Robot-assisted laparoscopic repair of renal
artery aneurysms
Pier Cristoforo Giulianotti, MD,a Francesco Maria Bianco, MD,a Pietro Addeo, MD,a
Antonella Lombardi, MD,b Andrea Coratti, MD,b and Fabio Sbrana, MD,a Chicago, Ill; and Grosseto, Italy
Objective: The aim of this article is to report our experience in the repair of renal artery aneurysms using robot-assisted
surgery.
Methods: Between December 2002 and March 2009, five women with a mean age of 63.8 years (range, 57-78 years)
underwent robot-assisted laparoscopic repair of renal artery aneurysms by the same surgeon at two different institutions,
the Department of General Surgery, Misericordia Hospital, Grosseto, Italy (three patients) and the Division of Minimally
Invasive and Robotic Surgery at the University of Illinois, Chicago (two patients). The mean size of the lesions was 19.4
mm (range, 9-28 mm). Four of the lesions were complex aneurysms involving the renal artery bifurcation. Two patients
were symptomatic and three had hypertension. In situ repair by aneurysmectomy was performed in all cases, followed by
revascularization. In complex aneurysms, an autologous saphenous vein graft was used for the reconstruction.
Results: The mean operative time was 288 minutes (range, 170-360 min) and the estimated surgical blood loss was 100
ml (range, 50-300 ml). Warm ischemia time was 10 minutes in the patient treated by aneurysmectomy, followed by direct
reconstruction. The average warm ischemia time was 38.5 minutes (range, 20-60 min) for patients treated with
saphenous vein graft interposition. The mean time to resume a regular diet was 1.6 days (range, 1-2 days). The mean
postoperative length of hospital stay was 5.6 days (range, 3-7 days). No postoperative morbidity was noted. The mean
follow-up time for the entire series was 28 months (range, 6-48 months). Color Doppler ultrasonography examination
showed patency in all reconstructed vessels. One patient had stenosis of one of the reconstructed branches, which was
treated with percutaneous angioplasty.
Conclusions: Robot-assisted laparoscopic repair of renal artery aneurysms is feasible, safe and effective. The technical
advantages of the robotic system allows for microvascular reconstruction to be performed using a minimally invasive
approach, even in complex cases. This approach may also allow for improved postoperative recovery and reduce the
morbidity correlated with open repair of renal artery aneurysms. Although more experience and technical refinements are
necessary, robot-assisted laparoscopic repair of renal artery aneurysms represents a valid alternative to open surgery.
( J Vasc Surg 2010;51:842-9.)
Renal artery aneurysms (RAA) are a rare occurrence
with a reported incidence by angiographic studies varying
from 0.6% to 1.0%. Most of these lesions are asymptomatic
and are detected in patients during radiologic studies for
hypertension.1,2 Indications for treatment are based on
several factors including operative risk, presence of local
symptoms, hypertension, and anticipated pregnancy in
women; as well as anatomical features of the RAA such as
size.3,4 Treatment for RAA involves endovascular techniques and surgical repair, depending on the location of
aneurysm along the renal artery. For complex RAA located
at renal artery bifurcation, and for those involving distal
From the Division of General, Minimally Invasive, and Robotic Surgery,
Department of Surgery, University of Illinois at Chicago,a and the Department of General Surgery, Misericordia Hospital, Grosseto.b
Competition of interest: none.
Reprint requests: Pier Cristoforo Giulianotti, MD, Division of General,
Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood St., Ste. 435 E, Chicago, Illinois 60612 (e-mail:
piercg@uic.edu).
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline
review of any manuscript for which they may have a competition of
interest.
0741-5214/$36.00
Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.
doi:10.1016/j.jvs.2009.10.104
842
branches, open surgical repair by in situ or ex vivo repair,
respectively, represents the gold standard of treatment.5-7
In an effort to reduce the invasiveness and morbidity
associated with open surgical RAA repair, the laparoscopic
approach has been proposed as a possible alternative. However, the latter technique has not gained widespread acceptance due to the technical limitations of laparoscopy. For
this reason, only a few cases have been reported in the
literature.8,9
Over the last 10 years, the use of a robotic system has
significantly augmented the surgeon’s dexterity in performing complex minimally invasive procedures. The application of the robot in the field of vascular surgery has largely
been reported for aortic and cardiac surgery,10,11 yet remains poorly applied for RAA repair.12 In this article, we
describe our experience using robot-assisted surgery for
laparoscopic repair of five RAA.
METHODS
Between December 2002 and March 2009, five patients with RAA underwent robot-assisted laparoscopic
repair by the same surgeon (PCG) at two hospitals. Three
of the five were performed at the Department of General
Surgery, Misericordia Hospital in Grosseto, Italy (from
December 2002 to April 2007), and the other two were
performed at the Division of Minimally Invasive and Ro-
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Volume 51, Number 4
Giulianotti et al 843
Table I. Demographic data and aneurysm characteristics
Patient
Associate conditions/risk
factors
Aneurysms
(dimension-side)
Renal pain
Nephrolithiasys, hypertension
18 mm-Rt
III
Renal pain
Hypertension
20 mm-Lt
F/57
F/59
II
II
Solitary kidney
—
28 mm-Lt
09 mm-Rt
F/66
II
Incidental
Incidental (candidate
for LKD)
Incidental (lower
right back pain)
First posterior right
arterial branch
Main trunk of renal
artery
First order bifurcation
First order bifurcation
Hypertension, diabetes,
Hypercholesterolemia,
degenerative joint disease
22 mm-Lt
First order bifurcation
Gender/age
ASA
1
F/78
II
2
F/59
3
4
5
Symptoms
Location along the course
of the renal artery
ASA, American Society of Anesthesiology Classification; LKD, living kidney donation; Lt, left; Rt, right.
botic Surgery of the University of Illinois, Chicago (from
April 2007 to March 2009). Patients who presented with
RAA at the two centers during the study period were
routinely considered for the minimally invasive robotic
approach. Presence of associated abdominal aortic aneurysms, ruptured lesions, or specific contraindication to laparoscopy (American Society of Anesthesiologists [ASA] status IV, cardiac or respiratory insufficiency) were considered
as exclusion criteria to robotic repair. Presence of solitary
kidney or previous abdominal surgery was not considered
part of the exclusion criteria.
Medical records of the five patients were retrospectively
reviewed for patient demographics, preoperative symptoms, location and size of the lesions, operating time,
morbidity, duration of hospital stay, and follow up. Table I
lists the demographic and baseline variables, as well as
aneurysm characteristics. All patients were female, with a
mean age of 63.8 years (range, 57-78 years). Two patients
with RAA were symptomatic for flank pain. One was affected by nephrolithiasis, and, upon investigation for sudden onset of flank pain, a right renal aneurysm was discovered. The patient was hospitalized and an abdominal
computed tomography (CT) scan revealed a single right
renal stone as well as a right renal aneurysm. During her
hospital stay, the patient spontaneously passed the kidney
stone following medical therapy and underwent surgery
two weeks later. Lesions were incidentally discovered in the
other patients during radiologic investigation for coexisting
disorders (solitary kidney since birth and back pain due
to degenerative joint disease) or during a preoperative
work-up for possible living kidney donation. Three patients
had preoperative diagnosis of hypertension. Hypertension
was defined as systolic blood pressure ⱖ140 mm Hg,
diastolic pressure ⱖ90 mm Hg, or the use of antihypertensive medications. Blood pressure response after interventions was estimated using the American Heart Association
guidelines.13
Three aneurysms affected the left renal artery and two
affected the right one. One aneurysm was located along the
main renal artery trunk and four were complex aneurysms
located at the main artery bifurcation or beyond. (Fig 1) At
the preoperative radiologic work-up, the mean size of the
aneurysms was 19.4 mm (range, 9-28 mm).We elected to
repair RAA in three patients because of aneurysm size and
hypertension. The fourth repair was performed due to the
presence of solitary kidney, and the fifth to kidney donation. According to the American Society of Anesthesiology
classification, the status of four patients was ASA II and
ASA III in one patient. Patency of repair was evaluated
during follow up using color Doppler ultrasonography
(US). One patient had an MRI one year after the repair (Fig
2) and another had an abdominal CT scan six months
following the repair. Blood pressure status, dosage of hypertension medications, and status of renal function were
also evaluated.
Surgical technique. In all cases, robot-assisted laparoscopic RAA repair was performed using the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif). Technical details regarding the use of these robotic systems have
previously been reported.14 Patients were placed in a 30degree left (or right) semidecubitus position, according to
the lesion side. A Verres needle was inserted in the left
hypocondrium to insufflate the abdomen to 14 mm Hg.
The initial 12-mm trocar was placed in the right (or left)
pararectal line, at the supraumbilical side, for the 30-degree
telescope. Two 8-mm robotic ports (for the operative
robotic arms) were placed in the right (or left) iliac region
and epigastrium, respectively. An 8-mm port (fourth arm)
was then introduced in the right (or left) flank and a 12-mm
port served as an assistant instrument in the mesogastrium.
The robotic cart was placed behind the patient’s left
shoulder and docked to the robotic ports (Fig 3).
For the right RAA, the procedure was initiated using a
robotic monopolar hook and an ultrasound dissector, with
mobilization of the right colonic flexure. After incising the
posterior peritoneum overlying the lateral aspect of the
duodenum, the duodenal loop and the pancreatic head
were mobilized and gradually retracted medially until the
right renal hilum was exposed. For the left RAA, the left
colonic flexure was mobilized by incising the splenocolic
ligament and detaching the insertion of the mesocolon at
the inferior border of the pancreas. The posterior aspect of
the left pancreas was dissected free by its posterior attachments and reflected medially by the fourth robotic arm
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April 2010
844 Giulianotti et al
Fig 1. Schematic drawing of RAA aneurysms location and type of repair performed. (A) Patient 1; (B) Patient 2; (C)
Patient 3, 5: (D) Patient 4.
until the renal hilum was exposed. The renal vein was
dissected and looped for vascular control. The proximal
renal artery was then completely isolated and surrounded
with tape.
The aneurysms were accurately and cautiously isolated,
taking care to recognize all branches directed from the
aneurysm to the renal parenchyma. The dissection was
carried out until complete control of the distal branches was
achieved. After stopping the pneumoperitoneum in anticipation of the vein graft for vascular reconstruction, an 8-10
cm saphenous vein graft was procured from the right groin.
This was fashioned using an ex-vivo bench technique so as
to make a Y-shaped graft using a running suture of Prolene
6/0 to anastomose one sidearm to the main graft and then
introduce it using Endo Catch (Covidien AG, Mansfield,
Mass) through the 12-mm assistant’s port. After administration of mannitol, furosemide, and systematic heparin,
laparoscopic clamps (Aesculap, Center Valley, Pa) were
placed proximally on the main renal artery and distally
(main renal artery and first-order or second order branches,
respectively), and aneurysmectomy was performed. Reconstruction was achieved in one case by an end-to-end anastomosis between the two edges of the main renal artery
using a single running polytetrafluoroethylene (PTFE) suture (CV-6 GORE-TEX; W.L. Gore & Associates, Flagstaff, Ariz). In the four remaining cases, the reconstruction
was achieved by the interposition of the saphenous Y graft
using continuous PTFE sutures (CV-6/CV-7, TTc-9 needles GORE-TEX) (Fig 4).
In order to minimize the warm ischemia time, the
kidneys were partially reperfused, once anastomosis be-
tween the main renal artery and one peripheral branch was
completed, and while the third anastomosis was being
performed. In one patient (Patient 4; Table II) with three
separate first-order renal branches originating from the
aneurysm, two branches were tailored and sutured together
to create one common orifice. It was then anastomosed to
one saphenous branch. Aneurysm specimens were retrieved
using an Endo Catch through the assistant’s port. Color
Doppler ultrasound (US) was used intraoperatively to assess the correct quality of reperfusion.
RESULTS
The operative data are summarized in Table II including type of reconstruction, use of the fourth robotic arm,
operative time, warm ischemia time, estimated blood loss,
and length of hospital stay. The overall mean operative time
(defined as the time from initial skin incision to the final
skin stitch) was 288 minutes (range, 170-360 min) and the
estimated blood loss was 100 ml (range, 50-300 ml). The
warm ischemia time was 10 minutes for the patient requiring an end-to-end reconstruction while the mean warm
ischemia time was 38.5 min (range, 20-60 min) for the
patients who underwent reconstruction with interposition
of a Y saphenous vein graft. The mean time to resume a
regular diet was 1.6 days (range, 1-2 days). The mean
postoperative stay was 5.6 days (range, 3-7 days).
Postoperative serum creatinine levels were normal in all
patients but one (Patient 4; Table II). In this patient, the
postoperative serum creatinine level returned to normal
range by postoperative day three. Symptoms resolved postoperatively in the symptomatic patients and postoperative
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Volume 51, Number 4
Fig 2. Magnetic resonance imaging (MRI) before (A) and after
the repair of right renal artery aneurysms (B).
recovery was uneventful in all patients. At mean follow up
of 28 months (range, 6-48 months), four patients had
normal renal function and showed patency of the reconstructed vessels on the color Doppler examination. One
patient had a stenosis of one of the reconstructed branches
six months after the repair (Patient 5). This was associated
with a raised serum creatinine level from 0.9 mg/dL to 1.2
mg/dL). The stenosis was treated with percutaneous angioplasty. There was no change in the status of hypertension that was recorded. All three patients who had a preoperative diagnosis of hypertension remained at the same
preoperative dosage of medications.
DISCUSSION
In recent years, the diagnosis of RAA has increased,
mainly due to the rising number of radiologic studies
carried out for the study of systemic hypertension. Complications of RAA involve spontaneous rupture, distal embolization, renal infarction, renovascular hypertension, and
arteriovenous fistula. When indicated, possible treatments
for RAA include endovascular therapies such as selective
Giulianotti et al 845
coil embolization or stenting, and open surgical repair. At
dedicated centers, open surgical RAA repair has shown
good long-term clinical outcomes and symptomatic remission in most patients. In spite of a limited mortality, however, open RAA repair has also been associated with significant morbidity in the context of major intrabdominal
surgery.5,15
Among endovascular techniques, stents represent a
possible alternative to surgical repair for RAA because they
allow for organ flow preservation with minimal surgical
trauma and warm ischemia time. Nevertheless, the current
use of stents is restricted to RAA involving the main renal
artery trunk, with edges located at least 15 mm away from
the renal bifurcation and renal ostium.16,17 As a result,
complex RAA that involve renal artery bifurcation, or that
present a wide neck, are not suitable for endovascular repair
because of the associated risks of branch occlusion and renal
infarction. Furthermore, data are still lacking regarding the
long-term patency of this treatment and its superiority as
compared with surgical bypass.
A midline incision is generally used for in situ repair to
allow complete exposure of the aorta, renal arteries, and
kidneys. In ex vivo repair, the kidney may be reimplanted in
orthotopic position or heterotopic position. In the latter
position, some authors use an extended retroperitoneal
approach from the flank (for procuring the kidney) to the
pelvis (for autotransplantation).18
Minimally invasive laparoscopic surgery has been applied recently to the field of vascular surgery to reduce the
operative trauma, diminish postoperative pain complications and hospitalization, and minimize incision-related
morbidity.19 For RAA repair, Gill et al in 2001 performed
a complete laparoscopic repair of RAA located at the renal
artery bifurcation.8 This procedure consisted of bivalving
the renal aneurysms, partially excising the excess aneurysm
sac, and carefully trimming for adjustment to the diameter
of the renal artery. Reconstruction was achieved by suturing the anterior wall using continuous running of nonabsorbable sutures. The same technique was later reported
by other authors.9 More recently, repair of RAA involving
secondary and tertiary renal artery branches using a minimally invasive approach has been reported by different
authors, thus establishing the feasibility of this procedure
and short term outcomes.20,21 This procedure involves
laparoscopic nephrectomy with ex vivo repair and heterotopic autotrasplantation.
The shortcoming of laparoscopy for RAA repair might
be related to the technical limitations of this technique. In
situ repair of complex RAA requires fine dissection in a deep
narrow field, as well as precision and time effective microvascular anastomoses on small caliber vessels. In open
surgery, this would be achieved with the use of magnification and dedicated microsurgical instruments.3 Traditional laparoscopic instruments are not suited for microsurgery, however, because of their length and fulcrum effect.
The natural tremor of the surgeon’s hand is amplified by
the length of instruments, which makes micro-reconstruction difficult, or even impossible.22 The loss of hand-eye
846 Giulianotti et al
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April 2010
Fig 3. Operative room set-up and positioning of ports for left renal artery aneurysms repair. 1: 12-mm trocar for
endoscope; 2: 8-mm trocar for right robotic arm; 3: 8-mm trocar for left robotic arm; 4: 8mm trocar for the fourth
robotic arm; 5: 12mm trocar for assistant instruments.
coordination and the counterintuitive movement of endoscopic instruments represent additional difficulties. The
visual system available in laparoscopy, which consists of an
endoscopic camera, offers two dimensions of view with loss
of depth perception and unsteadiness. Furthermore, during
long operations, the unnatural position assumed by the
surgeon can increase fatigue.
Robotic surgery addresses most of the technical limitations of laparoscopic surgery. The use of the da Vinci
system allows for a more ergonomic approach and recreates
the hand-eye coordination that is lost during laparoscopic
surgery. It also provides improved ergonomics for the
operating surgeon, who is now seated at a surgical console.
The system provides three-dimensional vision which offers
excellent resolution, depth perception, and magnification.
The visual component is steady and under the direct control of the operating surgeon. The availability of a motion
scaling system allows for fine movements and tremor filtering eliminates problem associated with natural tremor. The
seven degrees of freedom afforded by the articulating in-
struments with EndoWrist technology reproduce the exact
movements of the surgeon’s hand, wrist, and fingers. This
allows for precise suturing in all directions. The advantages
of the robot over standard laparoscopy for vascular anastomoses have been reported in experimental studies on aortic
and coronary anastomoses. 23,24 In clinical settings, robotic
technology has a short learning curve with regard to the
creation of aortic anastomosis as compared to conventional
laparoscopic surgery.25 We started to use the robotic da
Vinci Surgical System in October 2000, when it first became available at our institution. Since that time, its application has been extended from general to thoracic and
vascular surgical procedures. We performed the first RAA
robot-assisted repair in December 2002.14,26
The robotic system makes it possible to perform microvascular anastomosis using a minimally invasive approach.
The fourth robotic arm on the system is under the direct
control of the surgeon and allows constant and stable
retraction of the neighboring organs, providing optimal
exposure of the operative field. As a general rule, the total
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Giulianotti et al 847
Fig 4. Endoscopic view of a robot-assisted laparoscopic left renal artery aneurysm repair. (A) Isolation of the
aneurysm; (B) Aneurysmectomy; (C) Anastomosis between the main renal artery trunk and the saphenous vein graft;
(D) Intraoperative view after completing the first two anastomoses; and (E) at the end of the vascular reconstruction.
An, Aneurysm; e, End-to-end anastomoses; f, First order renal artery branches; m, Main left renal artery trunk; s, Second
order renal artery branches; vg, Venous graft.
Table II. Type of renal artery reconstruction and operative data
Patient
Type of renal artery reconstruction
1
Aneurysmectomy ⫹ Y saphenous
vein graft
Aneurysmectomy and E-E
anastomosis
Aneurysmectomy ⫹ Y saphenous
vein graft
Aneurysmectomy ⫹ Y saphenous
vein graft
Aneurysmectomy ⫹Y saphenous
vein graft
2
3
4
5
Operative
time
(min)
WIT
Preoperative
creatinine
(mg/dL)
Postoperative
(day one)
creatinine (mg/dL)
EBL
Fourth
arm
Time to
regular
diet
310
25
0.9
0.8
50
Y
2
170
10
1.1
0.9
300
N
1
300
20
1.0
0.9
50
Y
2
360
60
0.9
1.4
50
Y
2
300
49
0.8
0.9
50
Y
1
E-E, End to end; EBL, estimated blood loss; LOS, length of stay; WIT, warm ischemia time.
absence of tactile feedback using the robotic system has led
us to use PTFE sutures for the reconstruction because they
are less prone to breakage with manipulation as compared
with the polypropylene sutures. This has also been described by others for aortic reconstruction.27
The robotic system facilitates a safe and time efficient
reconstruction in the case of RAA involving the main renal
trunk, and limits the total time of warm ischemia to 10
minutes. For complex aneurysms, we adopted an in situ
repair using a saphenous vein graft interposition. It is
important to note, however, that there are both advantages
and drawbacks of this technique. Complete resection of the
renal artery aneurysm, followed by an autologous graft
interposition, allows for the excision of all diseased arterial
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April 2010
848 Giulianotti et al
segments.28,29 As shown in the description of the technique, and in contrast to the open in situ repair with
autologus saphenous graft, the dissection is limited only to
the renal hilum vessels, thus preserving the perirenal collateral circulation and ensuring a limited residual renal perfusion during the clamping period.30 Additionally, the use of
a branched saphenous graft makes it possible to partially
reperfuse the kidney after the first two anastomoses,
thereby limiting the total clamping period and warm ischemia time. In our experience, this type of repair results in a
mean warm ischemia times of 38 minutes. This long period
of time is not, however, significantly more than those
reported by other authors for laparoscopic RAA repair
which is limited to aneurysm tailoring alone.8,9
Murray et al, in a series of 15 cases of open in situ repair
of RAA, reported a mean renal ischemia time of 45.4
minutes.31 The technique used by these authors, however,
was the aorto-renal bypass with a branched saphenous vein
graft. This technique has the main advantage of limiting the
ischemia time to only a portion of the kidney for the time
required to complete a single end-to-end anastomosis.
Compared with this technique, ours has the drawback of
needing a total warm ischemia time. Furthermore, two of
our four complex RAA cases required additional time due
to the need to reconstruct three distal branches in one
patient and the difficulty in reconstructing a posterior
branch in another patient. Seki et al reported three cases of
RAA repair by in situ technique with a median ischemia
time of 70 minutes. This is not comparable, however,
because of the different techniques of reconstruction required and the systematic use of cold surface cooling.18
In general, the use of renal cold perfusion is recommended when warm ischemia times are expected to exceed
30 minutes. Crutchley et al reported a series of 29 in situ
branch renal artery repairs with a mean cold ischemia time
of 125 ⫾ 40 minutes and a mean operative time of 7.75
hours.32 We did not use a cold renal perfusion because we
expected the ischemia time to be less than 30 minutes.
Unfortunately, this was not the case in two of our cases
where a longer ischemia time occurred.
Some reports have suggested that longer times (⬍1
hour) can be tolerated without clinical consequences33 and
this was our experience in this small series as well. Renal
cooling using an angiographic catheter in the renal artery or
ice slush in a laparoscopic bag has been reported for laparoscopic partial nephrectomies.34,35 However, these approaches can be quite cumbersome and not feasible for the
vascular reconstruction of distal branches. Further development of this technique should be carried out in this direction.
In our series, the mean postoperative stay was 5.7 days.
This length of stay is difficult to compare with historic series
of open RAA repair, as is the mean blood loss, because there
is a lack of data with regard to these parameters in most
major series reported.5,15,32 However, our length of stay
does appear shorter than for those reported in a series of
open surgery repairs for renovascular disease.36 Addition-
ally, no incision-related morbidity has been observed in our
experience.
Of the five patients treated, three had hypertension.
The association of hypertension with RAA has been well
described in the literature.2,5 Apart from the association of
RAA to renal artery stenosis, possible explanations include
segmental ischemia due to microembolization from intraaneurysm thrombus, kinking of the distal renal artery, or
other flow-related phenomenon. In this series, we elected
to repair the aneurysms due to the size and associated
presence of hypertension, and its role on the related risk of
rupture. The rate of cure of hypertension following RAA
repair has been reported and varies from 50% to 100%.3 In
our experience, hypertension was still present following
surgery and we can assume it will remain, based on similar
reports.37 However, because it is only three cases, it is
difficult to say with certainty.
Our experience has several limitations that deserve
comment. First, robotic systems are expensive and, while
we did not perform a cost-analysis for this small group of
patients, we can assume that this kind of repair is more
expensive than open repair. However, with increased use
and wider application of the system, these costs can be
reduced. Furthermore, as the technique is increasingly applied, its benefits in terms of reduced incision-related morbidity and early recovery on a larger basis do have the
potential to reduce costs even more.
At the same time, if the postoperative results in patients
with prolonged warm ischemia time are good, the ability to
use a cold perfusion when needed does represent a technical
challenge that should be addressed and improved upon in
order to allow for a wider application of this technique.
Finally, due to the complexity required, this technique
should be performed in centers with extensive experience in
robotic surgery and renal artery aneurysm repair.
CONCLUSIONS
We report five cases of RAA in which in situ repair with
renal revascularization has been performed with robotassisted surgery. The technical advantages of the robotic
system make it feasible to perform microvascular reconstruction in cases of complex RAA using a minimally invasive approach. This approach can reduce the morbidity that
is associated with open surgery for repair of RAA and can
improve the postoperative recovery. Although more experience and technical refinements are necessary, the robotassisted laparoscopic approach represents a valid alternative
to open surgery for RAA.
The authors would like to thank Ms Karen Dutro and
Mr Sanchit Bathia for the editing of this article and for the
illustrations of this article.
AUTHOR CONTRIBUTIONS
Conception and design: PG, AP
Analysis and interpretation: AP, AL, FS
Data collection: FB, AC, AL
Writing the article: AP, PG
JOURNAL OF VASCULAR SURGERY
Volume 51, Number 4
Critical revision of the article: FB, AL, AC, FS
Final approval of the article: PG, FB, PA, AL, AC, FS
Statistical analysis: PA, AL
Obtained funding: NA
Overall responsibility: PG
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Submitted Jul 28, 2009; accepted Oct 8, 2009.