Complication Arising from a Duplicated Inferior Vena Cava following Laparoscopic Living Donor Nephrectomy: A Case Report P.G. Christakis, B. Cimsit, and S. Kulkarni ABSTRACT Selecting a kidney for living donor nephrectomy is driven by the tenet that donors are left with the higher functioning kidney. Traditionally, the left kidney is used because it has a longer renal vein, which aids anastamosis, and has an easier surgical approach. Anomalous left renal vasculature is not considered a contraindication to living donor nephrectomy. In the case of duplicated inferior vena cava, no specific considerations have been reported. We present a 42-year-old patient with infrarenal duplication of the vena cava who underwent laparoscopic living donor nephrectomy. His postoperative course was compli- cated by painful scrotal swelling necessitating multiple emergency room visits. Ultrasonog- raphy revealed bilateral hydroceles 5 weeks after surgery, which resolved with the use of a scrotal sling. Intraoperative ligation of a visibly dilated left gonadal vein was the likely etiology. Careful consideration should be taken in living donor nephrectomy in patients with duplication of inferior vena cava. L APAROSCOPIC techniques for living donor nephrec- tomy have become increasingly common following reports of a shorter hospital stay, faster recovery time, and less postoperative analgesic requirement compared with open techniques. 1 Traditionally, the left kidney is preferred because of the longer renal vein, even in cases of anomalous left renal vasculature or when a laparoscopic approach is used. 2–4 A rare vascular anomaly that has been reported in living donor nephrectomy is duplication of the inferior vena cava, which has an estimated incidence of 0.5%–3%. 3,5,6 Herein, we present the case of a patient with an infrarenal duplicated vena cava who underwent successful laparo- scopic left donor nephrectomy, but had a postoperative course complicated by his anomalous vascular anatomy. CASE PRESENTATION A 32-year-old man with no significant past medical history pre- sented to the Yale-New Haven Transplant Center to be a kidney donor for his 45-year-old cousin with end-stage renal disease secondary to hypertension who had been on dialysis for 6 years. After an extensive medical and psychological evaluation, he was approved for donation. His preoperative computerized tomogra- phy (CT) imaging revealed a duplicated inferior vena cava below the level of the left renal vein (Figs 1 and 2). The left kidney measured 13 cm with a single widely patent renal artery and a left renal vein which merged with the duplicated inferior vena cava and drained into the right vena cava. The right kidney measured 12 cm with a single widely patent renal artery that bifurcated 1.1 cm lateral to the aorta and caudal to the medial margin of the right vena cava. There was a wide right renal vein and a small lower pole right renal vein, as well as an extrarenal pelvis noted on the right. A laparoscopic left donor nephrectomy was performed using 3 trochars including a 12-mm periumbilical port, a 5-mm left subcos- tal camera port, and a 5-mm left anterior axillary line port. A Pfannenstiel incision was made to deliver the kidney. The left renal vein was visualized and noted to have a dilated gonadal contribu- tion, and to merge with the left vena cava at the confluence with the right vena cava. There were no intraoperative complications and the procedure was completed without difficulty. The postoperative course was uneventful and the patient was discharged home on postoperative day 3 with good renal function and pain control. On postoperative day 7, he was seen in clinic and noted to have left scrotal swelling with tenderness, which he attributed to having walked a lot the day prior. The following day he developed a low-grade fever (100.9°F), sore throat, chills, and body aches, and presented to the emergency room. Bloodwork revealed a white blood cell count of 16,300/L (normal, 4,000 – 10,000) and serum creatinine of 1.7 mg/dL (normal, 0.5–1.2). He underwent abdominal/pelvic CT with oral contrast, which showed no abscess. A chest x-ray revealed no evidence of pneumonia. His symptoms were consistent with a viral upper respiratory infection, and the left scrotal swelling was attributed to the intraoperative From the Yale School of Medicine (P.G.C.), New Haven, Connecticut; and Yale-New Haven Transplant Center (B.C., S.K.), New Haven, Connecticut. Address corresponding to Panos Christakis, Yale School of Medicine, 367 Cedar Street, New Haven, CT 06511. E-mail: Panos.Christakis@yale.edu 0041-1345/12/$–see front matter © 2012 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.transproceed.2011.11.064 360 Park Avenue South, New York, NY 10010-1710 1450 Transplantation Proceedings, 44, 1450 –1452 (2012)