Robot-assisted renal artery aneurysm repair with a saphenous vein Y-graft interposition

Robotic Surgery for Elective Repair of Visceral and Renal Artery Aneurysms: A Systematic Review

Background: The treatment choice of visceral artery aneurysms in an elective setting is debated. The durability and the risk of reintervention with endovascular treatment are still reasons for concern, whereas open surgery is invasive and burdened by major complications. In anecdotal reports and isolated studies, robotic-assisted surgery seems to provide the possibility of a minimally invasive treatment and the durability of traditional open surgery, but the literature supporting this view is scarce. This review aims to collect the results of robotic-assisted surgery in the treatment of visceral artery aneurysms. Methods: A systematic search of the main research databases was performed: the study endpoints were mortality and conversion rates, perioperative morbidity, and freedom from late complications and reinterventions. Results: We identified 16 studies on 53 patients. All cases underwent successful resection, with three conversions to laparoscopy. Perioperative and aneurysm-related mortality were nil. Over a median follow-up of 9 months, two reinterventions were reported (3.6%). Conclusion: The robotic technique is safe and effective in treating splenic and renal artery aneurysms, and it should be considered as a valuable alternative to endovascular and open repair, although larger sample sizes and a longer-term follow-up are necessary to confirm such results.

Robot-Assisted Laparoscopic Retroperitoneal Renal Artery Aneurysm Repair: A Rare Case Report and Literature Review

INTRODUCTION

The treatment of renal artery aneurysms (RAAs) includes surgical repair and endovascular techniques. Surgical repair is divided into open surgery repair and laparoscopic surgery repair. Laparoscopic RAA has fewer postoperative complications than open surgery. Some experiences with robotic RAA repair via transperitoneal access have been recently reported. However, no report could be found on the treatment of retroperitoneal RAA with the da Vinci robot-assisted surgery thus far.

CASE PRESENTATION

Here, the surgical management of an 8.6-mm right-sided RAA via robot-assisted laparoscopic retroperitoneal approach in a 58-year-old man who presented with flank discomfort is reported. The aneurysm was resected, and the renal artery was reconstructed. The total operative time was 2 h with a warm ischemia time of 25 min, and the estimated surgical blood loss was 50 mL. The patient resumed a regular diet on postoperative day 2, and the hospital stay lasted 5 days. No intraoperative nor postoperative morbidity was reported. Follow-up imaging and functional analysis demonstrated resolution of the aneurysm and preservation of renal function after 2.5 months.

CONCLUSIONS

Robot-assisted laparoscopic retroperitoneal RAA repair is flexible and safe. The greatest advantage of retroperitoneal surgery is direct access to the renal artery. Furthermore, it could reduce the injury in the abdominal organs and avoid abdominal adhesion. This approach may also allow for improved postoperative recovery, reduce the morbidity correlated with transperitoneal RAA, and thus may be considered as an alternative to transperitoneal surgery for RAAs in the future.

Robotic Surgery For in situ Renal Artery Aneurysm Repair: Technical Note and Literature Review About a Mini- Invasive Alternative

CASE REPORT

Classical surgical options for renal artery aneurysm (RAA) are usually restricted to endovascular surgery or open repair, either using an in-situ or ex-situ approach. A 45-year-old woman presenting with a 20-mm complex RAA with hilum location, not suitable for endovascular repair renal was treated with a mini-invasive robotic approach. This approach allowed an in-situ reconstruction in a complete mini-invasive manner with the Da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA). The robotic system was used for both surgical exposure and aneurysmectomy with patch closure. Clamping time was 38 minutes (warm ischemia), total operative time was 210 minutes.

LIITERATURE REVIEW

A comprehensive literature review was performed concerning the studies reporting a robotic approach for RAA. Main outcomes of interest were surgical technique, total operative time, clamping time, blood loss and postoperative renal function. Seven studies were identified, reporting a total of 20 RAAs. Most of the RAA were treated by aneurysmoraphy (n=9). Median total operative time varied between 228 and 300 min (range: 155 - 360 minutes), median clamping time varied between 26 and 44 minutes (range: 10 - 82 minutes). Median blood loss was comprised between100 and 150 mL (range: 25 - 650 mL). No alteration of renal function in the early post-operative period was reported.

CONCLUSION

RAA in-situ repair with a robotic approach is feasible and safe and should be considered as an alternative to open surgical repair when endovascular technique cannot be an option.

Robotic Renal Artery Aneurysm Repair

BACKGROUND

Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques.

OBJECTIVE

To report our experience with robotic RAA repair.

DESIGN, SETTING, AND PARTICIPANTS

Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs.

SURGICAL PROCEDURE

Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8-3)cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n=5), excision with end-to-end anastomosis (n=2), aneurysmectomy with branch reimplantation (n=1), prosthetic interposition graft repair (n=1), and simple nephrectomy (n=1; this patient's data were excluded from analysis).

MEASUREMENTS

Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy.

RESULTS AND LIMITATIONS

All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3-6)h, warm ischemia time 26 (19-32)min, hypothermic renal perfusion time 34 (29-69)min, and estimated blood loss 100 (25-400)ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2-6)d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2-67)mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study.

CONCLUSIONS

Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs.

PATIENT SUMMARY

We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise.