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 case in the WashU Medicine news release ?
This is a video of the world's first robotic simultaneous liver kidney transplant. The recipient is a 69 year old male, and the organs came from a 25-year-old female donor. This is the port placement for the liver transplant portion of the case. There was a periambilical gel port. It starts off with suprahepatic cable dissection. The IVC and the hepatic veins are dissected free. Most of the dissection is done using bipolar. The groove between the right hepatic vein and the middle and left hepatic vein is developed, and then we proceed dissection in the gastrohepatic ligament and then start mobilizing the caudate of the IVC. Short hepatic veins and cordate branches are divided between ties and clips. And then we clean up the cava and then are able to get circumferential control of the common trunk of middle and left hepatic vein. This is divided early using the robotic stapler. Then we proceed with porta hepatis dissection. Here the hepatic artery is being dissected. Can see the right and left branches separately. Laterally, circumferential control is obtained of the common bile duct. Which is then divided between clips. We continue dissection to expose the portal vein. And then you proceed with division of the hepatic arteries. The right and left hepatic arteries are divided separately. This is the view at the end of the dissection of the porta hepatis. Then the remaining attachments on the right side are taken down. Uh, uh, the short cable, uh, branches are divided between toys and clips, and we continue to mobilize the liver off the diaphragm. The right hepatic vein is then dissected free as the final step. Portal vein orientation is marked prior to placement of bulldog clamps and then division in the hilum. And then the remaining right hepatic vein is divided again with the robot stapler. This completes the hepatectomy. It shows a view, um, with the liver out. The liver is then, the cava is then partly clamped with the Stratinsky clamp. The old liver is removed, new liver is placed, anterior venotomy is made in the IVC and then we proceed with a side to side cava cavastomy anastomosis using, uh, for oogortex suture. Start from the top down. Now you can see the, uh, donor cava on the left and the recipient cava on the right. A continuous anastomosis is done. Every few sutures, the suture is locked. Um, just to prevent it from loosening up, uh, because the bleeds in the posterior aspect are hard to, to, to address. We continue, uh, the anastomosis coming additionally down to the lower end. And then starting off from the interior wall. The same continuous anastomosis. The preservative solution has been flushed out of the liver prior to its placement in the abdomen. Uh, sutures are cut and then we proceed with the portal vein anastomosis. So, this is an end to end portal portal anastomosis. The ends have been trimmed. We proceed with the continuous anastomosis using 6OPDS, uh, sorry, 6O vortex. Um, the posterior wall of the anastomosis is being, uh, created here. And then we start, uh, along the anterior aspect, anterior wall of the anastomosis. When the anastomosis is completed, a slight expansion not is left, so that the anastomosis expands. This shows reperfusion. You can see the color of the liver changing. Artery is being prepared. Small bulldog is placed distally. We performed the anastomosis using the right left hepatic artery bifurcation of the recipient and essentially an end to end anastomosis. 7oproline is being used. Given the nice size of the artery, we did a continuous, um, uh, suture anastomosis. If it's smaller, an interrupted one is done. This again is 7oprolene. Corner stitches cut. Uh, a tied and cut and then we proceed with the anterior. Uh, wall anastomosis. Artery anastomosis completed. Artery is superfused. Shows a view of the artery. You can see the hepatic artery, suture lines and the portal vein suture lines. Then the bile duct anastomosis, um, so this is, uh, uh, an end to end anastomosis. A little bit of a size mismatch. Um, and we used, um, uh, 50PD or 60PDS, uh, suture for, uh, this anastomosis, interrupted sutures, Then an ultrasound shows good flow. Uh, kidney transplant, uh, port placement is essentially the same. Two extra ports had to be placed on the left side. Uh, it starts off with, uh, dissection of the iliac vessels. This is the external iliac vein, which is being dissected free. And the external iliac artery next to it. So we just mobilize enough length for the anastomosis. Here's the arteries being dissected. External iliac vein is then clamped. Kidney is inserted. Um, we make up anotomy to match in size the renal vein diameter, and then we proceed with the end to side renal vein to external iliac vein anastomosis using continuous sixogoretex suture. Back wall is done and now the front wall is completed. Sutures tied, bulldog is placed and clamps are removed from the external iliac vein. Artery artery is made in the external iliac artery and then we proceed with the renal artery to external iliac artery anastomosis and, um, uh, sixtal cortex suture is also used for this. Same technique, first the back row, then the front row. Of the front wall Steroids have been administered at this point, um, and then the kidneys reperfused. Ultrasound is done to confirm good flow. This is the view after reperfusion, the anastomosis, and then we proceed with the bladder anastomosis. Uh, the ureter has been spatulated. It's anastomosis of the bladder. A single stent is placed, and then full thickness bites are taken on both sides. Um, sort of, um, mucosa, mucosa, anastomosis is performed. This is the final, uh, post-op course. The patient had excellent function of both grafts, had a little bit of delirium, uh, which persisted. Um, was discharged to rehab on day 12 without any complications. Uh, this is the final view of the incisions at two months. He's healed pretty well, remains complication free, uh, to date. Thank you.
