Robot-Assisted Kidney Transplantation

Summary

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

Abstract

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels.

After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

Introduction

Kidney transplantation contributes to prolonged survival and a better quality of life compared with peritoneal dialysis or hemodialysis¹. Although the open approach is the standard procedure for kidney transplantation, robotic-assisted techniques have been recently adopted^2,3,4. Specifically, robot-assisted kidney transplantation (RAKT) has several advantages over open kidney transplantation: minimal postoperative pain, better cosmesis, fewer wound infections, and shorter hospital stay⁵. Moreover, minimally invasive access ....

Protocol

This study got approval from the Institutional Review Board of Asan Medical Center (IRB number: 2021-0101).

1. Pretransplant preparation

1. Patient selection
   1. Include patients with end-stage renal disease who require kidney transplantation.
      NOTE: RAKT may not be considered if a recipient is younger than eighteen years old.
   2. Exclude those with any kind of untreated malignancy or active infection.
   3. Ensure that the recipient is suitable for surgery with respect to cardiac and pulmonary function and appropriate for a minimally invasive approach.
   4. Do not consider RAKT if a patient has a h....

Results

We set up a routine clinical pathway for recipients who have RAKT at our center. Renal Doppler ultrasound is performed one day post-transplant and technetium-99m diethylenetriamine penta-acetic acid renal scan two days post-transplant. For venous thromboembolism prophylaxis, an intermittent pneumatic compression device is applied during the first 24 h after RAKT. Foley catheter is removed on the fourth postoperative day. On the fifth day, a closed-suction drain is removed after confirming no intra-abdominal complication .......

Discussion

Although laparoscopic and robotic-assisted techniques have been widely applied for living donor nephrectomy, kidney transplantations are still mainly performed using conventional open techniques. Recently, however, a minimally invasive approach for kidney transplantation has been increasingly used. Compared with traditional open surgery, minimally invasive kidney transplantation has a lower risk of surgical site infection, incisional hernia, and wound dehiscence, as well as shorter hospitalization¹²

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
12 mm Fluorescence Endoscope, 30°	Intuitive Surgical	370893	robotic instrument
8 mm Blunt Obturator	Intuitive Surgical	420008	robotic instrument
8 mm Instrument Cannula	Intuitive Surgical	420002	robotic instrument
ATRAUMATIC ROBOTIC VESSEL CLIPS	RZ Medizintechnic GmbH	300-100-799
BARD INLAY OPTIMA URETERAL STENT	BARD Medical	78414	4.7 Fr./14 cm
Black Diamond Micro Forceps	Intuitive Surgical	420033	robotic instrument
COATED VICRYL 4-0	Ethicon Endo-Surgery, Inc.	W9437
Da Vinci Si, X, or Xi	Intuitive Surgical
Fenestrated bipolar forceps	Intuitive Surgical	470205	robotic instrument
GELPORT LAPAROSCOPIC SYSTEM	Applied Medical Resources Corporation	C8XX2	standard laparoscopic equipment
GORE-TEX SUTURE CV-6	W.L. Gore and Associates Inc.	6M02A
GORE-TEX SUTURE CV-7	W.L. Gore and Associates Inc.	7K02A
HEMO CLIP	WECK	523735
HEM-O-LOK CLIP	WECK	544220
Hot Shears (Monopolar Curved Scissors)	Intuitive Surgical	420179	robotic instrument
laparoscopic atraumatic grasping forceps			standard laparoscopic equipment
laparoscopic irrigation suction set			standard laparoscopic equipment
Large Clip Applier	Intuitive Surgical	420230	robotic instrument
Large Needle Driver	Intuitive Surgical	420006	robotic instrument
Maryland Bipolar Forceps	Intuitive Surgical	420172	robotic instrument
Medium-Large Clip Applier	Intuitive Surgical	420327	robotic instrument
OPEN END URETERAL CATHETER	Cook Incorporated	21305	heparin flushing
PDS II 6-0 (DOUBLE)	Ethicon Endo-Surgery, Inc.	Z1712H
Potts Scissors	Intuitive Surgical	420001	robotic instrument
ProGrasp Forceps	Intuitive Surgical	420093	robotic forceps
Small Clip Applier	Intuitive Surgical	420003	robotic instrument
VESSEL LOOP BLUE MAXI	ASPEN surgical	011012pbx
VESSEL LOOP RED MINI	ASPEN surgical	011001pbx
XCEL BLADELESS TROCAR	JOHNSON & JOHNSON	2B12LT	standard laparoscopic equipment