Ensure proper sutures and equipment have been prepared for the case per above specifications and that supplies for open conversion and a vascular stapler are within close proximity.

Positioning. The patient is placed in a modified flank position at 45–60° using Laminectomy bolsters. The patient’s iliac crest is positioned over the break in the table and the table is flexed, if needed, to open the hips and create space for the robotic arms. The patient is securely fastened to the bed and the upper arm is placed either on an arm support or pillows. All pressure points are padded adequately to prevent positioning injuries.

Pneumoperitoneum is established using either the Veress or open (Hasson) technique.

Port placement (Fig. 6.2). The initial optical port is placed under direct observation using the 8-mm robotic Visiport™ (Xi) or the 12-mm visible port (Si) (VeraOne™, Medtronic, Minneapolis, MN). The remainder of the robotic trocars are placed under vision with the two main working arms triangulating to the tumor and the fourth arm positioned just superior and medial to the iliac crest for upward retraction on the kidney. Use of the long bariatric robotic trocar for the fourth arm helps reduce clashing of the robotic arms. For right-sided cases, a 5-mm port is placed immediately inferior to the xyphoid process for insertion of a locking grasper that can be used for liver retraction. A 12-mm assistant port is placed 6–8 cm superiomedially to the camera port in line with the inferior robotic arm, fourth arm, and camera port.

Robot docking. The robot is brought in at a 15° angle toward the patient’s head with the arms positioned to provide maximal working space and limit instrument clashing. Instrumentation for the 4-arm approach includes a 30° down lens, monopolar scissors for the right hand, fenestrated bipolar forceps for the left arm, and a Prograsp forceps for the fourth arm.

Bowel reflection. The peritoneum is incised lateral to colon to reflect the colon medially. The proper plane of dissection is readily apparent by identifying the color difference between the pale fat of the retroperitoneum and the brighter yellow fat of the mesentery. On the left, dissection continues beyond the splenic flexure until the spleen lies medially without additional traction. Care must be taken to avoid injury to the vessels of the splenic hilum as well as the tail of the pancreas. On the right, care is taken to kocherize the duodenum medially. The peritoneum overlying the superior pole of the kidney is incised along the inferior aspect of the liver to allow for upward retraction during hilar dissection. A locking grasper is inserted through the sub-xyphoid port, passed beneath the liver, and affixed to the lateral body wall musculature to retract the liver superiorly. With either side, the medial dissection is complete once the adrenal is identified superiorly and the gonadal vein inferiorly.

Ureteral identification and hilar dissection. A 3–4 cm incision is made in Gerota’s fascia medial to the lower pole along the lateral side of the gonadal vein in order to identify the ureter (Fig. 6.3). The ureter and surrounding perinephric fat is lifted superiorly and the attachments to the posterior wall are bluntly dissected along the psoas muscle. The fourth arm is inserted into this opening to balance the kidney laterally and place the hilum on stretch.

Renal hilar dissection. Dissection continues medial to the ureter from inferior to superior by releasing the anterior fascia along the entirety of the medial surface of the kidney and separating the retroperitoneal fat into packets for ligation. The fourth arm tension should be continually adjusted to assure the hilum remains on stretch. Once the renal vein is identified, a window is created posteriorly to expose the renal artery. Preoperative cross-sectional imaging should be scrutinized closely for identification of accessory arteries and veins that may require additional dissection.

Lesion identification. The perinephric fat is carefully dissected from the renal capsule in the region of the tumor in order to expose several centimeters of normal renal capsule circumferentially around the tumor. For lateral and posterior tumors, the dissection should continue until the kidney can be rotated for adequate exposure. Fat may be removed and sent to pathology or left attached to the tumor surface to be used for retraction.

Lesion demarcation. An intraoperative ultrasound is used to verify the mass and systematically demarcate the boarders of dissection, assuring an adequate surgical margin. The fat over tumor can be left on a handle for dissection or removed at this point and sent for histologic analysis. Use of TilePro® allows for simultaneous visualization of the tumor and ultrasound (Fig. 6.4).

Preparation for dissection. It is imperative to assure all instrumentation is ready and available prior to clamping of the renal artery. Utilization of a routine checklist helps reduce the possibility of missing supplies/instrumentation. It is our practice to check that all ports are placed deep enough to expose the robotic remote center (thick black line on port) and prevent dislodgement during instrument exchange. Bulldog clamps (depending on the number vessels) are placed medial to the kidney in preparation for clamping.

Lesion excision. The hilum is placed on stretch and a bulldog clamp is placed on the renal artery(s) (Fig. 6.5). We do not routinely clamp the renal vein [31]. If desired, indocyanine green can be administered to ensure complete vascular control using the fluorescence light on the daVinci Robotic system (Firefly, Fig. 6.6). Using the monopolar scissors, the capsule and immediate underlying parenchyma are incised using electrocautery, followed by a combination of blunt and cold excision to dissect around the contour of the mass, leaving an adequate parenchymal margin. Intermittent cautery can be used to control any small vessels encountered during the dissection. The bed is inspected. If there appears a tumor at the deep resection margin, this can be excised separately, though we do not routinely send a deep margin (Fig. 6.7).

Closure of the excision bed. A 6-inch, 3-0 barbed suture with a Lapra-Ty at the end is used to over sew the base of the defect, with openings in the collecting system closed separately from vasculature when present. The process can be repeated with additional sutures as needed to assure the entire base has been over sewn. If planning an early clamping technique, the hilar clamps can be removed at this point and additional arteries can be over sewn.

Renorrhaphy. The renal defect is closed using the sliding-clip renorrhaphy technique [32] (Fig. 6.8). We start the suture at the side farthest from the assistant to allow for easier access for final clip placement. The suture is passed 1 cm from the renal defect in an interrupted fashion leaving approximately 1 cm of space between each suture. After all sutures are placed, a Hem-o-lock clip is applied, and the sutures are alternatively tightened to prevent excessive tension on any one individual suture.

The vascular clamps are removed keeping the renorrhaphy in view if possible. If bleeding is encountered, the sutures may be further tightened. When necessary, additional renorrhaphy sutures or hemostatic agents can be utilized to stop bleeding. Once all sutures are placed and tightened, Lapra-ty clips are used to secure the sliding clip (Fig. 6.9).

Completion of case. If there is a large defect in the renal collecting system or there is concern for postoperative leak, a drain can be introduced through the fourth arm port and placed inside of Gerota’s fascia. The fascia is then re-approximated with a vicryl or barbed suture. The specimen is placed into a laparoscopic bag and brought through an assistant port depending on location and the size of the specimen. The incisions are then closed, irrigated, and injected with local anesthetic.