Fifteen-year-old Dibali did not know she was living in one college about two years ago. She had a dull, long-lasting pain on her left flank in and out as she was growing up. But she has been in so much pain for the past two years that it will only last 10 minutes. Only when the frequency of these attacks increased did I consult a doctor. That’s when she found out she was born with a developmental abnormality that caused her kidneys to fuse together on the left side. Which means that she technically has one kidney and not a healthy kidney. Not only that, she had a cyst the size of a tennis ball, which doctors at BLK-Max Super Specialty Hospital have now removed through robotic surgery, saving her unique kidney, avoiding a transplant and giving her a new life.
“This was one of the most complex cases to deal with in my 30 years as a surgeon,” said Dr. Surender Dabas, Senior Director and HOD, Surgical Oncology and Robotic Surgery, BLK- Max Super Specialty Hospital. Deepali was born with a kidney embedded in the left side of her body and for practical purposes she did not have the right kidney. She had a large cyst (10 x 10 cm) in that merging kidney, which required immediate surgical intervention. To make matters worse, the cyst was very difficult to locate because it was sitting on an overlapping area of the ureters, renal arteries, and venules. Not only that, the renal vessels and ureters had mixed abnormally with the cyst and injury to any of these structures would have been disastrous for the patient. A slight tilt here and there and the single college will be destroyed. We’ll have to remove it after that, then go for a transplant and limit her to a lifelong protocol of immunosuppressants. Our challenge was to open the kidney, remove the tumor completely to prevent it from recurring and sew it up again without damage. Due to the precision of the surgery, we had to stop the renal artery for some time, and we only had a window of 12-20 minutes. That’s why I chose high-precision robotic surgery. Not only were we able to accurately perform it, but we were able to save the kidneys, says Dr. Dabas, who has done 20 years of cancer surgery and ten years of robotic surgery. And in all these years, he has not come across a case as complex as that of Debaly.
“I have successfully performed robotic resection of the cystic mass. Using robotic technology, and microdissection of the surrounding structures, blood vessels and ureters, the team was able to successfully dissect the cystic mass with minimal blood loss and preservation of the surrounding structures,” Dr. Dabbs explains.
The case was also challenging due to the baby’s smaller size and smaller stomach, but thanks to the robotic surgery, she recovered quickly without any postoperative complications and was discharged from the hospital on the fourth postoperative day. “She now has minimal scarring and her follow-up is good,” says Dr. Dabbs.
Para-pelvic renal cysts are usually located on the hilum of the kidney and can over time put pressure on the renal pelvis, blood vessels, other organs, and lymphatic vessels. This can lead to increased nephritis, renal vascular hypertension, and eventually kidney failure. Because Dibali had an integrated kidney, she developed serious complications if treatment was delayed.
Talking about the status of robotic surgery as a life-saving option, Dr. Dabas said that Deepali did not have many options in traditional laparoscopic surgery. “Firefly technology allows us to send a dye to the target part of the body which is why we got a very clear view of the cyst. The robotic arm has more maneuverability than the human arm and can make cuts with great precision.”
Arguing the widespread use of robotic surgery in general hospitals and surgeon training, says Dr. Dabas, “The cost of robotic surgery is gradually coming down and is now covered under medical insurance. Besides, the technology changes every two to three years to become more accurate, easy and controlled.” If we do not accept or encourage the widespread use of technology, we will miss out on surgeries like this where we can give a young girl a second chance at life. It is heartening that many government hospitals in South India are using robotic technology.”