Surgical Technique

The donor nephrectomy is performed under general anesthesia, with the patient placed in the right decubitus position with pressure points padded. The operating table is flexed to maximize the exposure of the left kidney during the procedure. A 7-cm midline incision is performed immediately below the umbilicus, taken down through the fascia and into the abdominal cavity. A LAP DISC hand port is inserted, and pneumoperitoneum is achieved with 14 mmHg CO2 insufflation.

Under direct visualization, a 12-mm trocar is placed at the level of the umbilicus on the left side of the abdominal wall, two 8-mm trocars are placed in the sub-xiphoid and left lower lateral abdomen, and another 12-mm trocar is placed in the left inguinal region. The da VinciĀ® Robotic Surgical System is then brought into position, and the arms are connected to the trocars.

The descending colon is freed from the lateral peritoneal attachments using electrocautery and reflected medially. The 3D view offered by the robotic system allows for a quick and safe identification of the ureter during dissection along the psoas (Fig. 15.2).

Fig. 15.2 Left ureter identification
Fig. 15.3 Left renal vein

The ureter is dissected free circumferentially in a cephalad direction, beginning at the level of the left common iliac artery. The posterior attachments of the kidney are then taken down. In this phase of the operation, the robot is particularly helpful in the dissection of the upper pole of the kidney from the retroperito-neal fat and the spleen, thanks to the articulated arm that reproduces the action of the human wrist.

The gonadal vein is identified medially and followed superiorly up to its junction with the left renal vein (Fig. 15.3).

The renal vein is then dissected free, and its tributaries (gonadal, lumbar and left adrenal veins) are divided between locking clips. At this point, the kidney is retracted medially and the main renal artery and any accessory renal artery are identified and dissected free up to the level of the aortic take-off.

The ureter is clipped twice distally at the level of the iliac artery and sharply transected. At this point, intravenous heparin at the dose of 80 units/kg is given. In the initial 60 cases, the renal artery was transected using a linear cutting vascular stapler (LCS, Ethicon). After experiencing three failures of the stapling device, resulting in conversion to open procedure, we modified the technique by first placing a locking clip (Hem-o-Lok, Weck Closure Systems, Research Triangle Park, N.C.) at the take-off of the renal artery, and then dividing the artery with the stapling device. We used the stapling device alone for the transection of the renal vein in all cases. At this point, the left kidney is removed through the lower midline incision and taken to the back table where it is flushed with cold infusion of University of Wisconsin solution (ViaSpanā„¢ Barr Laboratories, Pamona, N.Y.). Laparoscopic inspection of the renal bed is then performed to ensure hemostasis while intravenous protamine of appropriate dosage is administered. After evacuation of the pneumoperitoneum and removal of the trocars, the lower midline fascia is closed with a running no. 1 absorbable monofilament. The skin incisions are closed with subcuticular 4-0 absorbable monofilament and routinely infiltrated with 0.25% bupivacaine with epinephrine.

The robotic dissection of the left kidney with its vascular pedicle was successfully completed in all cases. However, in four cases conversion to open procedure was necessary because of abovementioned failure of the stapling device (three cases) and bleeding from renal vein laceration (one case). Mortality was 0%, while postoperative morbidity included pneumonia (n = 1), mild pancreatitis (n = 1), and superficial wound infections (n = 3), all successfully treated with conservative management. The mean hospital stay for robotic-assisted living-donor nephrectomy was comparable to standard and significantly shorter than was the open nephrectomy (P = 0.05).

The mean warm ischemia time was 79 s (ranging between 70 and 95 s).

The mean hospital stay decreased from 2.5 to 2.0 days, compared with standard laparoscopic donor ne-phrectomy. The patients were able to return to work after an average of 26 days (ranging from 12 to 49 days). All patients reported that although the laparoscopic approach did not influence their ultimate decision to donate a kidney, it did alleviate the anxiety surrounding their decision. One-year patient survival was 100%, while the 1-year graft survival was 98.8%. The incidence of delayed graft function was 0%. Two grafts were lost to acute rejection and renal thrombosis, respectively. We did not observe any urological complication. Average serum creatinine at 6 months post-transplant was 1.3 mg/dl.

In our experience, robotic-assisted donor nephrec-tomy has been an excellent tool to improve the safety and comfort of our living donors for kidney transplantation. Of course, experienced centers can obtain comparable results with pure laparoscopic techniques. However, the increased ability for a precise dissection and 3D visualization of the operative field provided by the robotic system is quite valuable. In the context of an advanced minimally invasive surgical center performing a large volume of complex laparoscopic procedures, the robot is becoming a critical component. If the transplant center operates in an institution supporting such a minimally invasive surgical center, it is logical and appropriate to use robotic technology to optimize living-donor care.

Furthermore, the robotic console is connected with the operating arms through cables. It is only a matter of improving the ability to transmit through cables the information before telerobotic surgery can be extensively applied. The advantages in terms of training and supporting peripheral centers in their effort to master complex operation would be invaluable.

15.4 Liver Transplantation

15.4.1 Technological Innovations in Transplant Surgery: from "Crash Clamp Technique" to Modern Instruments of "Intelligent" Dissection, Hemostasis

Fueled by the chronic scarcity of cadaveric donors, living-donor liver transplantation has become an accepted transplantation technique.

After the first attempts by Raia [14] and Strong [15] demonstrated the feasibility of the procedure, Broelsch in 1990 performed the first clinical series of living-related liver transplant in pediatric recipients [16, 17]. In the late 1990s, the procedure of living-donor liver transplant evolved from the left lateral hepatectomy for children to the more difficult and complicated prone right and left hepatectomy for adult patients.

Today, adult-to-adult living-donor liver transplantation is performed routinely in Europe, Asia, and the United States. Safety of the donor and the necessity of preserving the portion of the liver to be transplanted have totally changed the surgical approach to the hepa-tectomy. Vascular structures like the portal vein, the hepatic artery, the hepatic veins, and bile duct cannot just be ligated, but must be carefully dissected, preserved, and cut in order to provide intact vascular and biliary structures for the implantation. Complications that could be "accepted" in a patient undergoing hepa-tectomy for a liver tumor must be avoided in a healthy donor.

Consequently, the past 15 years have seen a tremendous effort to improve the surgical technique, especially the parenchymal transection of the liver with the aim of decreasing blood loss, operative time, complication incidence, and obtaining perfect vascular and biliary structures for the anastomosis in the recipient. Already in 1990, Broelsch wrote in relation to the complication incidence, "We think they can be prevented in future cases ... by meticulous parenchymal transection." The parenchymal transection was at that time performed by a combination of "crash clamp technique," and the hemostasis was provided by monopolar coagulator and/or by sealing of the cut surfaces with fibrin glue. In the following decade, several technical innovations have made living liver donation safer and have modified the surgical approach to liver parenchymal tran-section. Living-donor liver transplantation is the only transplantation method in Japan and the Far East, and it is performed in 46 centers in Europe and in 56 centers in the United States [18]. In terms of results, the more recent data from European Liver Transplant Registry [19] show that survival of living-related liver transplantation in children is better than cadaveric liver transplantation. In adults, living-donor liver transplan tation has the same patient and graft survival as cadaveric transplantation while assuring almost no primary nonfunction (4 vs. 8%, respectively) and fewer early re-transplants of the liver (1 vs. 10%, respectively).

The confidence realized by many transplant surgeons in performing live-donor hepatectomy has allowed a broadening of the indications for the procedure, offering to many patients with previously untreatable conditions a chance for cure. An example of the expansion in indications is the patients affected by large hepatocellular carcinoma who now undergo living-donor liver transplantation [3-5, 20, 21]. It is paramount to perform the transection of the liver parenchyma, respecting all the anatomic vital structures and preventing any technical complication like bile leaks, bleeding, and vascular thrombosis. The transplant surgeon has many instruments that can be useful to obtain such an outcome. These instruments can be divided in three different groups: instruments that provide pure dissection, pure hemostasis and simultaneous dissection and hemostasis. The following describes their application in transplant surgery.

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