title: Ontogeny of a surgical technique: Robotic kidney transplantation with regional hypothermia.
abstract: BACKGROUND
  Innovation 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.
  
  
  METHODS
  Multiple 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.
  
  
  RESULTS
  Overall, 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).
  
  
  CONCLUSIONS
  We 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.
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA. Electronic address: asood1@hfhs.org.
authors.forename: Akshay
authors.initials: A
authors.lastname: Sood
authors.affiliation: Nuffield Department of Surgery, University of Oxford, Oxford, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
authors.affiliation: Department of Urology, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Philipp
authors.initials: P
authors.lastname: Dahm
authors.affiliation: Kidney and Urology Institute, Medanta - The Medicity, Gurgaon, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Ahlawat
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Wooju
authors.initials: W
authors.lastname: Jeong
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Mahendra
authors.initials: M
authors.lastname: Bhandari
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods; D007668:Kidney / Q000601:surgery; D016030:Kidney Transplantation / Q000379:methods* / Q000639:trends; D008297:Male; D008875:Middle Aged; D065287:Robotic Surgical Procedures / Q000379:methods* / Q000639:trends
keywords: IDEAL; Kidney; Minimally-invasive; Surgical innovation; Transplantation