CHAPTER 56: Minimally Invasive Kidney Transplantation

INTRODUCTION

• Minimally invasive surgery reduces perioperative morbidity. Benefits include, but are not limited to, smaller incision, lesser surgical site infection, blood loss and postoperative pain, shorter hospital stay and convalescence period, and better cosmesis^1–5

• Indeed, the role of minimally invasive surgery in donor nephrectomy has been well established⁶; however, its utility for recipient surgery has not been rigorously evaluated

• Being fragile and immunocompromised, patients undergoing kidney transplantation (KT) are at a higher risk for developing perioperative complications than the renal donor. Complications affect not only short-term patient convalescence adversely but also compromise long-term graft and patient survival.^7–10 Thus, transplant recipients may benefit substantially from minimally invasive surgery

• Minimally invasive approaches to KT have been described recently

  • In 2010, Modi et al. introduced the technique of laparoscopic KT,¹¹ and Giulianotti et al. described their technique of robotic KT (RKT)¹²

  • Both groups noted a slightly slower return of graft function.^13,14 These studies were performed without renal cooling

  • We reasoned that warm ischemia may have played a role in the slight delay in recovery of graft function and sought to develop a technique for RKT that eliminated warm ischemia during the recipient surgery

• Here, we describe our novel technique of RKT with regional hypothermia

PATIENT SELECTION

Patients were inducted into the study if they expressed the desire to undergo minimally invasive surgery. Patient selection criteria are detailed below (informed consent was obtained in each case)^15,16:

• Inclusion criteria:

  • Irreversible renal disease, defined as end-stage renal disease (ESRD) or anticipated ESRD within the next 12 months (preemptive transplant)

  • Matched living donor

• Exclusion criteria:

  • Previous major abdominal surgery with a high suspicion for intraabdominal adhesions

  • Significant atherosclerotic disease of the iliac vessels (> 30% blockage)

  • Immunologically high-risk transplant

  • Second transplant

  • Simultaneous dual/multiple organ transplant

INSTRUMENTS

Robotic Instruments and Ports

• Robotic 8 mm ports × 3

• Robotic Maryland bipolar grasper

• Robotic monopolar curved scissors

  • Covertip accessory

• Robotic Black Diamond microforceps

• Robotic large needle driver

• Robotic Hem-o-Lok applier

• Robotic ProGrasp forceps (on the 4th arm)

Laparoscopic Instruments

• Micro France laparoscopic grasper

• Suture passer

• Hem-o-Lok applier (5 mm, 10 mm, 12 mm)

  • Weck clips: 5 mm, 10 mm, 12 mm

• Bulldog clamps with appliers (Scanlan International, Saint Paul, MN)

Disposables

• GelPOINT platform × 1 (Applied Medical Corp, Rancho Santa Margarita, CA)

• 12 mm camera port × 1 and 12 mm assistant port × 1

• 5-F ureteric catheter for flushing

• Sutures:

  • 5-0 CV-6 ePTFE (Gore-Tex; W L Gore & Associates Inc, Flagstaff, AZ)

  • 4-0 PDS/3-0 V-Loc CV23 6″ (Covidien Inc, New Haven, CT)

Other

• Ice slush machine (OR Solutions Model: ORS-1075 H5)

• Slush machine drape (OR Solutions Model: ORS-321)

• Toomey syringes (modified)

• 3.6 mm aortic punch ...