Standard and Recommended Checkpoints at Revascularization to Prevent Complications in Robotic Kidney Transplant

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Introduction: Vattikuti Urology Institute technique of robotic kidney transplant (RKT) with regional hypothermia1 has been associated with reduced blood loss and a low rate of vascular complications when compared with open surgery.2 The procedure has been described previously. This video demonstrates the importance of proper bench preparation before RKT, checkpoints during surgery to prevent these complications, and the suggested intraoperative sequence to manage hemorrhage during surgery.

Materials and Methods: Four major checkpoints are identified during surgery: (1) The first check is during the declamping of venous anastomosis. The renal vein is clamped after anastomosis is complete, and external iliac vein continuity is restored by removing the proximal clamp. This provides an opportunity to test the anastomosis with backflow from the inferior vena cava. (2) The second checkpoint is after the arterial anastomosis. The renal artery is clamped before removing the distal external iliac artery clamp. This provides enough backflow from the distal external iliac artery, to check the integrity of arterial anastomosis. Any small bleeding points in the anastomosis may be managed at this point. The graft is then perfused by removing the clamps from graft vein and artery, with the proximal external iliac artery clamp still in place. Proximal clamp is now slowly released, while watching for any brisk bleed or abnormal blood filling of the field. This last clamp may be applied back on the external iliac artery proximally to reduce the bleed and to manage it with packs, diathermy, or additional sutures. (3) The third checkpoint is after cutting open the graft jacket from its hilar opening proximally and distally to bare the graft, which allows its visual inspection for color and turgidity. Small bleeding perforators are managed with bipolar diathermy at this point. The revascularized graft is flipped from the pelvic hollow to the right iliac fossa, turning it at 180° around the external iliacs. (4) The peritoneal flaps prepared previously are brought together over the graft. At this point, the external iliac vessels and both the anastomoses can be inspected. This is the fourth checkpoint during surgery. If any bleeding is encountered during removal of clamps, systematic reapplication of clamps helps in identifying and tackling the source of bleed. The second case demonstrated in this video had bleeding from an unrecognized avulsed branch of the graft renal artery managed by systematic clamping and repair of the graft renal artery.

Results: A total of 125 RKTs were done by a single surgeon. Six cases needed sequential management of bleeding. There was no renal artery stenosis, thrombosis, or major vascular complications. One case had to be re-explored for increased drain output. The patient had a recent coronary angioplasty and was on antiplatelet agents. This case had a negative re-exploration and was managed by topical hemostatic agents and blood transfusion.

Conclusions: RKT has a low rate of vascular complications in this series. A meticulous and systematic checklist-based approach helps identify and manage hemorrhage intraoperatively.