V04-01: Robotic Assisted Left Renal Vein Transposition
We present a video of a robotic assisted left renal vein transposition to treat a patient with renal nutcracker syndrome (RNS).
A healthy 19 year old female with a BMI 19 kg/m2 presented with a 2 year history abdominal pain without a discernable etiology. She underwent an extensive work up including abdominal duplex ultrasound (US), computed tomography (CT), magnetic resonance imaging, endoscopy, and psychiatric evaluation. A follow up CT later demonstrated worsening compression of her left renal vein by the superior mesenteric artery (SMA) in the absence of other etiology. A left renal venogram demonstrated a 70% stenosis, and a pressure gradient of 3mmHg. Multiple large venous lumbar collaterals were also seen. Intravascular US identified vascular webs and confirmed chronic venous compression.
After induction of general anesthesia, the patient was placed in a modified lithotomy position. Standard sterile prep and drape was performed. Six robotic ports were inserted in the bilateral lower abdomen (two 12mm, four 8mm). She was placed in steep Trendelenburg. The robotic surgical system was docked and connected to the ports. The small bowel was retracted cephalad and to the left upper quadrant. The base of the small bowel mesentery was incised. The retroperitoneal space was developed. The left renal vein was mobilized. The left adrenal and gonadal veins were divided with a vessel sealing device and a vascular stapler respectively. Vascular control of the suprarenal inferior vena cava (IVC), infrarenal IVC, and right renal vein were obtained with vessel loops. Lumbar veins were ligated and divided selectively. Intravenous heparin was given. The left renal vein was clamped near the hilum with a bulldog clamp. The renal vein was then transected at the confluence with the IVC with a small cuff of the IVC and closed with 5-0 prolene suture in running fashion. Vascular webs were excised from the intima of the renal vein. The left renal vein was then re-anastomosed to the IVC more distally in a tension free end-to-side fashion with a running 5-0 prolene suture. The patient was discharged on post-operative day 1. At her one week postoperative visit, she demonstrated a full recovery from her surgery and reported significant improvement in her abdominal pain. At 2 months she reported no recurrent of her symptoms.
Robotic assisted left renal vein transposition is a feasible surgical technique to treat patients with this condition.