Patient positioning can be made easier when using a specific operating table that allows for bed movement during the operation (TruSystem^® 7000dV OR Table Package, TRUMPF Medizin Systeme GmbH & Co, Saalfed, Germany); however, a robot-specific operating table is not required. First, the patient is placed supine on the operating table with the right arm on an armboard and the left arm padded and tucked. This position is used if the robotic platform will be docked on the patient’s left side. If the patient is obese or other reasons prohibit tucking the left arm, then the arm can be secured to an armboard with the shoulder abducted. It is important to communicate patient positioning with the anesthesia team, specifically if arms will be tucked, as the anesthesia provider may elect to place additional intravenous access or reposition the blood pressure cuff.

After placement of sequential compression devices, a padded footboard is secured to the bed to prevent the patient from slipping when in reverse Trendelenburg position. Additionally, a strap or tape across the pelvis or upper thigh is used to secure the patient to the bed. Usually, a lower body-warming blanket is used to maintain the patient’s temperature during the operation. An orogastric tube to decompress the stomach and a urinary catheter to decompress the bladder may be placed at the discretion of the surgeon. Caution is encouraged knowing that there may be significant difficulty in cases of gastric volvulus. Once the patient is secured to the bed, it is advisable to place the patient in steep reverse Trendelenburg to assure there is no undue pressure on extremities or shifting of patient position before the bed is again leveled and the abdomen prepped. As a routine, flexible upper gastrointestinal endoscopy is performed at the completion of the operation to inspect the fundoplasty. The location of the endoscopy tower must be considered when orienting the equipment in the room as well.

After the abdomen is prepped from the nipples to the pubis and laterally to the operating table, sterile drapes are secured to the skin. The first 8 mm robotic trocar is located 12–15 cm inferior to the xyphoid and approximately 1–2 cm left of midline, as this location allows for adequate camera distance from the robotic arms but also permits easy visualization high in the mediastinum. A robotic trocar without the obturator is pressed against the skin at this location to mark the site and size of incision. Injection of local anesthetic precedes an 8 mm transverse incision, insertion of a Veress needle, saline drop test, and establishment of pneumoperitoneum to 15 mmHg. When the patient is deemed low risk an 8 mm robotic trocar can be inserted directly; however, in higher risk patients it is advisable to perform trocar placement under laparoscopic visualization. This may necessitate the setup of a 5 mm laparoscope and/or tower.

While robotic trocar positioning is dictated by surgeon and patient factors, there are several generalizable strategies for robotic trocar placement that differ from laparoscopic trocar placement for the repair of PEH (Fig. 5.2). First, robotic trocars should be placed at least 8 cm apart from one another whenever possible to minimize robotic arm collisions. Second, the robotic arms and instruments are often longer than most laparoscopic instruments; so robotic trocars can be placed further from the target anatomy. In fact, if the robotic trocars are placed too close to the target anatomy, it my limit degrees of freedom and impede usability of the robotic instruments. Third, the robotic trocars can be positioned in a more crescent-shaped orientation rather than a staggered “W” orientation, which some surgeons adopt for laparoscopic repair of PEH.

The robotic trocar position most conducive to repair of small and large PEH, fundoplasty, and/or gastropexy is illustrated in Fig. 5.2, which shows a relatively universal location for robotic and accessary trocars for repair of PEH. In addition to the camera trocar, additional 8 mm robotic trocars are placed under direct visualization at the following locations: right upper quadrant (anterior axillary line, 3–4 cm inferior to the costal margin), left upper quadrant (anterior axillary line, 3–4 cm inferior to the costal margin), left flank (mid axillary line, 3–4 cm inferior to the costal margin). All these trocars should be at least 8 cm from one another whenever possible. If needed, an accessory trocar is placed in the right abdomen, between the right upper quadrant trocar and the camera trocar. Most often, this trocar is a 10–12 mm disposable trocar. When available, constant pneumoperitoneum , smoke/steam evacuation, and valve-free access to the peritoneal cavity is possible through a specialized trocar (AirSeal^® System, SurgiQuest Inc., Milford, CT) and may minimize loss of pneumoperitoneum that can occur when passing needles or other devices. Lastly, a disposable 5 mm trocar is placed in the hypogastrium to dilate a track for passage of the medium-sized Nathanson liver retractor blade. Once the trocars are liver retractor are placed and secured, respectively, the patient is positioned in steep reverse Trendelenburg .

The specifics of docking vary depending on the platform (S, Si, or Xi). A complete description of docking for the S/Si and Xi platforms is beyond the scope of this chapter; however, a brief detail of docking the Xi system follows. In advance, the robotic platform is draped (all four arms) and oriented according to the docking location (patient’s left, right, etc.) and the operative field (upper abdomen, pelvis, etc.). Once oriented (patient left side, upper abdomen field), the robotic platform is positioned and the arms centered over the camera trocar. At this time (Xi only), the camera trocar is docked (arm 2) and the 30° camera inserted to facilitate automatic reorientation of the remaining robotic arms. Then, all remaining robotic trocars are docked to the platform and instruments inserted, taking care to avoid injury to surrounding structures. Various strategies exist to improve mobility of robotic arms in relation to one another depending on the platform; however, it is important to assure before beginning the operation that the robotic arms do not apply pressure to or injury the patient outside of the sterile field.

The instruments preferred for the operation will vary by surgeon preference but with experience the following instruments seem to facilitate the operation by minimizing instrument exchanges. The operation begins with Cadiere grasper placed through the right upper quadrant trocar (arm 1), a Cadiere or fenestrated bowel grasper passed through the left flank trocar (arm 4), and ultrasonic shears placed through the left upper quadrant trocar (arm 3). Alternatively, a bipolar electrosurgery device can be used in place of ultrasonic shears depending on surgeon preference. For suture repair of the PEH with or without fundoplasty, the energy device is exchanged for a robotic needle driver (arm 3). If an accessory trocar is used, sutures can be cut using disposable endoshears, which may be less expensive than the robotic scissors; however, if an accessory trocar is not placed then the robotic scissors can be used to cut sutures.

Using the robotic Cadiere graspers (or alternative atraumatic graspers), the stomach and other contents of the PEH are manually reduced, taking care to notice the tension on these structures (Fig. 5.3). In the opinion of the authors, it is critical that surgeons performing RAL PEH repair can safely and effectively evaluate tension on tissues without the use of haptic feedback , a critical part of the learning curve. While dissection may begin on the right or left crus of the diaphragm, herein is detailed the procedure beginning with dissection of the right crus of the diaphragm. Using an atraumatic grasper (arm 4), the stomach is retracted caudad and to the patient’s left, exposing the gastrohepatic ligament. Using ultrasonic shears (arm 3), the gastrohepatic ligament is divided, taking care to avoid injury to the vagus nerve coursing along the lesser curve of the stomach and any variant anatomy (replaced left hepatic vessels). Both the right crus of the diaphragm and the inferior vena cava posterior to the caudate lobe of the liver are identified.

The right crus is gently retracted laterally utilizing a Cadiere grasper (arm 1) allowing for incision of the peritoneal sac by ultrasonic shears (arm 3). When incising the peritoneal sac along the right crus of the diaphragm, it is best to leave the crus covered by its investing peritoneum whenever possible. Dissection moves from posterior to anterior long the right crus, across the phrenoesophageal ligament, until reaching the anterior aspect of the left crus of the diaphragm. Care should be taken to identify and protect anatomical variants whenever possible (Fig. 5.4). The PEH sac is dissected from surrounding tissues using a combination of blunt dissection and ultrasonic shears. Care is taken to identify and protect the posterior vagus nerve during dissection of the right crus of the diaphragm. One way to identify the right/posterior vagus nerve is to find the point near the gastroesophageal junction , where the vagal nerve fibers begin to decussate. Once identified, maintaining a plane of dissection lateral to the right/posterior vagus nerve, specifically keeping the nerve against the esophagus, is a method to avoid injury to this important structure.