WashU Medicine transplant surgeons Adeel Khan, MD, and Jessica Lindemann, MD, PhD, perform the first reported robotic combined liver and kidney transplant at the WashU Medicine and Barnes-Jewish Transplant Center. They walk through the operative approach — how the two transplants were sequenced, how robotic access was established, and how the liver was transplanted through a single ~3-inch incision, with the kidney transplanted through the same incisions the following day. The discussion covers patient selection for a minimally invasive approach in combined hepatic and renal failure, along with the technical considerations that made the case feasible.
In this video
Sequencing and planning for a same-patient dual-organ transplant
Robotic access and the console/bedside workflow
Minimizing the incision versus the 16–20 of traditional open surgery
Selecting patients who may benefit from a minimally invasive approach
Read More: Full Press Release
This is a video of the world's first robotic simultaneous liver kidney transplant. I'm a consultant for Intuitive Surgical. Uh, our recipient is a 69-year-old male with end-stage liver disease and renal disease. Male is 30, on dialysis, and the donor was a female in the mid-20s, liver weight of 1300 g. This is the traditional open liver kidney transplant incision. As you can see, it incurs considerable morbidity, uh, and this is after the robotic approach with just one periambilical incision for graft extraction and insertion. Uh, starts off with a liver transplant program. This is the port placement, shows first placement of an air seal peri-ambilically and placement of 4 robotic ports. Camera is in the third arm, um, and then for the kidney transplant, 2 additional ports, number 3 and number 4, are, uh, inserted. Uh, and this is what it looks like at the end with a single drain around the liver transplant. Operation starts off by mobilization of the suprahepatic IVC. Here the cava is being dissected. What we're trying to do is get the groove between the right hepatic vein and the middle and left hepatic veins. And then we move on to the hepato, um, uh, gastric ligament and, uh, here the caudate is being taken off the IVC. We dissect out the short hepatic veins between the caudate and the IVC and then try to obtain control of the middle and left hepatic vein and you can see that is being divided with the stapler. Then we move on to the portahepatis. Uh, you can see the hepatic arteries on the right. Uh, circumferential control is obtained of the common bile duct, which is then, uh, divided, uh, in between, uh, clips. Uh, and then we dissect out the portal vein posteriorly. And you can see, um, uh, the portal vein there. The right and left hepatic arteries are divided separately. And then, uh, this is what, uh, the portal hepatitis looks at the end. Bile ductal hepatic artery divided and the portal vein is in the back. The remaining, uh, adhesions to the right side are taken down and control is obtained of the right hepatic vein. Portal vein is then, uh, clamped and divided in the hilum. And as a last step of the hepatectomy, the right hepatic vein is divided. And this completes the hepatectomy. This is the view of the right upper quadrant with the liver out. Clamp is placed on, uh, the cava to partially clamp it. Then the old liver is taken out and the new liver placed. Then we start off with the site to site chiva chivastomy anastomosis. Uh, 40 Gore-Tex suture is, uh, used for this, um, uh, continuous anastomosis. We, um, occasionally will lock across the stitch just to, um, minimize the chance of bleeding after reperfusion as, The lateral side of the anastomosis is hard to visualize once the liver is in place. We continue uh to place the sutures as we come down on the posterior wall to the lower corner. And then we'll start off from the anterior, uh, aspect of the anastomosis, again, from a top-down approach. After completion of the KL anastomosis, we move on to the portal vein anastomosis. Sixogoretex suture is being used for this. Uh, again, the back, uh, row is, uh, being completed first in a continuous fashion. Gotex suture has the advantage that it's uh easy to handle, it does not break easy, and it doesn't have the memory like Prolean. Here we move on to the interior wall of the portal vein anastomosis. And then, uh, we leave a little bit of an expansion not to allow the anastomosis to expand. And the liver is then reperfused. The warm ischemia time was 45 minutes. Then we move on to the artery anastomosis. That is done between the recipient, uh, hepatic artery and the donor celiac artery. Uh, 70 prolene suture is being used. Uh, since we used the bifurcation point of the artery, we were able to, uh, do a continuous anastomosis, um, uh, but sometimes interrupted anastomosis is also done, especially if the arteries are small. After the backside, um, Is done, we move on to the front wall of the anastomosis, um, and again, um, we, uh, continuous, we run it using continuous sevenoprolene suture. Now suture is tied and the artery is reperfused. This is the view, the hepatic artery in the portal vein. Last thing, we move on to the bileectinastomosis. Um, there's a little bit of a size mismatch with the, uh, donor duct being larger than the recipient duct. 60 PDS suture is being used and, uh, an interrupted, uh, technique is employed and we make up for the little bit of the size discrepancy with every, uh, stitch, so that in the end, the end result is pretty good. Um, the last few sutures have been tied down. Ultrasound is done and then we move on to the kidney transplant. So the ports are switched, robot is undocked, We start off by dissecting uh the external iliac vessels in the recipient um on the right side. Um, here we can see the vein in the artery. Being dissected separately. Obtain control And we mobilize enough length to be able to clamp, external iliac vein is clamped, and then the kidney is placed. And this is the left donor kidney. We move on with the iliac vein anastomosis, showing the end of the external, uh, end of the renal vein to the side of the external iliac vein, and again, sixovoretex suture is used. Continuous technique is employed. Front wall of the anastomosis is completed. Clamp is applied on the renal vein and then the clamps are applied on the artery. Arteriotomy is made in the external iliac artery and then an end renal artery to side external iliac artery. Anastomosis is completed again using sixo Gore-Tex, period. In this case, the donor kidney had a single artery and a single vein. And the anastomosis is being completed. And then the kidney will be reperfused shortly. You can see the kidney picking up. Ultrasound shows good flow. Uh, this is a view of the artery and the vein anastomosis. Then, uh, the, uh, opening is made in the bladder and we proceed with the ureter anastomosis using, um, a 60 PDS suture. A stent is placed across the anastomosis and this is just a continuous, um, um, uh, anastomosis. We typically do not use a drain, and uh this is the view. A single drain is used to drain the liver, and this is the view at 3 months post-op. Patient's healed very well. Patient had an uneventful post-op course, did great, excellent liver and kidney function, no surgical complications or readmissions. And was discharged home on day 12. So we've done over 1300 robotic cases in the transplant service, um, you know, uh, about 13 robotic liver transplants, 125 robotic kidney transplants, very good outcomes for both, uh, and, um, in conclusion, this is the first robotic SLK in the world, shows the natural evolution of experience in robotic transplantation and is a commitment to vision, um, that we have for safe integration of robotics and transplant. Thank you.
