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Medicine

Robot-Assisted Kidney Transplantation

Published: July 19th, 2021

DOI:

10.3791/62220

1Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine

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

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.

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 adopted2,3,4. 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 ....

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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 .......

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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 .......

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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

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We thank Dr. Joon Seo Lim from the Scientific Publications Team at Asan Medical Center for his editorial assistance in preparing this manuscript.

....

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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

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