The primacy belongs to the specialists of the Ismett of Palermo. Assisted by colleagues from Pisa, in 2012 they were the first in Italy to perform a liver transplant from a living donor with robotic surgery. The only precedent, on that date, however, bore an Italian signature at the bottom. The one of Pier Cristoforo Giulianottiwhich a few months earlier in Chicago had paved the way for this perspective, described in an article in the magazine Transplant International. After Palermo, Italy made an “encore”. The protagonists, this time, are the white coats of the Modena polyclinic, where on October 13 a 36-year-old man donated half of his organ to his mother: a 68-year-old woman suffering from liver cancer.
All stages with the robot
All the phases of the intervention – from the removal of the organ from the donor to the re-implantation in the recipient, for a total duration of eight hours and fifteen minutes – were carried out with the Da Vinci robot. That is the most accurate evolution of laparoscopy. An approach already widespread in resections of part of the organ, due to an oncological disease. But still quite rare in the field of transplants, where the advent is considered of no small importance. Both for the donor, who in this case was discharged just 48 hours after the collection. Both for the recipient, who returned home in six days after being subjected to a very delicate operation: with unprecedented accuracy.
Living liver transplant: in Italy just over 200 in 10 years
Globally, there are no official figures. What is certain, however, is that up to now the use of robotic surgery in living liver transplants has remained an exception in our country. For two reasons, basically. The interventions of this type from living donors are on the increase, but in Italy they still represent a small part of the total transplants of this organ. Specifically, in 2021 there were 37: out of 1,359, almost all of which were carried out in the open air. Since 2012, 201: of which 140 on children. The second reason refers to the use of robots in this area of surgery, more widespread in Asian countries (Korea, India) and the Middle East (Saudi Arabia): where technology has progressed hand in hand with the spread of the culture of donation. while living (accentuated in Buddhist and Shinto countries).
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The most complex surgical procedure ever
In our country – with such a limited diffusion: subjecting a healthy person to surgery to remove a portion of his organ remains a challenge yet to be won – skills are concentrated in a few centers. This is logical, since liver transplantation is described as the most complex surgical procedure ever. Living donor interventions are mostly carried out at the Bambino Gesù Pediatric Hospital in Rome and at the Ismett in Palermo. In 2021, as documented by the report of the National Transplant Center, the numbers of the Modena center have grown a lot (7 live interventions). A path, the one carried out in the Emilian polyclinic, which culminated with the intervention a few weeks ago.
In living transplantation, the health of the donor comes first
To coordinate the first intervention carried out with robotic surgery was Fabrizio Di Benedetto, director of oncological, hepato-bilio-pancreatic surgery and liver transplants: “The robotic approach makes it possible to improve the quality of life of donors and to maintain the same very high safety standards required in living donation. In particular, thanks using the robot, we can resort to small skin incisions respecting the integrity of the abdominal wall and extracting the half liver from a small incision above the pubis: similar to that made during a caesarean section “. By doing so, the surgical and aesthetic impact of the intervention is minimized. But above all, the family member who has chosen to donate the organ to a relative with an advanced liver disease is allowed to quickly resume their routine. The program foresees that the donor is subsequently followed on an outpatient basis.
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A procedure to be limited to a few centers (with great experience)
“This result demonstrates the efficiency of the Italian transplant system,” he adds Ugo Boggi, director of the operative unit of general surgery and transplants of the hospital-university of Pisa and president of the Italian Society of Organ and Tissue Transplantation, which met yesterday in Trieste for the national congress. The use of robotics in the field of transplants is only possible if there is a vast experience of minimally invasive surgery: in the field of oncological or general surgery. And it is of great importance especially for donors, healthy subjects who undergo surgery with a gesture of great generosity. “The maximum technical and technological effort must be reserved for them to maximize global results”, is the thought of the specialist, who ten years ago was in the Ismett operating room, where the first living liver transplant with procedure was completed. robotic.
For which interventions is the robot used?
The use of the Da Vinci Robot – in Italy present in over 100 hospitals, even if some structures are already choosing more recently developed devices – has revolutionized rather wide areas of oncological surgery. Urologists were the forerunners: with interventions on the kidneys, prostate and bladder. Then it was the turn of gynecologists and abdominal surgeons, now ready to resort to the maximum evolution of laparoscopy also for the treatment of benign diseases.
Operating field ten times larger
The Robot uses a 3D video camera which, once it enters the abdomen, enlarges the operating field up to ten times. Thus, despite having only made a couple of holes in the patient’s abdominal wall, the surgeon achieves stable, high-definition vision. The camera is placed at the end of one of the four arms on the Robot. While the other three are connected to the surgical tools needed during the operation. The surgeon follows all the phases of the operation from the operating room. But he is away from the patient and performs the operation by controlling the robotic arms that “move” on the patient’s body from the console. In this way, physical effort is reduced and the risk of tremors is eliminated.
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More accurate sutures
The greater accuracy in the sutures, especially when dealing with a deep and highly vascularized organ such as the liver, also reduces the risk of bleeding. “Robotic surgery has recently entered the field of transplants, but it is here to stay”, is the synthesis of the thought expressed by an international group of surgeons in a meta-analysis published in the “Journal of Clinical Medicine“.” Laparoscopy has limitations in this area. Robotics takes up all the steps of open surgery in a closed abdomen. And with the advantage of minimally invasive “. According to Boggi” the robot is not yet a frontier for all transplants, but it could also find space in uterus and lung transplants: especially when a child receives the organ of an adult ” .
More bodies are needed to bring down the waiting list
There is also another reason why it is worth trying to consolidate this trend. “Reducing the impact of surgical removal on the donor as much as possible is a fundamental incentive to convince more and more people to donate even while they are alive – he explains. Massimo Cardillo, at the helm of the National Transplant Center -. The hope is that these results obtained also in Italy represent a starting point for the other centers in our country. The goal is to reduce the list of over a thousand patients waiting for a new liver. “A figure that is destined to remain at least constant, in light of the broadening of the indications for which organ transplantation can be used. , the treatment of tumors, for which organ replacement today seems to be the most effective therapeutic solution.
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To this we must add that, in Modena, a clinical study has started to evaluate the efficacy of transplantation in the treatment of liver metastases caused by colon cancer (in a selected category of patients). The first surgery of this type was carried out in July. But considering the numbers of the latter disease (almost 44 thousand diagnoses made in 2021) and the frequent spread to the largest organ in our body, it is reasonable to imagine that in the coming years many more patients may need a transplant.
Living donation is also a reality for the kidney
The theme of living donation also concerns another organ: the kidney. As confirmed by a study just published in the journal Jama Network Open the procedure has a better impact on the survival of patients with chronic renal failure than dialysis. And, as shared by the scientific community during the last congress of the Italian Society of Nephrology, it should already be encouraged as the first hypothesis of organ replacement therapy. When a patient has not yet finished on dialysis. In 2021, in Italy, 341 successful transplants were possible thanks to the donation of the organ from a living person.
What happens elsewhere
A figure never obtained before, but that can be improved if we look at what is happening in other countries, including in Europe: such as Holland, the United Kingdom, Spain and France. In addition to the cultural awareness of the population, the improvement of this performance also includes the spread of minimally invasive nephrectomy using robots. “Living donation represents a great opportunity to expand the number of transplants – concludes Boggi -. The studies already available tell us that the risk of death for those who donate is low, but it is still important to keep track of adverse events to make a correct communication”.