Is there a role of robotic surgery in abdominal organs transplantations?

Abstract

Abdominal organs transplantations represent the only potentially curative treatment in several end stage-diseases, but despite the improvement of the surgical techniques and the overall good outcomes, the invasiveness of these procedures is still very high. Therefore, the possible application of minimally invasive surgery in this field would be of great interest. Until a few years ago this application was not even considered because of the kinematic limitations of laparoscopy which makes very challenging to carry out the reconstructive phases of the transplant. Instead, more recently, since the successful introduction of the da Vinci Surgical System, the possible application of robot-assisted Surgery (RAS) in organ transplantation has become a reality [1]. Indeed, with RAS, several limitations of laparoscopic technique for minimally invasive surgical procedures have been overcome, particularly with its latest version, the da Vinci Xi, capable to ensure an easy docking, a wide range of motion with its small, thin arms, the ability to attach the endoscope to any arm, and a highly flexible access to different anatomical regions [2]. Thus, thanks to these features, the execution of vascular anastomoses has become feasible, offering a new impetus in proposing a minimally invasive approach to patients suitable for an abdominal solid organ transplantation. However, although the technical feasibility of RAS to certain abdominal transplantations procedures has been recently demonstrated by several groups [1], we think that its use in this field is still affected by some main limitations that prevent its wide diffusion. In fact, the first critical issue is related to the donor organ’s insertion and manipulation through a narrow incision, with the associated risk of organ damage and/or difficult positioning. Furthermore, this limitation together with the longer execution time of vascular anastomoses, could negatively impact on the ischemia time, the reduction of which is instead crucial, especially nowadays that organs procurement from deceased marginal donors is becoming more and more frequent to shorten the continuously growing waiting lists [3, 4]. For all these reasons, although dedicated clinical postoperative follow-up strategies [5, 6] and optimized immunosuppressant therapies [7, 8] have contributed today to very good outcomes in abdominal solid organs transplantations even with marginal donors, the reduction of operative time for the reconstructive phase is still a major critical factor, and can represent a major limitation for a wide application of RAS. Finally, the use of RAS for organ transplantations on a wider scale could clash with two other non-clinical fundamental matters, such as the necessity of a continuous availability of the robotic system for a non-elective surgery and the economical sustainability of this approach [9]. In conclusion, we think that RAS in transplant surgery is an appealing and promising technique, and without any doubt it represents an open window out to the future, but today it is still far to become the new standard approach, particularly for deceased donor organs transplantations.