REVIEW URRENT C OPINION
Robotic-assisted pancreas transplantation: where are we today? Ivo Tzvetanov, Giuseppe D’Amico, Lorena Bejarano-Pineda, and Enrico Benedetti
Purpose of review To analyze the current status of robotic-assisted pancreas transplantation as a treatment option for diabetic patients. Recent findings Pancreas transplant recipients continue to suffer high rates of technical complications, including wound infections, fascial dehiscence, and postoperative ventral hernias. Robotic technology can potentially contribute to decreasing these dangerous complications and improve the postoperative course of pancreas transplantation. Summary Current literature on both robotic pancreas and robotic kidney transplant were reviewed in order to determine feasibility, safety, and efficacy of robotic pancreas transplantation. To date, only three cases of robotic pancreas transplantation, two of which were solely pancreas transplantation and one combined pancreas–kidney transplantation, have been reported in a single publication by an Italian group. Their preliminary data show that robotic pancreas transplantation is feasible and well tolerated. The authors believe that robotic pancreas transplantation could have a prominent role in lone pancreas transplantation performed in overweight recipients, in parallel to their experience with fully robotic kidney transplant in morbidly obese candidates. Broader experience with this innovative approach will be necessary to establish if robotic pancreas transplantation will be a beneficial option for diabetic patients needing beta-cell replacement. Keywords pancreas transplantation, robotic-assisted pancreas transplantation, surgical complications
INTRODUCTION Pancreas transplantation provides the only proven method to restore physiological glycemic control and prevent progression of complications in selected type I and II diabetic patients. Refinements in surgical technique and immunosuppressive therapy have considerably improved outcomes, with graft survival rates of 85, 72, and 60% at 1, 5, and 10 years, respectively, after simultaneous pancreas and kidney transplant; and 79, 55, and 50% after pancreas transplantation alone [1]. The incidence of surgical complications is, however, still high (around 25–30%) and the rates of re-laparotomy are between 31 and 32% [2–6]. Pancreas transplant recipients have a number of specific risk factors for technical complications including their primary disease, more frequent and longer antiT-cell induction therapy, a duodenal cuff with high risk of bacterial and fungal contamination, and an organ such as the pancreas being very prone to www.co-transplantation.com
inflammation and auto-digestion. A reduction of post-transplant morbidity would be greatly welcomed and could possibly make pancreas transplantation a more appealing treatment option for selected diabetic patients, especially for obese candidates. During the past decades, minimally invasive surgical techniques have shown significant benefits over standard open techniques in several fields of surgery. Demonstrated benefits include reduced recovery time, decreased pain and suffering, and fewer wound complications [7]. The Division of Transplantation, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA Correspondence to Ivo G. Tzvetanov, MD, FACS, Division of Transplantation, University of Illinois Hospital & Health Sciences System, 840 South Wood Street, 402 CSB, Chicago, IL 60612, USA. Tel: +1 312 996-6771; fax: +1 312 413 3483; e-mail: [email protected] Curr Opin Organ Transplant 2014, 19:80–82 DOI:10.1097/MOT.0000000000000044 Volume 19 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Robotic-assisted pancreas transplantation Tzvetanov et al.
KEY POINTS Pancreas transplant recipients continue to suffer high surgical complications. The robotic technology can be an answer to the surgical morbidity. Preliminary data showed that robotic pancreas transplantation is feasible and well tolerated. Robotic pancreas transplantation in overweight recipients may be the best subset to implement this surgical approach.
infections have been recognized as a major risk factor for decreased graft survival after kidney transplant [19]. In our series, we did not encounter any SSI in a population expected to have a rate between 15 and 25% for the open procedure. To date, our results have been excellent overall in a challenging subset of morbidly obese patients (BMI between 35 and 60) usually denied access to kidney transplantation [14 ]. &
CURRENT EXPERIENCE IN ROBOTIC PANCREAS TRANSPLANTATION To date, the only published experience of robotic pancreas transplantation was reported in 2012 by Boggi et al. [20 ]. The small series presented consists of two solitary robotic pancreas and one simultaneous pancreas–kidney transplants. The pancreas grafts were transplanted after a mean cold ischemia time of 7 h and 20 min. Operative time was 3 and 5 h, respectively, for pancreas transplantation alone and 8 h for combined pancreas–kidney transplantation. Mean warm ischemia time was 30 min. All grafts had a homogeneous reperfusion without any bleeding from vascular anastomosis. In one case, an intraoperative bleed from the mesenteric root was controlled robotically, without conversion to open surgery. Mean blood loss was 170 ml; no recipients required blood transfusion. The postoperative course of all patients was uneventful. All three recipients were out of the bed on postoperative day (POD) 1 and were able to stand and walk on POD 2. From a technical standpoint, the pancreas was placed above the right psoas muscle with vascular anastomosis to the distal inferior cava and the right common iliac artery. A midline 7 cm incision was used to assist in placing the graft in the proper location and apply vascular clamps as well as to perform the duodeno-jejunal anastomosis. All three patients recovered well after surgery without technical complications. At a mean follow-up time of 8 months, they were all insulinindependent and otherwise doing well. &&
introduction of advanced surgical robotic devices, such as the Da Vinci surgical system, has expanded the ability to perform complex surgical procedures in a minimally invasive fashion and has removed most of the technical barriers of conventional laparoscopy [8,9]. The robot eliminates counterintuitive motion and instrument tremor; the visualization is three-dimensional with a very stable camera that does not move unless the surgeon actively modifies its position. The instruments have ‘endowrists’ with great capacity of articulation, making their function similar to that of the human wrist and thus allowing a more precise two-handed movement for dissection and reconstruction. The availability of an accessory arm allows the surgeon to retract without the need for an assistant. The application of robotic techniques in solid organ transplantation is still limited to a few highly specialized centers, but some potential benefits have already been reported in the literature. The donor nephrectomy for kidney transplantation has been the first application of the robotic surgical system in the transplant field [10–12]. Since the first case in our Institution in September 2000, we have performed over 800 robotic donor nephrectomies with excellent results in terms of short operative time, minimal blood loss, and ability to use without any problem obese donors or kidney with very complex anatomy [13,14 ]. We have also reported the first combined robotic donor distal pancreatectomy and nephrectomy for living donor simultaneous pancreas–kidney transplant and robotic right hepatectomy for living donor liver transplant [15–17]. Over the past 3 years, our group has successfully performed over 80 fully robotic renal transplants in obese recipients [14 ,18]. We chose to apply the robotic technique only to morbidly obese individuals in need for kidney transplantation in the attempt to reduce the high rate of wound infections which commonly complicate the open procedure in this subset of recipients. Superficial surgical site (SSI) &
&
CONCLUSION The high incidence of surgical complications continues to be a major issue in pancreas transplantation [2–5]. As a consequence, pancreas transplantation is associated with a high rate of re-laparotomy that negatively impacts graft and patient survival. Troppmann et al. [5] showed that the patient survival at 1 and 5 years was 80 and 74%, respectively, in patients with re-laparotomy versus 95 and 90% in patients without re-laparotomy (P ¼ 0.03). The incidence of wound complications in open pancreas transplantation is around 15% [3,21], and the rate of incisional hernias at the site of the midline incision is quite substantial. Hanish
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Pancreas transplantation
et al. [22] have shown that obese recipients (BMI >30) are at increased risk of overall complications following pancreas transplantation. Specifically, obese recipients experienced higher frequencies of dehiscence, ventral hernia, intra-abdominal infection, and necrotizing fasciitis. Lynch et al. [19] showed, in kidney-transplant recipients, that SSIs are related to a significant risk of premature graft loss [hazard ratio 2.194, 95% confidence interval (CI) 1.357–3.546] and a tendency toward inferior patient survival (hazard ratio 1.681, 95% CI 0.940–3.007). Furthermore, they demonstrated that a BMI above 30 is a risk factor for wound infection (23.7% in obese group versus 10.5% in nonobese group; P < 0.001) and fascial dehiscence (4.2% in obese group versus 1.1% in nonobese group; P ¼ 0.002). In our experience with robotic kidney transplantation [14 ], we demonstrated a significant drop in wound infection rates in obese recipients (0% in robotic group versus 28.6% in standard open transplant; P ¼ 0.004). Therefore, performing pancreas transplantation robotically could theoretically provide some advantages in comparison with conventional open pancreas transplantation. The robotic system could have a beneficial impact on the incidence of SSI, fascial dehiscence, and late incisional hernias. This benefit could be particularly important for pancreas transplantation in obese candidates, who are becoming increasingly more numerous as the percentage of obese individuals in the USA continues to climb. Boggi et al. [20 ] have demonstrated that robotic pancreas transplantation is feasible and well tolerated; we believe that this strategy should be explored. Overweight patients in need of pancreas transplantation alone may be the best subset of recipients to implement this innovative approach. Only larger studies with appropriate follow-up will be able to establish the real merits of robotic pancreas transplantation in the treatment of diabetes. &
&&
Acknowledgements None. Conflicts of interest Disclosure section: The authors of this manuscript have no conflicts of interest to disclose.
82
www.co-transplantation.com
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas transplantation. Curr Opin Organ Transplant 2012; 17:100–105. 2. Banga N, Hadjianastassiou VG, Mamode N, et al. Outcome of surgical complications following simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2012; 27:1658–1663. 3. Douzdjian V, Abecassis MM, Cooper JL, et al. Incidence, management and significance of surgical complications after pancreatic transplantation. Surg Gynecol Obstet 1993; 177:451–456. 4. Manrique A, Jime´nez C, Lo´pez RM, et al. Relaparotomy after pancreas transplantation: causes and outcomes. Transplant Proc 2009; 41:2472– 2474. 5. Troppmann C, Gruessner AC, Dunn DL, et al. Surgical complications requiring early relaparotomy after pancreas transplantation: a multivariate risk factor and economic impact analysis of the cyclosporine era. Ann Surg 1998; 227:255–268. 6. Sutherland DE, Gruessner RW, Dunn DL, et al. Lessons learned from more than 1000 pancreas transplants at a single institution. Ann Surg 2001; 233:463–501. 7. Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997; 226:483–489. [discussion 489–490] 8. Herron DM, Marohn M Grou. A consensus document on robotic surgery. Surg Endosc 2008; 22:313–325. [discussion 311–312] 9. Hubert J. Robotic-assisted laparoscopy: general principles. Ann Urol (Paris) 2007; 41:298–305. 10. Horgan S, Vanuno D, Sileri P, et al. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. Transplantation 2002; 73:1474– 1479. 11. Louis G, Hubert J, Ladriere M, et al. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. An evaluation of 35 procedures. Nephrol Ther 2009; 5:623–630. 12. Hubert J, Renoult E, Mourey E, et al. Complete robotic-assistance during laparoscopic living donor nephrectomies: an evaluation of 38 procedures at a single site. Int J Urol 2007; 14:986–989. 13. Horgan S, Benedetti E, Moser F. Robotically assisted donor nephrectomy for kidney transplantation. Am J Surg 2004; 188:45S–51S. 14. Oberholzer J, Giulianotti P, Danielson KK, et al. Minimally invasive robotic & kidney transplantation for obese patients previously denied access to transplantation. Am J Transplant 2013; 13:721–728. The robotic technique may help to reduce health disparities due to end-stage renal disease (ESRD) in populations with higher prevalence of obesity. 15. Horgan S, Galvani C, Gorodner V, et al. Robotic distal pancreatectomy and nephrectomy for living donor pancreas–kidney transplantation. Transplantation 2007; 84:934–936. 16. Giulianotti PC, Tzvetanov I, Jeon H, et al. Robot-assisted right lobe donor hepatectomy. Transpl Int 2012; 25:e5–e9. 17. Oberholzer J, Tzvetanov I, Mele A, Benedetti E. Laparoscopic and robotic donor pancreatectomy for living donor pancreas and pancreas–kidney transplantation. J Hepatobiliary Pancreat Sci 2010; 17:97–100. 18. Giulianotti P, Gorodner V, Sbrana F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient. Am J Transplant 2010; 10:1478– 1482. 19. Lynch RJ, Ranney DN, Shijie C, et al. Obesity, surgical site infection, and outcome following renal transplantation. Ann Surg 2009; 250:1014–1020. 20. Boggi U, Signori S, Vistoli F, et al. Laparoscopic robot-assisted pancreas && transplantation: first world experience. Transplantation 2012; 93:201– 206. An insight into robotic-assisted pancreas transplantation. First experience in the world. 21. Everett JE, Wahoff DC, Statz C, et al. Characterization and impact of wound infection after pancreas transplantation. Arch Surg 1994; 129:1310–1316. [discussion 1316–1317] 22. Hanish SI, Petersen RP, Collins BH, et al. Obesity predicts increased overall complications following pancreas transplantation. Transplant Proc 2005; 37:3564–3566.
Volume 19 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Robotic-assisted pancreas transplantation: where are we today? Ivo Tzvetanov, Giuseppe D’Amico, Lorena Bejarano-Pineda, and Enrico Benedetti
Purpose of review To analyze the current status of robotic-assisted pancreas transplantation as a treatment option for diabetic patients. Recent findings Pancreas transplant recipients continue to suffer high rates of technical complications, including wound infections, fascial dehiscence, and postoperative ventral hernias. Robotic technology can potentially contribute to decreasing these dangerous complications and improve the postoperative course of pancreas transplantation. Summary Current literature on both robotic pancreas and robotic kidney transplant were reviewed in order to determine feasibility, safety, and efficacy of robotic pancreas transplantation. To date, only three cases of robotic pancreas transplantation, two of which were solely pancreas transplantation and one combined pancreas–kidney transplantation, have been reported in a single publication by an Italian group. Their preliminary data show that robotic pancreas transplantation is feasible and well tolerated. The authors believe that robotic pancreas transplantation could have a prominent role in lone pancreas transplantation performed in overweight recipients, in parallel to their experience with fully robotic kidney transplant in morbidly obese candidates. Broader experience with this innovative approach will be necessary to establish if robotic pancreas transplantation will be a beneficial option for diabetic patients needing beta-cell replacement. Keywords pancreas transplantation, robotic-assisted pancreas transplantation, surgical complications
INTRODUCTION Pancreas transplantation provides the only proven method to restore physiological glycemic control and prevent progression of complications in selected type I and II diabetic patients. Refinements in surgical technique and immunosuppressive therapy have considerably improved outcomes, with graft survival rates of 85, 72, and 60% at 1, 5, and 10 years, respectively, after simultaneous pancreas and kidney transplant; and 79, 55, and 50% after pancreas transplantation alone [1]. The incidence of surgical complications is, however, still high (around 25–30%) and the rates of re-laparotomy are between 31 and 32% [2–6]. Pancreas transplant recipients have a number of specific risk factors for technical complications including their primary disease, more frequent and longer antiT-cell induction therapy, a duodenal cuff with high risk of bacterial and fungal contamination, and an organ such as the pancreas being very prone to www.co-transplantation.com
inflammation and auto-digestion. A reduction of post-transplant morbidity would be greatly welcomed and could possibly make pancreas transplantation a more appealing treatment option for selected diabetic patients, especially for obese candidates. During the past decades, minimally invasive surgical techniques have shown significant benefits over standard open techniques in several fields of surgery. Demonstrated benefits include reduced recovery time, decreased pain and suffering, and fewer wound complications [7]. The Division of Transplantation, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA Correspondence to Ivo G. Tzvetanov, MD, FACS, Division of Transplantation, University of Illinois Hospital & Health Sciences System, 840 South Wood Street, 402 CSB, Chicago, IL 60612, USA. Tel: +1 312 996-6771; fax: +1 312 413 3483; e-mail: [email protected] Curr Opin Organ Transplant 2014, 19:80–82 DOI:10.1097/MOT.0000000000000044 Volume 19 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Robotic-assisted pancreas transplantation Tzvetanov et al.
KEY POINTS Pancreas transplant recipients continue to suffer high surgical complications. The robotic technology can be an answer to the surgical morbidity. Preliminary data showed that robotic pancreas transplantation is feasible and well tolerated. Robotic pancreas transplantation in overweight recipients may be the best subset to implement this surgical approach.
infections have been recognized as a major risk factor for decreased graft survival after kidney transplant [19]. In our series, we did not encounter any SSI in a population expected to have a rate between 15 and 25% for the open procedure. To date, our results have been excellent overall in a challenging subset of morbidly obese patients (BMI between 35 and 60) usually denied access to kidney transplantation [14 ]. &
CURRENT EXPERIENCE IN ROBOTIC PANCREAS TRANSPLANTATION To date, the only published experience of robotic pancreas transplantation was reported in 2012 by Boggi et al. [20 ]. The small series presented consists of two solitary robotic pancreas and one simultaneous pancreas–kidney transplants. The pancreas grafts were transplanted after a mean cold ischemia time of 7 h and 20 min. Operative time was 3 and 5 h, respectively, for pancreas transplantation alone and 8 h for combined pancreas–kidney transplantation. Mean warm ischemia time was 30 min. All grafts had a homogeneous reperfusion without any bleeding from vascular anastomosis. In one case, an intraoperative bleed from the mesenteric root was controlled robotically, without conversion to open surgery. Mean blood loss was 170 ml; no recipients required blood transfusion. The postoperative course of all patients was uneventful. All three recipients were out of the bed on postoperative day (POD) 1 and were able to stand and walk on POD 2. From a technical standpoint, the pancreas was placed above the right psoas muscle with vascular anastomosis to the distal inferior cava and the right common iliac artery. A midline 7 cm incision was used to assist in placing the graft in the proper location and apply vascular clamps as well as to perform the duodeno-jejunal anastomosis. All three patients recovered well after surgery without technical complications. At a mean follow-up time of 8 months, they were all insulinindependent and otherwise doing well. &&
introduction of advanced surgical robotic devices, such as the Da Vinci surgical system, has expanded the ability to perform complex surgical procedures in a minimally invasive fashion and has removed most of the technical barriers of conventional laparoscopy [8,9]. The robot eliminates counterintuitive motion and instrument tremor; the visualization is three-dimensional with a very stable camera that does not move unless the surgeon actively modifies its position. The instruments have ‘endowrists’ with great capacity of articulation, making their function similar to that of the human wrist and thus allowing a more precise two-handed movement for dissection and reconstruction. The availability of an accessory arm allows the surgeon to retract without the need for an assistant. The application of robotic techniques in solid organ transplantation is still limited to a few highly specialized centers, but some potential benefits have already been reported in the literature. The donor nephrectomy for kidney transplantation has been the first application of the robotic surgical system in the transplant field [10–12]. Since the first case in our Institution in September 2000, we have performed over 800 robotic donor nephrectomies with excellent results in terms of short operative time, minimal blood loss, and ability to use without any problem obese donors or kidney with very complex anatomy [13,14 ]. We have also reported the first combined robotic donor distal pancreatectomy and nephrectomy for living donor simultaneous pancreas–kidney transplant and robotic right hepatectomy for living donor liver transplant [15–17]. Over the past 3 years, our group has successfully performed over 80 fully robotic renal transplants in obese recipients [14 ,18]. We chose to apply the robotic technique only to morbidly obese individuals in need for kidney transplantation in the attempt to reduce the high rate of wound infections which commonly complicate the open procedure in this subset of recipients. Superficial surgical site (SSI) &
&
CONCLUSION The high incidence of surgical complications continues to be a major issue in pancreas transplantation [2–5]. As a consequence, pancreas transplantation is associated with a high rate of re-laparotomy that negatively impacts graft and patient survival. Troppmann et al. [5] showed that the patient survival at 1 and 5 years was 80 and 74%, respectively, in patients with re-laparotomy versus 95 and 90% in patients without re-laparotomy (P ¼ 0.03). The incidence of wound complications in open pancreas transplantation is around 15% [3,21], and the rate of incisional hernias at the site of the midline incision is quite substantial. Hanish
1087-2418 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-transplantation.com
81
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pancreas transplantation
et al. [22] have shown that obese recipients (BMI >30) are at increased risk of overall complications following pancreas transplantation. Specifically, obese recipients experienced higher frequencies of dehiscence, ventral hernia, intra-abdominal infection, and necrotizing fasciitis. Lynch et al. [19] showed, in kidney-transplant recipients, that SSIs are related to a significant risk of premature graft loss [hazard ratio 2.194, 95% confidence interval (CI) 1.357–3.546] and a tendency toward inferior patient survival (hazard ratio 1.681, 95% CI 0.940–3.007). Furthermore, they demonstrated that a BMI above 30 is a risk factor for wound infection (23.7% in obese group versus 10.5% in nonobese group; P < 0.001) and fascial dehiscence (4.2% in obese group versus 1.1% in nonobese group; P ¼ 0.002). In our experience with robotic kidney transplantation [14 ], we demonstrated a significant drop in wound infection rates in obese recipients (0% in robotic group versus 28.6% in standard open transplant; P ¼ 0.004). Therefore, performing pancreas transplantation robotically could theoretically provide some advantages in comparison with conventional open pancreas transplantation. The robotic system could have a beneficial impact on the incidence of SSI, fascial dehiscence, and late incisional hernias. This benefit could be particularly important for pancreas transplantation in obese candidates, who are becoming increasingly more numerous as the percentage of obese individuals in the USA continues to climb. Boggi et al. [20 ] have demonstrated that robotic pancreas transplantation is feasible and well tolerated; we believe that this strategy should be explored. Overweight patients in need of pancreas transplantation alone may be the best subset of recipients to implement this innovative approach. Only larger studies with appropriate follow-up will be able to establish the real merits of robotic pancreas transplantation in the treatment of diabetes. &
&&
Acknowledgements None. Conflicts of interest Disclosure section: The authors of this manuscript have no conflicts of interest to disclose.
82
www.co-transplantation.com
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas transplantation. Curr Opin Organ Transplant 2012; 17:100–105. 2. Banga N, Hadjianastassiou VG, Mamode N, et al. Outcome of surgical complications following simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2012; 27:1658–1663. 3. Douzdjian V, Abecassis MM, Cooper JL, et al. Incidence, management and significance of surgical complications after pancreatic transplantation. Surg Gynecol Obstet 1993; 177:451–456. 4. Manrique A, Jime´nez C, Lo´pez RM, et al. Relaparotomy after pancreas transplantation: causes and outcomes. Transplant Proc 2009; 41:2472– 2474. 5. Troppmann C, Gruessner AC, Dunn DL, et al. Surgical complications requiring early relaparotomy after pancreas transplantation: a multivariate risk factor and economic impact analysis of the cyclosporine era. Ann Surg 1998; 227:255–268. 6. Sutherland DE, Gruessner RW, Dunn DL, et al. Lessons learned from more than 1000 pancreas transplants at a single institution. Ann Surg 2001; 233:463–501. 7. Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997; 226:483–489. [discussion 489–490] 8. Herron DM, Marohn M Grou. A consensus document on robotic surgery. Surg Endosc 2008; 22:313–325. [discussion 311–312] 9. Hubert J. Robotic-assisted laparoscopy: general principles. Ann Urol (Paris) 2007; 41:298–305. 10. Horgan S, Vanuno D, Sileri P, et al. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. Transplantation 2002; 73:1474– 1479. 11. Louis G, Hubert J, Ladriere M, et al. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. An evaluation of 35 procedures. Nephrol Ther 2009; 5:623–630. 12. Hubert J, Renoult E, Mourey E, et al. Complete robotic-assistance during laparoscopic living donor nephrectomies: an evaluation of 38 procedures at a single site. Int J Urol 2007; 14:986–989. 13. Horgan S, Benedetti E, Moser F. Robotically assisted donor nephrectomy for kidney transplantation. Am J Surg 2004; 188:45S–51S. 14. Oberholzer J, Giulianotti P, Danielson KK, et al. Minimally invasive robotic & kidney transplantation for obese patients previously denied access to transplantation. Am J Transplant 2013; 13:721–728. The robotic technique may help to reduce health disparities due to end-stage renal disease (ESRD) in populations with higher prevalence of obesity. 15. Horgan S, Galvani C, Gorodner V, et al. Robotic distal pancreatectomy and nephrectomy for living donor pancreas–kidney transplantation. Transplantation 2007; 84:934–936. 16. Giulianotti PC, Tzvetanov I, Jeon H, et al. Robot-assisted right lobe donor hepatectomy. Transpl Int 2012; 25:e5–e9. 17. Oberholzer J, Tzvetanov I, Mele A, Benedetti E. Laparoscopic and robotic donor pancreatectomy for living donor pancreas and pancreas–kidney transplantation. J Hepatobiliary Pancreat Sci 2010; 17:97–100. 18. Giulianotti P, Gorodner V, Sbrana F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient. Am J Transplant 2010; 10:1478– 1482. 19. Lynch RJ, Ranney DN, Shijie C, et al. Obesity, surgical site infection, and outcome following renal transplantation. Ann Surg 2009; 250:1014–1020. 20. Boggi U, Signori S, Vistoli F, et al. Laparoscopic robot-assisted pancreas && transplantation: first world experience. Transplantation 2012; 93:201– 206. An insight into robotic-assisted pancreas transplantation. First experience in the world. 21. Everett JE, Wahoff DC, Statz C, et al. Characterization and impact of wound infection after pancreas transplantation. Arch Surg 1994; 129:1310–1316. [discussion 1316–1317] 22. Hanish SI, Petersen RP, Collins BH, et al. Obesity predicts increased overall complications following pancreas transplantation. Transplant Proc 2005; 37:3564–3566.
Volume 19 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
