Introduction: Robotic-assisted kidney transplantation (RAKT) has long shown solid results as a minimally invasive alternative to the standard open approach (OKT) for living donor and promising results for deceased donor. However, RAKT is still limited in those cases where the recipient’s iliac vessels present atherosclerotic plaques, frequently found in elder patients and in those subjected to long-term hemodialysis. Unlike OKT, where the surgeon can palpate the arterial plaques, in minimally-invasive surgery the haptic feedback is missing making the vascular clamping and arteriotomy unsafe. To overcome this limitation, 3-Dimensional (3D) imaging virtual reconstruction was employed using the Augmented Reality (AR) to intraoperatively locate the plaques, driving the surgeon during the crucial steps of KT.
Methods: Our study was conducted according to IDEAL model for surgical innovation. 3D printed and virtual models were obtained from high-accuracy conventional CT scan imaging and superimposed on the vessels during RAKT using the Da Vinci console software.
Results: In the IDEAL phase 0, 3D virtual models were obtained from patients with artery plaques, printed and compared to the vascular anatomy of the patient during 2 OKTs by manual palpation. In phase 1, the 3D virtual models of patients without plaques were superimposed during a combined open-robotic KT and 2 RAKTs. Anatomical fidelity was assessed by measuring and comparing the virtual model to the real vessels. Then, we employed the 3D AR on a clinical case without plaques during the vascular clamping and arteriotomy phases to gain insight of anatomy modification during vessel dissection. The correspondence of 3D virtual models with the real anatomy of patients with plaques was tested by scanning the iliac arteries with a robotic ultrasound (US) probe in 10 patients undergoing robotic-assisted iliac lymph-node dissection for prostate cancer. Finally, after US confirmation, the 3D-AR accurately enabled the surgeon to place the clamp and perform the arteriotomy safely in a clinical case with arterial plaques.
Conclusions: The employment of 3D-AR allowed to overcome one of the main limitations of RAKT, setting the foundation to expand its indications to patients with advanced atheromatic vascular disease.
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