Summary

Kidney Transplant is an inevitable outcome in people with End Stage Renal Disease. Open-incisional and laparoscopic Kidney Transplants were the norm till recently. However, these come with their own disadvantages. Further, obese patients are not eligible for Kidney Transplants due to reduced outcomes in open or laparoscopic procedures. This puts them on a painful path of lifelong dialysis. In recent times, Robotic Surgery has come as a boon for patients requiring kidney transplants, especially in the obese category. In this article, we will learn more.

Introduction

The kidneys (one each on either side of the body) are a vital organ. They eliminate wastes, excess fluid and toxins that make their way into the body through food, water, air and medication. They are also responsible for electrolytic balance in the body. That is, maintaining a healthy balance of water, certain salts and certain metals or minerals such as potassium, phosphorus, sodium and calcium.

Renal Disease or kidney disease is a condition in which the kidneys get damaged due to one or more reasons. The kidney loses its ability to filter out wastes, or the kidney function reduces progressively. The condition proceeds towards End Stage Kidney Disease (ESRD) which eventually leads to kidney failure. Once both the kidneys have failed, the immediate treatment is dialysis, wherein the blood is pumped out of the body into a machine which filters out the waste, after which, the purified blood sent back to the body. Dialysis sessions can be painful, tiring and must be performed thrice a week (either at home or in a healthcare centre). This can disrupt the patient’s professional and personal life significantly.

So, the long-term solution is Kidney Transplant (KT). The technical term for the procedure is Donor Nephrectomy. A healthy kidney taken from a live donor or a just-deceased person (cadaver) is transplanted into the recipient’s body. The donor can survive and live a normal life with just one kidney, and so can the recipient. The procedure can be done through an open-incisional surgery, a minimally invasive (MI) laparoscopic procedure, and in recent times – Robot Assisted procedures.

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Also Read: The Pros and Cons of Renal Transplantation

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Drawbacks of Open and MI KT

Open-incisional surgery used to be the gold standard for KT procedures till recently. But morbidity – or medical problems caused by this procedure/treatment – are several:

• high levels of post-operative pain
• need for higher doses of analgesia (pain-relieving medication) as a result of the above
• infection(s) at the surgical site
• delayed mobilization (ability of the patient to start moving around after a procedure)
• longer wound healing times
• long-term complications such as incisional hernia
• prolonged hospital stays
• prolonged recovery
• significant time to return to daily activities
• inferior cosmetic outcomes (ugly scars from the surgery)

The morbidity becomes more severe in patients who have a high BMI, who smoke, who have diabetes mellitus or who take high doses of immunosuppressant drugs such as steroids.

Minimally invasive procedures such as laparoscopy have emerged as a better alternative to open surgery. However, these come with their own limitations. The range of movement available for the surgical instruments (which affects flexibility and dexterity in the procedure), and the kind of visualization available are all mediocre with plenty of room for improvement. Tremors, or trembling of the surgeon’s hands can also affect the quality of intervention.

Further, patients with a high BMI or body-mass-index, basically people who are obese or overweight, are ruled out for open surgery and must go in for laparoscopy which comes with a slight risk of morbidity and inferior outcomes. The graft (transplanted kidney) may not last long, requiring yet another transplant. The patient may require lengthy hospitalization and intensive care. In some cases, the patient may not live long. Other option is to live with dialysis all their life, which is not an easy thing to do.

In recent years, Robot Assisted Kidney Transplant (RAKT, also called RART – Robot Assisted Renal Transplant) has emerged as the lifesaver for all those patients who are not a candidate for open KT or laparoscopic KT. This is especially true of obese or overweight patients. Worldwide, obesity is on the rise, both in developed countries of the west and developing countries like India. In such a scenario, the emergence of RAKT, as an alternative, has been timely.

How is RAKT done?

RAKT is done using the da Vinci Surgical System (from Intuitive Surgical, USA). The system consists of robotic arms carrying fine surgical instruments at the tip. The arms, the end of the arms (called EndoWrist) and the instruments attached to the tip can all rotate at large angles and move long lengths. This increases the range of movement and hence enhances the effectiveness of the robotic intervention. Another arm carries a sophisticated video camera that can bend, rotate and move very flexibly, and is also capable of 10x or 12x magnification. This results in very high-resolution, or detailed 3D images taken from angles that could not have been possible before. As a result, the chief surgeon gets the best possible inputs required to do a precise intervention. He/she is seated on a computer console that is close to the operating table. This means, he/she can see the operating field (area of surgery) both on the monitor and otherwise, directly.

The procedure is done under general anaesthesia to eliminate patient discomfort. The steps leading to the procedure (before the day of the procedure) and whatever happens on the day of the procedure have been detailed in our articles on other Robotic procedures (for heart and liver). The workflow is very similar. The donated kidney (called a ‘graft’) may be harvested just before the transplant, or it may be available in a kidney bank, under cold storage. It will be brought to the centre where transplant will happen.

The robotic arms will first disconnect the arteries and veins connected to the diseased kidney, remove the diseased kidney and pull it out of the body using one or more routes. Then the graft is carefully introduced into the recipient’s body and all the vascular connections are made again. Ice is used to keep the graft cool throughout the procedure.

The procedure has been fine-tuned and refined over several hundred transplants done around the world. Today, most KTs follow a standardized procedure called the Vattikuti-Medanta technique for KT procedures. It’s a matter of pride for us that surgeons of Indian origin are pioneers of this technique. The use of ice (to prevent a condition called warm ischemia) is also an innovation by them.

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Also Read: When do you need a renal transplant?

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Improved Outcomes and other benefits of Robot Assisted KT

Robotic KT or RAKT was first performed in 2001, in France using the da Vinci Surgical System. Whenever the field of view is narrow and deep, and requiring fine dissection and micro-suturing, as in the case of KT, a robotic procedure is a boon in itself.

The high-resolution, 3D views improve the hand–eye coordination hugely. The wristed instruments which can turn almost 360 degrees and the tracking or the ability for robotic movements to be made multiple times (which could fatigue a live surgeon) is a huge boost to the surgical team. Further, there is tremor filtration (no vibration or trembling of robotic arms as it could happen with a live surgeon are eliminated), and scaled motion (the arms can move long distances).

The small incisions which are of 6-10 cms in size required for the procedure makes it safe both for the live donor and the recipient.

All these factors hugely benefit the patient. They can enjoy improved perioperative outcomes (the graft will survive for long and work just fine), shorter hospital stays, less pain and reduced need for analgesics (pain-killers) and far lesser rates of infection (0-8 percent) at the surgical site compared to an open or MI KT.

Even the cosmetic outcomes are superior. Not only are the incisions smaller in size, but they are also higher up in position, on the abdomen, compared to open or MI KT. This makes it easy for the patient to monitor the incisions daily (to keep them clean and dry.).

Lesser risk of complications: Lymphocele is one of the complications of KT. This is a condition in which lymphatic fluid starts accumulating in pockets, in the body. However, patients who have undergone RAKT have shower much lower instances of lymphocele compared to those who had open or MI KT. Several studies have shown this.

Another complication from KTs is incisional hernia – or a tear in the abdominal wall thanks to the procedure. However, in patients who underwent a RAKT, instances of incisional hernia were between 0 to 6 percent.

An evolving domain

RAKT has not only become very popular, it is also evolving at a very rapid pace. Lessons and best practices learnt from thousands of KTs have been incorporated as techniques into the procedure and standardized over time. Newer innovations that are being increasingly attempted today, include: scarless surgery, gasless surgery, robotic dual-kidney transplantation and RKT using grafts with multiple vessels.

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

Chennai Alwarpet – 044 4000 6000 •  Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801    

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