Novel technique of vascular anastomosis in RAKT

Description

Robotic assisted Kidney Transplant (RAKT) is being done in selected centres across the world. The standardisation of the technique has been initiated by Vattikuti-Medanta technique but it is still evolving. One of the most crucial steps in RAKT is vascular anastomosis and bears a direct correlation with rewarm ischemia time. Our study aims at reducing the rewarm ischemia time by modifying the suturing technique with the introduction of a preplaced knot. In this technique, venous anastomosis is done using two Gore-Tex sutures which are cut to a length of 3.75 inches and a knot is tied extracorporeally between the two sutures. This preplaced knot suture is then placed inside the patient from the assistant port. The suture is passed at the distal apex of the renal allograft vein and also at the corresponding apex of the external iliac artery. The suture is tightened till the knot which was placed extracorporeally sits at the distal apex of the venous anastomosis thereby obviating the need to tie the sutures at the distal apex. Thereafter the posterior layer of anastomosis is performed in the usual fashion. At the proximal apex of the venous anastomosis the Gore-Tex suture is held by the fourth robotic arm. The second needle which lies in the preplaced knot suture at the distal apex of the venous anastomosis is then used to complete the anterior layer of the venous anastomosis. At the proximal apex of the anastomosis, the suture which was held by the fourth robotic arm is released and a knot is tied between the two sutures. For arterial anastomosis, we have modified this technique, and the fourth arm is utilized to hold the suture at the distal and proximal apex of the anastomosis, and the sutures are tied only twice, once at the distal apex and once at the proximal apex of the anastomosis.
In expert hands, every time a knot is tied, approximately 30 – 40 seconds are spent to tie the knot. Furthermore, in the usual technique, the knots are tied at least thrice while doing a single anastomosis, and the reliance on the bedside assistant is increased. By using this technique we were able to eliminate the dependence on the bedside assistant and also reduce the rewarm ischemia time.