机器人辅助肾移植
Summary
本文提供了来自活体供体的机器人辅助肾移植的技术细节。
Abstract
本文描述了来自活体供体的机器人辅助肾移植（RAKT）。机器人停靠在患者分开的双腿之间，放置在仰卧的特伦德伦堡位置。肾同种异体移植物由活体供体提供。在血管吻合术之前，通过在输尿管中插入双J支架来制备肾同种异体移植物，并通过将其包裹在冰袋中来降低吻合口的温度。放置一个用于机器人相机的 12 mm 或 8 mm 端口和三个用于机械臂的 8 mm 端口。在解剖髂血管和膀胱之前，通过将两侧的腹膜瓣抬高到腰肌上，为肾同种异体移植物创建一个腹膜袋。做一个6厘米的Pfannenstiel切口，将肾脏插入腹膜袋，在右髂血管的外侧。
用斗牛犬夹住髂外静脉后，进行静脉切开术，并用6/0聚四氟乙烯缝合线将移植肾静脉以端到端连续的方式与髂外静脉吻合。夹紧移植肾静脉后，髂静脉脱夹。随后钳夹髂外动脉、动脉切开术、6/0聚四氟乙烯缝合动脉吻合术、钳夹移植物肾动脉和髂外动脉脱夹。然后进行再灌注，并使用Lich-Gregoir技术进行输尿管膀胱造口术。腹膜在几个位置用聚合物锁定夹封闭，并通过其中一个工作端口放置一个封闭的吸入排水管。将气腹放气后，关闭所有切口。
Introduction
与腹膜透析或血液透析相比，肾移植有助于延长生存期和改善生活质量1。虽然开放式方法是肾移植的标准程序，但最近采用了机器人辅助技术2，3，4。具体来说，机器人辅助肾移植（RAKT）与开放式肾移植相比有几个优点：术后疼痛最小，美容效果更好，伤口感染更少，住院时间更短5。此外，微创通路和机器人技术使外科医生能够安全地对病态肥胖患者进行肾脏移植6，7，8，9。然而，由于其复杂性，RAKT需要一个学习曲线，以便在操作时间、功能结果和安全性方面实现足够的可重复性10。
具有多血管的同种异体移植物通常需要血管重建，这会导致冷热缺血时间延长。尽管RAKT存在技术挑战，但一项欧洲多中心研究报告称，使用具有多个血管的同种异体移植物进行RAKT在技术上是可行的，并导致有利的功能结果11。虽然在血管吻合术期间将肾同种异体移植物放置在骨盆内侧更为常见，但根据先前的报告4，5，6，7，8，9，在该方案中，同种异体移植物被放置在髂血管外侧的腹膜袋上。虽然在吻合术期间将同种异体移植物放在内侧并将其翻转到腹膜袋可能是安全的，但对于没有经验的外科医生来说，这种技术可能并不熟悉。此外，在腹膜袋和肾血管中以适当位置进行血管吻合更方便。本文介绍了无需翻转即可进行 RAKT 的分步过程。
Protocol
这项研究获得了峨山医疗中心机构审查委员会的批准（IRB编号：2021-0101）。 1. 移植前准备 患者选择包括需要肾移植的终末期肾病患者。注意：如果接受者未满 18 岁，则可能不考虑 RAKT。 排除任何未经治疗的恶性肿瘤或活动性感染患者。 确保受者在心脏和肺功能方面适合手术，并适合微创方法。 如果患者有腹部大手术史或严重腹膜内…
Representative Results
我们为中心患有RAKT的接受者建立了常规临床路径。移植后一天进行肾多普勒超声检查，移植后两天进行锝-99m二乙烯三胺五乙酸肾扫描。对于静脉血栓栓塞预防，在RAKT后的前24小时内使用间歇性气动加压装置。Foley导管在术后第四天移除。第五天，在非增强型计算机体层成像确认无腹内并发症后，移除闭合抽吸引流管。除非发生重大不良事件，否则患者在术后第六天出院。 在?…
Discussion
尽管腹腔镜和机器人辅助技术已广泛应用于活体供体肾切除术，但肾移植仍主要使用传统的开放技术进行。然而，最近，肾移植的微创方法已被越来越多地使用。与传统的开放手术相比，微创肾移植手术部位感染、切口疝和伤口裂开的风险更低，住院时间更短12、13、14、15、16。<…
Declarações
The authors have nothing to disclose.
Acknowledgements
我们感谢峨山医学中心科学出版团队的Joon Seo Lim博士在准备这份手稿时提供的编辑协助。
Materials
| 12 mm Fluorescence Endoscope, 30° | Intuitive Surgical | 370893 | robotic instrument |
| 8 mm Blunt Obturator | Intuitive Surgical | 420008 | robotic instrument |
| 8 mm Instrument Cannula | Intuitive Surgical | 420002 | robotic instrument |
| ATRAUMATIC ROBOTIC VESSEL CLIPS | RZ Medizintechnic GmbH | 300-100-799 | |
| BARD INLAY OPTIMA URETERAL STENT | BARD Medical | 78414 | 4.7 Fr./14 cm |
| Black Diamond Micro Forceps | Intuitive Surgical | 420033 | robotic instrument |
| COATED VICRYL 4-0 | Ethicon Endo-Surgery, Inc. | W9437 | |
| Da Vinci Si, X, or Xi | Intuitive Surgical | ||
| Fenestrated bipolar forceps | Intuitive Surgical | 470205 | robotic instrument |
| GELPORT LAPAROSCOPIC SYSTEM | Applied Medical Resources Corporation | C8XX2 | standard laparoscopic equipment |
| GORE-TEX SUTURE CV-6 | W.L. Gore and Associates Inc. | 6M02A | |
| GORE-TEX SUTURE CV-7 | W.L. Gore and Associates Inc. | 7K02A | |
| HEMO CLIP | WECK | 523735 | |
| HEM-O-LOK CLIP | WECK | 544220 | |
| Hot Shears (Monopolar Curved Scissors) | Intuitive Surgical | 420179 | robotic instrument |
| laparoscopic atraumatic grasping forceps | standard laparoscopic equipment | ||
| laparoscopic irrigation suction set | standard laparoscopic equipment | ||
| Large Clip Applier | Intuitive Surgical | 420230 | robotic instrument |
| Large Needle Driver | Intuitive Surgical | 420006 | robotic instrument |
| Maryland Bipolar Forceps | Intuitive Surgical | 420172 | robotic instrument |
| Medium-Large Clip Applier | Intuitive Surgical | 420327 | robotic instrument |
| OPEN END URETERAL CATHETER | Cook Incorporated | 21305 | heparin flushing |
| PDS II 6-0 (DOUBLE) | Ethicon Endo-Surgery, Inc. | Z1712H | |
| Potts Scissors | Intuitive Surgical | 420001 | robotic instrument |
| ProGrasp Forceps | Intuitive Surgical | 420093 | robotic forceps |
| Small Clip Applier | Intuitive Surgical | 420003 | robotic instrument |
| VESSEL LOOP BLUE MAXI | ASPEN surgical | 011012pbx | |
| VESSEL LOOP RED MINI | ASPEN surgical | 011001pbx | |
| XCEL BLADELESS TROCAR | JOHNSON & JOHNSON | 2B12LT | standard laparoscopic equipment |
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Citar este artigo
Lim, S. J., Ko, Y., Kim, D. H., Jung, J. H., Kwon, H., Kim, Y. H., Shin, S. Robot-Assisted Kidney Transplantation. J. Vis. Exp. (173), e62220, doi:10.3791/62220 (2021).