The Use of Three-Dimensional Augmented Reality During Robot-Assisted Living Donor Nephrectomy: A Case Report Technical Overview

Introduction and Objectives: The aim of this video is to describe the application of augmented reality (AR) technology of three-dimensional (3D) renal model during robot-assisted living donor nephrectomy (RALDN) for a safe and accurate hilum management. Materials and Methods: We present the clinical case of a healthy 29-year-old woman who has met all inclusion criteria for living kidney donation to her male 39-year-old partner affected by end-stage renal disease. A virtual 3D reconstruction of the left kidney based on contrast-enhanced abdominal CT scan was elaborated with D2P™ software: renal parenchyma, urinary collecting system, ipsilateral adrenal gland, and ureter, aorta, main renal artery, and vein with main segmental branches, gonadal and adrenal vein were included in the model. An AR-dedicated workstation was used to intraoperatively match the camera (Da Vinci® Xi/X™ Endoscope) video output with the AR-3D video stream. Processed images were sent back in real time to the surgeon's console through multi-input TilePro™ system. With right lateral position, one 8 mm optic robotic trocar was inserted in the left periumbilical site and pneumoperitoneum was achieved with 12 mm Hg CO2 insufflation. We performed a Pfannensteil incision through which GelPort® system was inserted. Additional two 8 and 12 mm robotic trocars and one 12 mm AirSeal® trocar were placed. Firefly™ Fluorescence was used to verify adequate vascular supply of resected ureter. AR-3D video stream was then used for the exact identification and dissection of renal hilum: the 3D virtual model was manually oriented through the AR-dedicated workstation by the assistant engineer. The overlapped 3D images of the renal model allowed the surgeon to identify the precise anatomy of the renal hilum early and safely. Intuitive endowrist stapler 30® was then used to seal and cut renal artery. Graft harvest was achieved with Applied Inzii Retrieval System® through GelPort® System to assure rapid graft retrieval, minimizing ischemia time. Results: Overall operative time was 270 minutes. Console time was 178 minutes. Time from renal artery division to graft harvest was 2 minutes 56 seconds. Overall ischemia time was 140 minutes (including harvest, back table, and transplant). The patient was discharged 4 days after surgery. Neither early nor late complications were reported; renal function at time of discharge was within normal range. Graft transplantation was effective. Conclusions: The use of AR during RALDN may improve the understanding of renal anatomy, thus facilitating the management of the hilum and enhancing the safety and the chances of an effective kidney transplant. No competing financial interests exist. Runtime of video: 8 mins 27 secs