Name:
Robotic Kidney Transplantation under Regional Hypothermia
Description:
Robotic Kidney Transplantation under Regional Hypothermia
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/be571cc4-5379-4a7f-a581-eb11861cabe3/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=J%2BUh4LVPBBfiiuCM1d%2FG9sPbN%2FxJ6T%2BDw6dMqOCGTQk%3D&st=2026-04-03T02%3A58%3A02Z&se=2026-04-03T07%3A03%3A02Z&sp=r
Duration:
T00H08M48S
Embed URL:
https://stream.cadmore.media/player/be571cc4-5379-4a7f-a581-eb11861cabe3
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/be571cc4-5379-4a7f-a581-eb11861cabe3/RKT2.m4v?sv=2019-02-02&sr=c&sig=D%2FSY5baq4%2Bz0tyiLQT86xabdwsUAOxWRkncdWzgF2bM%3D&st=2026-04-03T02%3A58%3A02Z&se=2026-04-03T05%3A03%3A02Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
[MUSIC PLAYING]
Segment:2 Patient positioning and Port placement.
RAJESH AHLAWAT: The patient is placed, fixed, and draped in supine position with a low lithotomy in a manner similar to the robotic radical prostatectomy. A hand assist device, GelPOINT, is placed via 5.5-centimeter vertical periumbilical incision. The device incorporates a 12-millimeter port for the lens as well as an assistant port. Pneumoperitoneum is created, and the patient is now moved to about 15 to 20 degrees Trendelenburg position.
RAJESH AHLAWAT: The primary arm ports are placed on the two sides of the GelPOINT device. The fourth arm is placed on the left side in anterior auxiliary line. An additional 12-millimeter assistant port is placed on the right side. The robot is then brought between the legs, and the docking is done.
Segment:3 Bed Preparation.
RAJESH AHLAWAT: The graft bed preparation commences with a 0 degree lens and with a bipolar device and hot shears as working instruments.
RAJESH AHLAWAT: The external iliac artery and vein are skeletonized from the level of iliac bifurcation to inguinal ligament. Some venous tributaries may need to be clipped and cut to free up sufficient external iliac vein length. The peritoneum distal to the cecum is horizontally divided in a T fashion starting from the center of the already incised peritoneum over the iliac.
RAJESH AHLAWAT: The proximal and distal peritoneal flaps are raised. These flaps are to be used to cover and fix the graft in right iliac fossa after the vascular anastomosis. The urinary bladder is now dropped. The bladder is filled with 200 milliliters of normal saline, and the site is prepared for urethra-vesical anastomosis on its right anterior superior aspect of the bladder. We prefer making a small detrusor tunnel at the proximal end of the prepared urethrovesicotomy site.
RAJESH AHLAWAT: Preparation of the graft kidney after harvest
Segment:4 Graft Preparation and hypothermia.
RAJESH AHLAWAT: is an important step. The graft, with some ice slush, is enclosed in a jacket made of gauze. Vessels are brought out through a hole in the gauze medially. The jacket is snugly closed laterally over the graft with some sutures. While the ureter may be seen coming out of the lower end of the jacket, a long, silk suture is left at the upper pole for flagging and correct orientation of the graft once placed intraperitoneally.
RAJESH AHLAWAT: The jacket helps in maintaining intracorporeal cooling as well as enables holding and movement of the graft atraumatically. The robotic lens is undocked. The pelvic bed is now cooled with ice slush, delivered through the GelPOINT device. Modified [INAUDIBLE] syringes with their front end cut off helped deliver an ice cylinder of 50 ml volume with each delivery.
RAJESH AHLAWAT: The graft kidney in its jacket is introduced inside the peritoneal cavity. The GelPOINT device cap is now closed and the lens arm redocked with 30 degree down-facing lens. The graph is oriented to be placed in true pelvic hollow over the iced bed. The graft vessels face the medial end of dissected external iliac vessels.
RAJESH AHLAWAT: The dissected length of external iliac vein
Segment:5 Venous anastomosis.
RAJESH AHLAWAT: is isolated with bulldog clamps proximally and distally. Appropriate venotomy is done with cold scissors, and the external iliac vein is flushed with heparinized saline. The graft renal vein is anastomosed to the clamped external iliac vein in an end-to-side fashion. Starting at the distal end and the posterior wall is completed first in a continuous manner.
RAJESH AHLAWAT: A GORE-TEX 5-0, CV-6 suture with a 9-millimeter needle is used. We prefer to use this unique, microporous, nonabsorbable, monofilament PTFE suture with some unique properties. The suture is soft and supple without memory and has sufficient strength for robotic handling. A knot is tied after turning the corner before proceeding to the anterior wall from the lower end up. The external iliac vein is flushed with heparinized saline before the final suture is pulled tight and tight.
RAJESH AHLAWAT: The graft renal vein is now clamped, and the iliac vein continuity is restored. The bulldog clamps are now applied
Segment:6 Arterial anastomosis.
RAJESH AHLAWAT: on either side of the dissected external iliac artery. A small arteriotomy incision is made. The external iliac artery is flushed clean with heparinized saline.
RAJESH AHLAWAT: A 6-French end-hole ureteric catheter comes handy for the purpose of flushing. The desired rounded opening is then created using 3.6-millimeter vascular punch inserted through the GelPOINT. The graft artery is anastomosed end to side with external iliac artery using the technique similar to venous anastomosis. A large robotic needle driver is used in the dominant hand.
RAJESH AHLAWAT: Robotic Black Diamond forceps being used in the nondominant hand works as a DeBakey to spread the edge and handle vascular tissue for precise suturing. [MUSIC PLAYING] A clamp is now placed on the renal artery, and the distal bulldog is removed from external iliac artery to check anastomotic integrity.
RAJESH AHLAWAT: The graft is then perfused, removing all clamps.
Segment:7 Revascularization and graft fixation.
RAJESH AHLAWAT: The pneumoperitoneum is dropped to 8 to 10 millimeters of mercury to have minimum impact on the now perfused renal graft. The graft jacket is now released, cutting it from its hilar opening proximally and distally to bare the graft and allowing its visual inspection of color, turgudity, and on-table diuresis.
RAJESH AHLAWAT: The revascularized graft is flipped from the pelvic hollow to the right iliac fossa, turning it at 180 degrees around the external iliac. The proximal and distal peritoneal flaps prepared during the preparation of the bed are brought together over the graft using Hem-o-Lok clips, thus retroperitonealizing lining it at its destination.
RAJESH AHLAWAT: [MUSIC PLAYING] The graft is now inspected for color and turgur, and the external iliac vessels and both anastomoses are inspected.
Segment:8 Uretero-vesicostomy.
RAJESH AHLAWAT: The ureter is brought out beneath the vas, and the previously made detrusor tunnel and its end is spatulated.
RAJESH AHLAWAT: The urethrovesicostomy is performed in a standard Lich-Greigor fashion. The ureter-to-bladder mucosa anastomosis is performed in a continuous fashion using continuous 4-0 PDS or Vicryl suture. A 6F, 16-centimeter, double-J stent is placed after completing the posterior layer and before proceeding to anterior layer of the anastomosis.
RAJESH AHLAWAT: The detrusor muscle is closed with continuous suturing over the urethra-vesical anastomosis using a 3-0 barbed suture, such as V-Loc. A 24F drain is placed in pouch of Douglas
Segment:9 Drain and closure.
RAJESH AHLAWAT: via the right 12-millimeter assistant port. A flat drain is placed via the fourth arm port and is left anterior to the urinary bladder. The wounds are closed in a standard manner.
RAJESH AHLAWAT: An on-table vascular Doppler of the graft is obtained to check vascularity before shifting the patient out to the transplant ICU.
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