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

This study got approval from the Institutional Review Board of Asan Medical Center (IRB number: 2021-0101).
1. Pretransplant preparation
<ol>
	<li>Patient selection
	<ol>
		<li>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.</li>
		<li>Exclude those with any kind of untreated malignancy or active infection.</li>
		<li>Ensure that the recipient is suitable for surgery ...

<ol>
	<li>Wolfe, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+mortality+in+all+patients+on+dialysis,+patients+on+dialysis+awaiting+transplantation,+and+recipients+of+a+first+cadaveric+transplant.">Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.</a> New England Journal of Medicine. 341 (23), 1725-1730 (1999).</li><li>Hoznek, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+assisted+kidney+transplantation:+an+initial+experience.">Robotic assisted kidney transplantation: an initial experience.</a> Journal of Urology. 167 (4), 1604-1606 (2002).</li><li>Breda, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation:+our+first+case.">Robotic-assisted kidney transplantation: our first case.</a> World Journal of Urology. 34 (3), 443-447 (2016).</li><li>Menon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia:+evolution+of+a+novel+procedure+utilizing+the+IDEAL+guidelines+(IDEAL+phase+0+and+1).">Robotic kidney transplantation with regional hypothermia: evolution of a novel procedure utilizing the IDEAL guidelines (IDEAL phase 0 and 1).</a> European Urology. 65 (5), 1001-1009 (2014).</li><li>Tzvetanov, I., D'Amico, G., Benedetti, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation:+our+experience+and+literature+review.">Robotic-assisted kidney transplantation: our experience and literature review.</a> Current Transplantation Reports. 2 (2), 122-126 (2015).</li><li>Giulianotti, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+transabdominal+kidney+transplantation+in+a+morbidly+obese+patient.">Robotic transabdominal kidney transplantation in a morbidly obese patient.</a> American Journal of Transplantation. 10 (6), 1478-1482 (2010).</li><li>Oberholzer, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+robotic+kidney+transplantation+for+obese+patients+previously+denied+access+to+transplantation.">Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.</a> American Journal of Transplantation. 13 (3), 721-728 (2013).</li><li>Tzvetanov, I. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+in+the+obese+patient:+10-year+experience+from+a+single+center.">Robotic kidney transplantation in the obese patient: 10-year experience from a single center.</a> American Journal of Transplantation. 20 (2), 430-440 (2020).</li><li>Garcia-Roca, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single+center+experience+with+robotic+kidney+transplantation+for+recipients+with+BMI+of+40+kg/m2+or+greater:+a+comparison+with+the+UNOS+registry.">Single center experience with robotic kidney transplantation for recipients with BMI of 40 kg/m2 or greater: a comparison with the UNOS registry.</a> Transplantation. 101 (1), 191-196 (2017).</li><li>Gallioli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learning+curve+in+robot-assisted+kidney+transplantation:+results+from+the+European+Robotic+Urological+Society+Working+Group.">Learning curve in robot-assisted kidney transplantation: results from the European Robotic Urological Society Working Group.</a> European Urology. 78 (2), 239-247 (2020).</li><li>Alberts, V. P., Idu, M. M., Legemate, D. A., Laguna Pes, M. P., Minnee, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ureterovesical+anastomotic+techniques+for+kidney+transplantation:+a+systematic+review+and+meta-analysis.">Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis.</a> Transplant International. 27 (6), 593-605 (2014).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retroperitoneoscopic+living-donor+nephrectomy+and+laparoscopic+kidney+transplantation:+experience+of+initial+72+cases.">Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: experience of initial 72 cases.</a> Transplantation. 95 (1), 100-105 (2013).</li><li>Oberholzer, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+robotic+kidney+transplantation+for+obese+patients+previously+denied+access+to+transplantation.">Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.</a> American Journal of Transplantation. 13 (3), 721-728 (2013).</li><li>Menon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia:+a+step-by-step+description+of+the+Vattikuti+Urology+Institute-Medanta+technique+(IDEAL+phase+2a).">Robotic kidney transplantation with regional hypothermia: a step-by-step description of the Vattikuti Urology Institute-Medanta technique (IDEAL phase 2a).</a> European Urology. 65 (5), 991-1000 (2014).</li><li>Tsai, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+renal+transplantation+in+the+retroperitoneum.">Robot-assisted renal transplantation in the retroperitoneum.</a> Transplant International. 27 (5), 452-457 (2014).</li><li>Sood, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+kidney+transplantation:+perioperative+considerations+and+key+6-month+outcomes.">Minimally invasive kidney transplantation: perioperative considerations and key 6-month outcomes.</a> Transplantation. 99 (2), 316-323 (2015).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+transplantation+following+transvaginal+insertion+of+the+kidney:+description+of+technique+and+outcome.">Laparoscopic transplantation following transvaginal insertion of the kidney: description of technique and outcome.</a> American Journal of Transplantation. 15 (7), 1915-1922 (2015).</li><li>Wagenaar, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive,+laparoscopic,+and+robotic-assisted+techniques+versus+open+techniques+for+kidney+transplant+recipients:+a+systematic+review.">Minimally invasive, laparoscopic, and robotic-assisted techniques versus open techniques for kidney transplant recipients: a systematic review.</a> European Urology. 72 (2), 205-217 (2017).</li><li>Gastrich, M. D., Barone, J., Bachmann, G., Anderson, M., Balica, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+surgery:+review+of+the+latest+advances,+risks,+and+outcomes.">Robotic surgery: review of the latest advances, risks, and outcomes.</a> Journal of Robotic Surgery. 5 (2), 79-97 (2011).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+assisted+kidney+transplantation.">Robotic assisted kidney transplantation.</a> Indian Journal of Urology. 30 (3), 287-292 (2014).</li><li>Vignolini, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+University+of+Florence+technique+for+robot-assisted+kidney+transplantation:+3-year+experience.">The University of Florence technique for robot-assisted kidney transplantation: 3-year experience.</a> Frontiers in Surgery. 7, 583798 (2020).</li><li>Musquera, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation:+update+from+the+European+Robotic+Urology+Section+(ERUS)+series.">Robot-assisted kidney transplantation: update from the European Robotic Urology Section (ERUS) series.</a> BJU International. 127 (2), 222-228 (2021).</li><li>Breda, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation:+the+European+experience.">Robot-assisted kidney transplantation: the European experience.</a> European Urology. 73 (2), 273-281 (2018).</li><li>Siena, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation+with+regional+hypothermia+using+grafts+with+multiple+vessels+after+extracorporeal+vascular+reconstruction:+results+from+the+European+Association+of+Urology+Robotic+Urology+Section+Working+Group.">Robot-assisted kidney transplantation with regional hypothermia using grafts with multiple vessels after extracorporeal vascular reconstruction: results from the European Association of Urology Robotic Urology Section Working Group.</a> European Urology Focus. 4 (2), 175-184 (2018).</li><li>Prudhomme, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation+in+obese+recipients+compared+to+non-obese+recipients:+the+European+experience.">Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience.</a> World Journal of Urology. 39 (4), 1287-1298 (2020).</li><li>Vignolini, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+a+robot-assisted+kidney+transplantation+programme+from+deceased+donors+in+a+referral+academic+centre:+technical+nuances+and+preliminary+results.">Development of a robot-assisted kidney transplantation programme from deceased donors in a referral academic centre: technical nuances and preliminary results.</a> BJU International. 123 (3), 474-484 (2019).</li><li>Ahlawat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia+versus+open+kidney+transplantation+for+patients+with+end+stage+renal+disease:+an+ideal+stage+2B+study.">Robotic kidney transplantation with regional hypothermia versus open kidney transplantation for patients with end stage renal disease: an ideal stage 2B study.</a> Journal of Urology. 205 (2), 595-602 (2021).</li></ol>

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</su...

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.&#160;Moreover, minimally invasive access and robotic technology enable surgeons to safely perform kidney transplants in morbidly obese patients6,7,8,9. However, due to its complexity, RAKT requires a learning curve to achieve sufficient reproducibility in the operation time, functional results, and safety10.
Allografts with multiple vessels usually require vascular reconstruction, which leads to extended cold and warm ischemic times. Despite the technical challenges of RAKT, a European multicenter study reported that RAKT using allografts with multiple vessels is technically feasible and leads to favorable functional results11. Although it is more common to place the kidney allograft in the pelvis medially during vascular anastomosis, according to previous reports4,5,6,7,8,9, the allograft was placed on the peritoneal pouch lateral to the iliac vessels in this protocol. Although it may be safe to put an allograft medially during anastomosis and flip it to the peritoneal pouch, this technique may not be familiar for inexperienced surgeons. Furthermore, it is more convenient to perform vascular anastomosis with the allograft in the peritoneal pouch and renal vessels in the proper position. This paper describes the step-by-step procedures for RAKT without flipping.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>12 mm Fluorescence Endoscope, 30&#176;</td>
			<td>Intuitive Surgical</td>
			<td>370893</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>8 mm Blunt Obturator</td>
			<td>Intuitive Surgical</td>
			<td>420008</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>8 mm Instrument Cannula</td>
			<td>Intuitive Surgical</td>
			<td>420002</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>ATRAUMATIC ROBOTIC VESSEL CLIPS</td>
			<td>RZ Medizintechnic GmbH</td>
			<td>300-100-799</td>
			<td></td>
		</tr>
		<tr>
			<td>BARD INLAY OPTIMA URETERAL STENT</td>
			<td>BARD Medical</td>
			<td>78414</td>
			<td>4.7 Fr./14 cm</td>
		</tr>
		<tr>
			<td>Black Diamond Micro Forceps</td>
			<td>Intuitive Surgical</td>
			<td>420033</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>COATED VICRYL 4-0</td>
			<td>Ethicon Endo-Surgery, Inc.</td>
			<td>W9437</td>
			<td></td>
		</tr>
		<tr>
			<td>Da Vinci Si, X, or Xi</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fenestrated bipolar forceps</td>
			<td>Intuitive Surgical</td>
			<td>470205</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>GELPORT LAPAROSCOPIC SYSTEM</td>
			<td>Applied Medical Resources Corporation</td>
			<td>C8XX2</td>
			<td>standard laparoscopic equipment</td>
		</tr>
		<tr>
			<td>GORE-TEX SUTURE CV-6</td>
			<td>W.L. Gore and Associates Inc.</td>
			<td>6M02A</td>
			<td></td>
		</tr>
		<tr>
			<td>GORE-TEX SUTURE CV-7</td>
			<td>W.L. Gore and Associates Inc.</td>
			<td>7K02A</td>
			<td></td>
		</tr>
		<tr>
			<td>HEMO CLIP</td>
			<td>WECK</td>
			<td>523735</td>
			<td></td>
		</tr>
		<tr>
			<td>HEM-O-LOK CLIP</td>
			<td>WECK</td>
			<td>544220</td>
			<td></td>
		</tr>
		<tr>
			<td>Hot Shears (Monopolar Curved Scissors)</td>
			<td>Intuitive Surgical</td>
			<td>420179</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>laparoscopic atraumatic grasping forceps</td>
			<td></td>
			<td></td>
			<td>standard laparoscopic equipment</td>
		</tr>
		<tr>
			<td>laparoscopic irrigation suction set</td>
			<td></td>
			<td></td>
			<td>standard laparoscopic equipment</td>
		</tr>
		<tr>
			<td>Large Clip Applier</td>
			<td>Intuitive Surgical</td>
			<td>420230</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>Large Needle Driver</td>
			<td>Intuitive Surgical</td>
			<td>420006</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>Maryland Bipolar Forceps</td>
			<td>Intuitive Surgical</td>
			<td>420172</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>Medium-Large Clip Applier</td>
			<td>Intuitive Surgical</td>
			<td>420327</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>OPEN END URETERAL CATHETER</td>
			<td>Cook Incorporated</td>
			<td>21305</td>
			<td>heparin flushing</td>
		</tr>
		<tr>
			<td>PDS II 6-0 (DOUBLE)</td>
			<td>Ethicon Endo-Surgery, Inc.</td>
			<td>Z1712H</td>
			<td></td>
		</tr>
		<tr>
			<td>Potts Scissors</td>
			<td>Intuitive Surgical</td>
			<td>420001</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>ProGrasp Forceps</td>
			<td>Intuitive Surgical</td>
			<td>420093</td>
			<td>robotic forceps</td>
		</tr>
		<tr>
			<td>Small Clip Applier</td>
			<td>Intuitive Surgical</td>
			<td>420003</td>
			<td>robotic instrument</td>
		</tr>
		<tr>
			<td>VESSEL LOOP BLUE MAXI</td>
			<td>ASPEN surgical</td>
			<td>011012pbx</td>
			<td></td>
		</tr>
		<tr>
			<td>VESSEL LOOP RED MINI</td>
			<td>ASPEN surgical</td>
			<td>011001pbx</td>
			<td></td>
		</tr>
		<tr>
			<td>XCEL BLADELESS TROCAR</td>
			<td>JOHNSON &#38; JOHNSON</td>
			<td>2B12LT</td>
			<td>standard laparoscopic equipment</td>
		</tr>
	</tbody>
</table>

robot-assisted kidney transplantation

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.

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 ...

Watch this Scientific Journal Video about Robot-Assisted Kidney Transplantation at JoVE.com

Robot-Assisted Kidney Transplantation

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 this protocol, we have suggested step-by-step procedures for robot-assisted kidney transplantation without flipping. It is more natural to perform vascular anastomosis with a allograft in the peritoneal pouch and the renal vessels in the proper position. This technique can be applied to other solid organ transplants, such as the liver and pancreas.We hope to expand the utility of minimally invasive surgical approaches using the robotic system in the field of transplantation. Robotic-assisted kidney transplantation can be studied only after getting some education about the robotic system. It is better to get help from an experienced surgeon.Before starting the procedure, prepare the robotic arms with the surgical instruments to perform intra-abdominal dissection. Place monopolar curved scissors in arm two, fenestrated bipolar forceps in arm three, and ProGrasp Forceps in arm four. Initiate the operative procedure by making an incision in the peritoneum along the right paracolic gutter to make a pouch for the kidney allograft.After the incision, dissect the right internal iliac vessels along their entire length and encircle each vessel with a vessel loop. For ureteroneocystostomy, dissect the bladder in the right corner and separate the bladder from the peritoneal incision. Open a cap of the gel port and insert slushed ice through the six-centimeter Pfannenstiel incision, followed by the kidney allograft wrapped in the ice-packed gauze.Then, place the allograft on the peritoneal pouch lateral to the iliac vessels on the right side. With the control of ProGrasp Forceps in robotic arm four, clamp the right external iliac vein by bulldog clamps. Then use Potts Scissors in a linear or oblique fashion to make a venotomy considering the diameter of the renal vein.Use a 6/0 ePTFE suture to anastomose to renal vein allograft to the right external iliac vein in an end-to-side continuous manner. Make a knot at the caudal end of veins, before intraluminally and continuously suturing the posterior wall of the external iliac vein and renal vein. Afterward, suture the anterior wall of the iliac vein in a continuous manner.And flush the lumen with the heparinized normal saline. Then, use a Silastic tube through the gel port to knot the anastomosis. Clamp the allograft renal vein with a bulldog clamp.Then, de-clamp the right external iliac vein, followed by clamping of the right external iliac artery with bulldog clamps. Make an arteriotomy in the right external iliac artery by creating a round hole with Potts Scissors without an arterial punch. And proceed to anastomose the allograft renal artery to the right external iliac artery, as demonstrated.If there is no evident bleeding at the anastomosis site, de-clamp the allograft renal vein and artery. And remove the ice-packed gauze. Then, use an irrigation tube to apply warm normal saline to the allograft through the gel port.To perform ureteroneocystostomy according to the Lich-Gregoir technique, put the distal end of the double J ureteral stent into the urinary bladder. Starting at the posterior corner of the incised bladder mucosa, perform a continuous suture using a 6/0 polydioxanone suture. And make a suture at the anterior corner.From the anterior corner to the posterior corner, perform a continuous suture. And use a 4/0 Polyglactin multi-filament absorbable suture to close the detrusor muscle anti-reflux tunnel in an interrupted manner. With the help of polymer locking clips, intermittently cover the kidney allograft with the incised peritoneum along the right paracolic gutter.Robot-assisted kidney transplantation, or RAKT, was performed on 21 recipients, including three obese patients. One patient suffered primary non-function due to renal vein thrombosis. The graftectomy was performed at three days after the kidney transplant and no delayed graft function was observed in the patient.A small number of patients had to undergo angioplasty of renal artery or renal vein on the back table before kidney transplant. The mean hospitalization days after the kidney transplant was 7.4. The mean estimated glomerular filtration rate, or eGFR, one month after RAKT was 74.9 milliliters per minute per meter squared.Unlike previous reports, we positioned the kidney allograft on the lateral side of the iliac vessels before vascular anastomosis, similar to the conventional open technique. This technique can help to prevent unexpected torsion or kinking of renal vessels. Following positioning the kidney allograft on the lateral side, venous and arterial anastomoses can be performed at the proper angle and length.It is necessary to compare the long-term clinical outcomes, including kidney allograft survival and biopsy-proven acute rejection between robotic-assisted and open kidney transplantation, especially in high-immunologic risk patients.

Research

JoVE Journal

Medicine

3.1K Views.  University of Ulsan College of Medicine. In this protocol, we have suggested step-by-step procedures for robot-assisted kidney transplantation without flipping. It is more natural to perform vascular anastomosis with a allograft in the peritoneal pouch and the renal vessels in the proper position. This technique can be applied to other solid organ transplants, such as the liver and pancreas.We hope to expand the utility of minimally invasive surgical approaches using the robotic system in the field of transplantation. Robotic...