Robotic Technology in Laparoscopic Living Donor Nephrectomy

From its introduction in Boston in 1954 by Murray, living-donor nephrectomy performed in an open fashion has proven over the years to be a safe and effective procedure. In the following four decades, thousand of patients affected by end-stage renal failure have been successfully treated with living-donor kidney transplantation. The data generated have confirmed the safety of a healthy donor to donate one kidney in terms of physical performances and quality of life [6, 7]. Although safe and technically very successful, open ne-phrectomy is quite traumatic for the donor, and causes significant pain and discomfort. The consideration of the altruistic nature of kidney donation has motivated the transplant community to focus not only on avoiding potential surgical complications, but also on obtaining a rapid and complete restoration of donor health and physical fitness. Laparoscopic techniques were evaluated in the mid-1990s to achieve these goals.

Laparoscopic resection of diseased kidneys was first introduced by Clayman in 1991 [8]. Ratner et al. performed the first successful laparoscopic donor nephrectomy at John Hopkins University in 1995 [9]. Since then, the number of laparoscopic donor ne-phrectomies has rapidly grown, contributing greatly in increasing the number of living donor kidney transplants performed in the United States. Several centers have reported an increase in living-donor kidney transplants as high as 200% after the introduction of laparoscopic nephrectomy. In 2001, the number of living donors has exceeded the number of cadaveric donors for kidney transplantation for the first time, and the trend continues to date [2].

Although the technique originally described by Ratner has remained substantially unchanged in its fundamental steps, significant technological improvements have been added in the last few years.

One of the most important technical innovations has been the introduction of hand-assisted devices [10]. The introduction of the hand-assisted technique has determined a shortening of the learning curve and contributed to widespread application of laparoscopic donor nephrectomy. Commonly, the hand-assisted device is placed through an approximately 7 cm midline infraumbilical incision. The surgeon's arm is inserted into the LAP DISC hand port (Ethicon, Piscataway, N.J.) and used for manual retraction, dissection, hemo-stasis, and finally for kidney retrieval while maintaining pneumoperitoneum (while pneumoperitoneum is maintained by the special seal of the hand port).

The main advantages of the hand-assisted technique include improved ability to control bleeding vascular injuries, reduced length of surgery, and reduced warm ischemia time for the kidney graft [11].

In comparison with the open technique, laparo-scopic nephrectomy has several recognized disadvantages, including increased operating room time, need for special equipment (usually quite costly), and limited ability of movement of the laparoscopic instruments, as well as two-dimensional (2D) rather than three-dimensional (3D) vision. In the attempt to improve the technical performance of laparoscopic donor nephrectomy, a program of robotic-assisted donor ne-phrectomy using the da Vinci® Robotic Surgical System was started in August 2000 (Intuitive Surgical, Sunny Valley, California).

Robotic surgery is a recent evolution of minimally invasive surgery aimed to obtain greater freedom of movement and to recreate the hand-eye coordination and 3D vision that is lost in standard laparoscopic procedures.

Technical details and various options currently available in robotic surgery are discussed in detail in Chap. 9.

The first robotic-assisted laparoscopic nephrectomy in a living human being was performed by Guillon-neau et al. [12]. The authors reported a case of a right nephrectomy performed in a 77-year-old woman with a nonfunctioning, hydronephrotic right kidney, using the Zeus Robotic System.

In July 2000, the da Vinci® Robotic Surgical System was approved by the US Food and Drug Administration (FDA) for clinical use in the United States. The da Vinci® Robotic Surgical System combines robotics and computer imaging to enable microsurgery in a laparo-scopic environment. The system consists of a surgeon's viewing and control console integrated with a highperformance, 3D monitor system and a patient side cart consisting of three robotic arms (Fig. 15.1).

Fig. 15.1 Robotic arms

While observing the image of the operative field, the surgeon can control instrument movements via hand-controlled manipulators directly linked via electronics to motor-driven arms. These motor-driven arms hold and move instruments with standard surgical tool tips. The software within the da Vinci® Robotic Surgical System translates the surgeon's hand, wrist, and finger movements into corresponding micromovements within the patient's body, without any time delay. The instrument movements are under direct, real-time control of the surgeon. By using a kinematic structure (joint movement), the movements of the surgeon at the console are translated to the correspondent smaller instrument tip movements in the surgical field. The da Vinci® Robotic Surgical System provides the surgeon the benefits of access through small incisions without giving up the dexterity, precision, and instinctive movements of open surgery. Tip articulations mimic the up-down and side-to-side flexibility of the human wrist. These articulations extend the surgeon's minimally invasive abilities to a new level. In this system, the surgeon sits remote from the patient at an operating console adjusted to provide an optimal ergonomic environment.

In August 2000, our group successfully performed the first robotic-assisted donor nephrectomy for kid-

ney transplantation with the da Vinci® Robotic Surgical System [13]. After a very favorable experience in a pilot study of 12 cases, we adopted robotic-assisted donor nephrectomy as our standard for living-donor kidney procurement. We discuss our current technique and the results to date below.

Between August 2000 and February 2004, we performed 112 robotic-assisted donor nephrectomies.

The donors were screened according to a thorough medical evaluation specified by a standardized protocol. Preoperatively, the donors underwent a spiral CT scan with 3D vascular reconstruction, which allows precise definition of the renal vascular anatomy.

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