Ontogeny of a surgical technique: Robotic kidney transplantation with regional hypothermia

• We provide a first-hand account of the evolution of a new surgical procedure.
• We demonstrate that the evolution of a surgical technique is a continuous process.
• We however note that the vast majority of changes occur early in the life-cycle of a procedure.
• Development of a surgical procedure beginning with pre-clinical trial may mitigate patient harm.

IntroductionInnovation is a hallmark of surgical practice. It is generally accepted that a new procedure will undergo technical changes during its evolution; however, quantitative accounts of the process are limited.MethodsMultiple groups, including our own, have recently described a minimally-invasive approach to conventional kidney transplantation (KT) operation. Unique to our experience is a structured development of the technique within the confines of a safe surgical innovation framework – the IDEAL framework (idea, development, exploration, assessment, long-term monitoring; stages 0–4). We here provide a first-hand narrative of the progress of robotic KT operation from preclinical trial to clinical application.ResultsOverall, 54 patients underwent robotic KT with regional hypothermia successfully. Major technical changes including selection of optimal patient position (flank vs. lithotomy), robotic instrumentation, vascular occlusion method (bulldog vs. tourniquet) and suture material (prolene vs. GoreTex) occurred early during the procedure development (IDEAL stage 0, preclinical). Minor technical changes such as utilization of the aortic punch for arteriotomy (case 3), use of barbed suture during ureteroneocystostomy (case 6) and extraperitonealization of the graft kidney (case 6) that increased the efficiency and safety of the procedure continued throughout procedure development (IDEAL stages 1–2, clinical stages).ConclusionsWe demonstrate that a surgical technique evolves continually; although, the majority of technical alterations occur early in the life-cycle of the procedure. Development of a new technique within the confines a structured surgical innovation framework allows for evidence based progression of the technique and may minimize the risk of harm to the patient.