing the probe individually in each artery at the end of reconstruction.
Step 3: The single inflow channel, thus created, is than anastomosed to either EIA in an end-to-side manner (figure 2d) or to IIA in an end-to-end manner (figure 3).
Figure 3: End-to-end anastomosis of single inflow channel created by double-barrel into IIA.
The main advantage of this ex-vivo reconstruction method is that the relatively difficult anastomosis of small vessels is performed on the back table under hypothermic conditions (thereby reducing warm ischemia) and with good illumination and there is no pressure on the surgeon to do it fast considering anastomotic warm time.(2)
With growing expertise, this technique has also been extrapolated for three renal arteries (TRAs) of similar length, where a single lumen is created by conjoining them in a side-to-side-to-side manner (figure 4) and also to DRAs with significant luminal discrepancy.(3)
Figure 4: Conjoined anastomosis technique for TRAs. Creation of a single ostium by side-to-side-to-side anastomoses (Image Courtesy: Dr Aditya Sharma, Lucknow).