Earlier this year I posted an article in General Surgery about how robotic surgery for cancer rectum was helping surgeons to approach difficult areas to excise the pathology more precisely. Dr Mohammed replied to say that you may have to think about this again and asked if the patients really benefitted from these robotic machines?

This present post may have an answer to his question. This post will also make you aware that there are some brilliant surgeons in India who are now teaching new techniques to surgeons in UK.

Evolution of Kidney Transplant Surgery Over Time:

Alexis Carrel received the Nobel Prize in 1912 for perfecting the technique of vascular anastomosis and doing autoplastic and homoplastic transplantation of the kidney and thyroid gland.

The first successful renal allograft transplant in human from a living donor was done by Joseph Murray in 1954 for which he received the Nobel Prize in 1990. This success resulted in the subsequent development of other solid organ transplantation such as heart, lung, and liver. In the following 40 years, several developments in immunotherapy and pharmacology of transplantation have occurred; nevertheless, the advancement in the technical aspects of surgery was limited.

The emergence of laparoscopic living donor nephrectomy in 1995 and subsequent introduction of robotic assisted surgery in 1999 signaled the development and advancement in the surgical technique in kidney transplants.

Drawbacks of Traditional Open Transplant Surgery

Traditionally open surgery for renal transplant surgery is carried out by incisions placed on the lower abdomen. The size and length of these incisions vary depending on the surgeon’s preference and the patient’s condition.

In general, the larger the incision, greater the degree of tissue damage. Post-operative pain and therefore recovery and convalescence period is also increased. Also they are cosmetically disfiguring.

In renal transplant patients, the presence of other co-existing conditions such as diabetes or obesity may complicate wound healing following surgery. Use of immunosuppressants is an additional risk factor. These concerns call for a minimally invasive approach in such cases.

Minimally Invasive Kidney Transplant Surgery

Laparoscopic renal transplant surgery was introduced recently and its effectiveness in reducing pain and tissue damage with improved healing was demonstrated. Robotic surgery, also referred to as computer-assisted surgery, or robotically-assisted surgery signals the technological advancements that use robotic systems to aid in surgical procedures. Robotically-assisted surgery was developed to overcome the drawbacks of previously existing minimally-invasive surgical procedures and to improve the capabilities of surgeons performing open surgery.

The first full Robot Assisted Kidney Transplant (RAKT) was reported by Giulianotti and his team from Chicago in the late 2000’s. Several RAKT surgeries have been reported since.

Professor Pranjal Modi, of the Institute of Kidney Diseases and Research Centre in Ahmedabad, India, has carried out more than 250 laparoscopic robot-assisted kidney transplants. He flew to London to mentor the surgical team at Guy’s during the first two robotic kidney transplant operations that were done in UK. The team, which used one of Guy’s and St Thomas’ NHS Foundation Trust’s two da Vinci Xi robots, travelled to India earlier this year to learn the technique directly from Professor Modi.

Following the operation Nizam Mamode, a consultant transplant surgeon at the hospital said, “We have been incredibly impressed with the difference in recovery. Normally these patients would be on morphine infusions for two to three days,” “We think [using the robot] they will require little or no morphine. That means they mobilize quicker, and if they mobilize quicker and they feel better, then we would expect their overall recovery to be better”.

“The first patient didn’t require any morphine at all and wanted to go home on day three,” Mamode added. “Normally, in an [open surgery] transplant, you make a big incision and you cut muscle to go in, which is then painful. Potentially it is going to revolutionize transplantation.”

Future of RAKT

Robotic-assisted kidney transplantation is fast emerging as a modality of minimally invasive surgery. Despite the interest in RAKT, the current high cost remains the most prohibitive factor limiting its more widespread use.

By achieving adequate kidney graft function and reducing surgical complications, robotic-assisted kidney transplantation offers hope to patients with End Stage Renal Disease (ESRD) to have more a realistic expectation regarding a more positive outcome following transplant. RAKT may even compensate the initial cost and prove profitable from a financial standpoint when viewed long term.

However, robotic surgery in organ transplantation involves usage of an advanced level of surgical technique. It requires a high degree of skill and expertise in any surgeon who considers using this method.

Larger trials and long-term follow-up of RAKT recipients will be required to determine its effectiveness.

As I had mentioned before, I will stress again that when newer methods of surgery are introduced, you must make sure that a surgeon is not allowed to perform the newer technique or use a newer machine on a patient until he or she is fully trained and has perfected the method under the supervision of a more experienced trainer.