Minimally invasive surgical techniques & recent advances in kidney transplantation

A kidney transplant (KT), sometimes known as a renal transplant, is a treatment for kidney failure at end stage renal disease (ESRD). Kidney transplant surgery is a major surgery during which a person with kidney failure receives a new kidney—either from a living donor or a deceased donor. A successful kidney transplant is closest to natural kidney function and considered the most effective treatment for ESRD—offering a chance for a longer, healthier life. The transplant procedure must be carried out as quickly as possible for the transplant to have the best chance of success.

Kidney transplant procedure
The kidney transplant procedure involves 3 main stages:

• First, an incision (cut) is made in your lower abdomen (tummy), through which the donated kidney is put into place. Your own kidneys will usually be left where they are, unless they're causing problems such as pain or infection.
• Second, nearby blood vessels are attached to the blood vessels of the donated kidney. This is to provide the donated kidney with the blood supply it needs to function properly.
• Finally, the ureter (the tube that carries urine from the kidney to the bladder) of the donated kidney is connected to your bladder.

When the kidney is properly in place, the incision in your abdomen will be closed with surgical staples, stitches or surgical glue. Although the procedure may sound relatively straightforward, it's very demanding and complex surgery that usually takes around 3 hours to complete.

Minimally invasive surgery
Minimally invasive surgery (MIS) has been a key innovation in surgery over the last 20 years, improving outcomes and becoming the standard of care in many areas. Within kidney transplantation, it has transformed the living donor nephrectomy operation, significantly improving outcomes. However, kidney transplantation has not changed significantly since it was first performed over 50 years ago until recently.

MIS techniques are methods developed to access body cavities, organs and tissues using smaller skin incisions. They have been shown to improve outcomes for many surgical procedures by reducing post‐operative morbidity  and by promoting a faster return to normal function after surgery. These techniques include small incision open surgery, laparoscopic surgery and robotic surgery.

•  Small incision open surgery has variously been described as mini‐incision kidney transplantation and minimal access kidney transplantation. This involves open transplantation with an incision limited to 10 cm or less.
• Laparoscopic surgery for kidney implantation also uses a reduced incision of about 7 cm for insertion of the kidney with an additional 3 to 4 ports for laparoscopic instruments. The main differences with open surgery being the anastomoses are all performed intracorporeally with laparoscopic instruments.
• Robotic‐assisted kidney transplantation is the latest development of minimally invasive surgery for kidney transplantation (MIKT). This procedure uses a small incision of about 7 cm to introduce the kidney with 4 or 5 laparoscopic ports. The key differences from laparoscopic transplantation are that the laparoscopic instruments are controlled remotely from a console by the surgeon and the instruments' design allows for an improved range of movement. This process has itself evolved from when it was first reported with a small open incision to the side of the lower abdomen followed by the robot being used to complete the anastomoses through this incision to retroperitoneal placement of the kidney through a similar incision but the anastomoses were completed transabdominally using the robot arms. A transabdominal technique has been developed and standardised. Variations of this technique are now being used worldwide.

Advantages of robotic kidney transplant surgery over open kidney transplant surgery

The technical advantage of robotic kidney transplant surgery over open kidney transplant surgery

• The robot replicates the surgeon’s hand movements, while minimizing hand tremors. The surgeon thus can not only make use of his/her experience and skills, but also operate with precision, dexterity and control in complex procedures.
• Especially useful when the operative field is deep and narrow, and requires fine dissection and micro suturing.

Improved patient outcomes:

• Robotic surgery in KT offers many benefits like:
• Decreased chances of complications as compared to open surgery, especially in immunocompromised and end-stage renal disease patients undergoing KT.
• Safer and more efficacious for obese patients who are otherwise not recommended for transplants.
• Minimal invasive surgery helps in reduced
• Blood loss
• Hospital stays
• Pain
• Postoperative complication rate
• Recovery time
• Surgical scars

Success rate of kidney transplant using robot assisted surgery
The graft survival rate i.e the survival rate of the donor kidney is dependent on the inherent characteristics of the recipient’s body, hence there are no significant differences between the open surgery and robot assisted kidney transplant surgery. However, the robotic kidney transplant surgery offers significant benefits in terms of

•  Low surgical site infection (range 0-8%)
•  Incisional hernia rates (range 0-6%)
•  Improved aesthetic outcomes

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