APPLICATIONS OF ROBOTIC SURGERY IN ORGAN TRANSPLANTATIONS - APPLICAZIONI DELLA CHIRURGIA ROBOTICA NEI TRAPIANTI D'ORGANO

Introduction: Surgical complications are a major disincentive to transplantation despite the undisputed benefits of restored organ function. Robot-assisted surgery is the new technological advance of the recent years. The da Vinci surgical system, a computer assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity in the setting of transplantation. We evaluate the feasibility and safety of this new surgical technique in living kidney donation, kidney transplantation and pancreas transplantation. Materials and methods: Robot assisted living donor nephrectomy was performed on 2 subjects. The immediate post-operative courses for these donors, and their respective recipients, were compared with those of 20 laparoscopic living donor nephrectomies, performed in the same period. Moreover robot assisted kidney transplantation was performed on 2 living kidney recipients and robot assisted laparoscopic pancreas transplantation was performed in further 3 recipients, performing a pancreas after kidney transplant, a simultaneous pancreas kidney transplantation, and a pancreas transplant alone. The grafting procedures were carried out through an 11 mm optic port, two 8 mm operative ports, and a 7 cm incision (midline for pancreas and suprapubic for kidney). The latter was used to introduce the grafts, handle vascular crossclamping, and create pancreas exocrine drainage into the jejunum or uretero-vescical anastomosis in case of kidney transplant. Results: No significant differences between the two donor groups with respect to age, gender, body mass index or renal vasculature were found. The average operative times and the warm ischaemia times were similar. There was no conversion to open surgery in both groups. The estimated blood loss was slight. Following nephrectomy, no complication occurred. The average duration of hospitalization was similar. The estimated creatinine clearance rate was equivalent for all donors, at 5 days and 1 month after nephrectomy. All kidneys started functioning immediately after the transplantation. The mean recipient estimated creatinine clearance was similar. Two kidneys, one from a 56-year-old mother to her 37-year-old daughter and one from a 49-year-old sister to her 48-year-old brother were transplanted laparoscopically using the DaVinci surgical system. Vascular anastomoses were carried out through a total of three additional ports. Surgery lasted 154 and 148 min, including 51 and 39 min of warm ischemia of the graft, respectively. Urine production started immediately after graft reperfusion. Renal function remains optimal at the longest follow-up of 10 and 3 months. The two solitary pancreas transplants lasted 3 and 5 hrs, respectively, the simultaenous pancreas kidney transplantation lasted 8 hrs. Mean warm ischemia time of the pancreas graft was 34 minutes. All pancreata functioned immediately, making their recipients insulin-independent. The kidney graft, revascularized after 35 minutes of warm ischemia, also functioned immediately and fully. No patient had complications during or after surgery; mean hospital stay was 21 ±5 days. After a mean follow-up period of 3.7 months, all recipients are alive with optimal graft function. Conclusion: Robotic assisted living donor nephrectomies were associated with no morbidity among donors, in which both the operative and warm ischaemia times were no longer duration, moreover had no observable adverse effects upon short-term graft function. On the other hand the daVinci surgical system allows the performance of kidney transplantation under optimal operative conditions. Further experience is needed, but it is likely that solid organ transplantation will not remain immune to robotics. We have also shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed in larger series, laparoscopic robot assisted pancreas transplantation could become a new option for diabetics needing beta-cell replacement