Summary
Dette papir indeholder tekniske detaljer for robotassisteret nyretransplantation fra en levende donor.
Abstract
Dette papir beskriver robotassisteret nyretransplantation (RAKT) fra en levende donor. Robotten er forankret mellem patientens adskilte ben, placeret i liggende Trendelenburg-position. Nyre allografts leveres af en levende donor. Før vaskulær anastomose fremstilles nyreallograften ved at indsætte en dobbelt-J stent i urinlederen, og temperaturen for anastomosen sænkes ved at pakke den ind i en ispakket gasbind. En 12 mm eller 8 mm port til robotkameraet og tre 8 mm porte til robotarme er placeret. En peritoneal pose er skabt til nyre allograft ved at hæve peritoneal klapperne på begge sider over psoas muskel, før dissekering iliac fartøjer og blære. Et 6 cm Pfannenstiel-snit er lavet til at indsætte nyren i peritonealposen, lateralt til højre iliac-kar.
Efter fastspænding af den eksterne iliac-vene med Bulldogs-klemmer udføres en venotomi, og graft-nyrevenen anastomoseres til den ydre iliac-vene på en ende-til-side kontinuerlig måde med en 6/0 polytetrafluorethylensutur. Efter fastspænding af graft nyrevenen er iliac venen delamped. Dette efterfølges af fastspænding af den eksterne iliacarterie, arteriotomi, arteriel anastomose med en 6/0 polytetrafluorethylensutur, fastspænding af graft nyrearterien og delamping af den eksterne iliac arterie. Reperfusion udføres derefter, og ureteroneocystostomi udføres ved hjælp af Lich-Gregoir-teknikken. Peritoneum er lukket et par steder med polymerlåseklemmer, og et lukket sugeafløb placeres gennem en af arbejdsportene. Efter deflatering af pneumoperitoneum lukkes alle snit.
Introduction
Nyretransplantation bidrager til langvarig overlevelse og en bedre livskvalitet sammenlignet med peritonealdialyse eller hæmodialyse1. Selvom den åbne tilgang er standardproceduren for nyretransplantation, er robotassisterede teknikker for nylig blevet vedtaget 2,3,4. Specifikt har robotassisteret nyretransplantation (RAKT) flere fordele i forhold til åben nyretransplantation: minimal postoperativ smerte, bedre kosmese, færre sårinfektioner og kortere hospitalsophold5. Desuden gør minimalt invasiv adgang og robotteknologi det muligt for kirurger sikkert at udføre nyretransplantationer hos sygeligt overvægtige patienter 6,7,8,9. På grund af sin kompleksitet kræver RAKT imidlertid en indlæringskurve for at opnå tilstrækkelig reproducerbarhed i driftstiden, funktionelle resultater og sikkerhed10.
Allografts med flere fartøjer kræver normalt vaskulær rekonstruktion, hvilket fører til længere kolde og varme iskæmiske tider. På trods af de tekniske udfordringer ved RAKT, rapporterede en europæisk multicenterundersøgelse, at RAKT ved hjælp af allografts med flere fartøjer er teknisk gennemførlig og fører til gunstige funktionelle resultater11. Selvom det er mere almindeligt at placere nyreallograften i bækkenet medialt under vaskulær anastomose, blev allograften ifølge tidligere rapporter 4,5,6,7,8,9 anbragt på peritonealposen lateralt til iliac-karrene i denne protokol. Selvom det kan være sikkert at lægge en allograft medialt under anastomose og vende den til peritonealposen, er denne teknik muligvis ikke kendt for uerfarne kirurger. Desuden er det mere bekvemt at udføre vaskulær anastomose med allograften i peritonealposen og nyrekarrene i den rigtige position. Dette papir beskriver de trinvise procedurer for RAKT uden at vende.
Protocol
Representative Results
Discussion
Selvom laparoskopiske og robotassisterede teknikker er blevet anvendt i vid udstrækning til levende donornefrektomi, udføres nyretransplantationer stadig hovedsageligt ved hjælp af konventionelle åbne teknikker. For nylig er en minimalt invasiv tilgang til nyretransplantation imidlertid i stigende grad blevet brugt. Sammenlignet med traditionel åben kirurgi har minimalt invasiv nyretransplantation en lavere risiko for kirurgisk infektion, snitbrok og sårdehiscens samt kortere indlæggelse 12,13,14,15,16.<sup class=…
Disclosures
The authors have nothing to disclose.
Acknowledgements
Vi takker Dr. Joon Seo Lim fra Scientific Publications Team på Asan Medical Center for hans redaktionelle hjælp til at forberede dette manuskript.
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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