Nephrologist’s Perspective :
Minimally invasive surgeries are gaining popularity all over the world. Laparoscopic surgery is being practiced in various surgical specialties. Robotic surgery is the new kid on the block and has several advantages over laparoscopic surgery, especially in certain surgical procedures including kidney transplantation.
The first documented use of a robot-assisted surgical procedure was in 1985 when the PUMA 560 robotic surgical arm was used in a delicate neurosurgical biopsy. In 1988, the same PUMA system was used to perform a transurethral resection. In 2000, the da Vinci Surgery System (Figure 1a), became the first robotic surgery system approved by the FDA for general laparoscopic surgery. Its three-dimensional magnification screen allows the surgeon to view the operative area with the clarity and high resolution. The one- centimeter diameter miniaturized operating arms and wrist like features of the operating arms precisely replicate the skilled movements of the surgeon at the controls, improving accuracy in small operating spaces. The da Vinci robotic surgical system has the advantages of three-dimensional vision, control of the camera by surgeon, articulated wristed instruments with seven degree of movements; these features make suturing more perfect and it tracks surgeon's movements. This eliminates human tremor which is essential for performing a good vascular anastomosis. Robotic procedures are rapidly becoming the new standard of care with rapid advancements in technology.
Robot assisted kidney transplantation (RAKT)
Traditionally, kidney transplantation is carried out through an incision in the lower abdomen; this requires a long incision (often above 15cm), especially in obese patients and children. Larger wounds are associated with more wound related morbidity (more pain, longer convalescence period and postoperative recovery, and poor cosmesis). Open kidney transplantation through a small incision was tried but had significant challenges especially for vascular anastomosis; hence it is not widely practiced.
The first RAKT was performed in France in 2002 but till 2009, it didn’t gain much attention. Initial experience about RAKT in 28 cases was published from Chicago, which showed promising results especially in obese patients. RAKT is a transperitoneal procedure compared to open kidney transplant (OKT) which is performed extraperitoneally. The drawbacks of transperitoneal approach include potential for bowel injury, undetected postoperative bleeding and urine leak. The graft was placed partially intraperitoneal and it would pose a challenge if a graft kidney biopsy has to be done in the post transplant period. Another complication was torsion of kidney at the time of final placement. Retroperitoneal approach in placing the graft was tried but had technical challenges. Maintaining intraoperative cooling was another challenge which was maintained by using ice slush; however it resulted in systemic hypothermia as the peritoneal cavity was exposed to ice slush. Tremendous technical advancements has been made in the last decade in the field of RAKT and the transplant surgeon in our centre Dr Kishore (Figure 1b) has contributed a lot. Our surgeon published an experience of total extra peritonealisation of the graft in 34 cases which would negate the above mentioned complications. The salient feature of our technique is fashioning of the peritoneal flap in such a manner by which the kidney is totally placed in the extra peritoneal space. This offers distinct advantages over existing techniques. In the intraoperative period, the reflected portion of the bladder and the adjoining peritoneum act as a barrier to the kidney covered in ice slush from having direct contact to underlying sigmoid colon. This allows free placement of ice slush over the kidney without concern of hypothermic damage to colon. This technique would mimic that of open transplantation and post transplant kidney biopsy is easy. A total extraperitoneal RAKT without creating a pneumoperitoneum should be the ultimate goal but is challenging with current robotic instruments and would be a reality in future.
Advantages of RAKT are less blood loss, less pain, shorter hospital stay, speedy recovery, less postoperative complications, lower incidence of wound related complications and better cosmesis (Figure 2) when compared to OKT.
Disadvantage are higher cost when compared to open surgery and the availability of expertise.
Figure 1: a) Da Vinci surgical robot with robotic arms, b) Dr. Kishore, our robotic surgeon, at the console of the Da Vinco robot
The diuresis following robotic transplantation is not different from open transplantation. Overall graft outcomes at one month and three months are not different in various studies, including our centre; rejections episodes were not different between the two techniques. Though it was initially considered in obese individuals due to discrete advantages, it is now being considered in all individuals including children with good results. Aster Medcity, Kochi has successfully done 234 kidney transplants so far. Kidney graft survival in our centre is 99%. at one year and 98% at 5 years.
Not many centres in the world are practicing RAKT. In India it is gaining more popularity and momentum. A couple of centres in North India has done the highest number of cases. In South India, Aster Medcity, Kochi was the first centre to start robotic kidney transplantation and has done maximum number of cases. So far 113 RAKT surgeries have been done at our institution with excellent results; this includes both children and adults. Our transplant unit is able to perform RAKT in children with complex congenital anomalies of urinary tract. This minimally invasive surgery would be the standard of care in future.