76 Weil R. Lai1 & Benjamin R. Lee2 1 Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA 2 Division of Urology, University of Arizona College of Medicine, Tucson, AZ, USA Laparoscopic and robot‐assisted procedures have become the cornerstone of a urologist’s surgical armamentarium over the past two decades. These minimally invasive procedures require additional equipment and operating room setup. Patient and operating room preparation are key features to successful and efficient surgery. It is imperative that the operating room personnel and surgeon are familiar with all equipment systems and proper preparation of equipment. Urology surgical team members also need to be able to troubleshoot unexpected occurrences during a case. Without proper preparation and positioning, patient safety and surgical outcomes may be compromised. In this chapter we describe key features of patient preparation and operating room configuration for common laparoscopic and robotic surgeries. Careful patient selection for minimally invasive urologic procedures is critical for successful outcomes. Patient selection begins with a thorough history and physical examination, including attention to cardiopulmonary status and previous abdominal surgeries. Medical and/or cardiovascular clearance may be warranted. Patients with chronic obstructive pulmonary disease require pulmonary clearance, including pulmonary function tests, because of the risk of hypercarbia. Appropriate laboratory data, such as complete blood count, basic metabolic panel, prothrombin time, partial thromboplastin times, and urinalysis with culture should be considered. Radiologic imaging is helpful for surgical planning. For example, computed tomography (CT) with intravenous contrast is valuable for delineating the renal vascular supply for laparoscopic nephrectomy or partial nephrectomy, or for identifying crossing vessels prior to pyeloplasty. The indications for laparoscopic and robotic urologic procedures are almost identical to those of open surgery. Absolute contraindications to minimally invasive surgery include uncorrectable coagulopathy, abdominal wall infection, massive hemoperitoneum, and generalized peritonitis [1]. Intestinal obstruction was formerly considered an absolute contraindication; however, many general surgeons will perform diagnostic laparoscopy for small bowel obstruction if the bowel is not too dilated. Historically, relative contraindications to minimally invasive surgery included morbid obesity, extensive prior abdominal/pelvic surgery, pelvic fibrosis, organomegaly, ascites, pregnancy, hernias, and iliac or aortic aneurysms. However, in this current day and age laparoscopic and robotic surgery can be safely performed in patients with morbid obesity and previous abdominal surgery with minor technical adaptations. For example, Trocar placement for laparoscopic renal surgery can be shifted laterally for obese patients and the Veress needle can be introduced off site from abdominal scars in patients with previous abdominal incisions during initial insufflation. Pregnancy is no longer considered a contraindication for laparoscopy. All patients should understand the risks, benefits, and alternatives of the proposed procedure. Complications associated with minimally invasive procedures are similar to their open counterparts with the exception of a few unique complications, including CO2 embolism, hypercarbia, postoperative crepitus, and shoulder pain from pneumoperitoneum. Every patient who undergoes a laparoscopic or robotic procedure should understand the potential for conversion to an open procedure and this should be documented in the written consent. For surgeons who have experience with laparoscopy, blood type and screen can be sufficient for most minimally invasive urologic procedures. Type and cross for 2 units of packed red blood cells is appropriate for more extensive procedures, such as partial nephrectomy and radical cystectomy. We do not recommend preoperative donation of autologous blood prior to robot‐assisted radical prostatectomy because of lower estimated blood loss due to pneumoperitoneal compression of venous blood supply with the laparoscopic approach [2]. Preference for bowel preparation varies from surgeon to surgeon. It is our recommendation that patients take a half bottle of magnesium citrate the day before surgery for transperitoneal laparoscopic or robotic renal procedures. Many minimally invasive urologic surgeons do not routinely administer a bowel preparation prior to laparoscopic or robotic renal or prostate surgery. Our preference for bowel preparation prior to robot‐assisted radical cystectomy is mechanical bowel preparation only with an oral electrolyte solution. We no longer routinely administer antibiotic bowel preparation (i.e. oral neomycin and metronidazole); however, broad‐spectrum antibiotics are administered intravenously within 60 minutes of incision. Operating room setup, experienced nursing staff, and a team approach are keys to a smooth procedure. All operating room personnel should be familiar with the operating room setup and basic equipment function. Minimally invasive procedures require more equipment than standard open procedures; thus, the operating room should be large enough to accommodate the laparoscopic tower and the robotic system. All equipment should be tested prior to each procedure to make sure it is functional, including the aspiration–irrigation system, electrocautery, CO2 insufflation, camera, and light source. If anticipated to be used, the argon beam electrocautery or saline‐enhanced radiofrequency cautery should also be tested prior to partial nephrectomy. Lists of equipment necessary for laparoscopic and robotic renal surgery, as well as robotic pelvic surgery, are given in Boxes 76.1–76.3. An open tray should be either set up or immediately available in the room in the event rapid conversion to open surgery is needed. The room configuration for renal surgery varies from left to right side and from laparoscopic to robotic cases. Aerial diagrams of room setup for laparoscopic transperitoneal renal surgery and robotic pelvic surgery are shown in Figures 76.1–76.3.
Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery
Introduction
Patient preparation
Informed consent
Consent for blood products
Bowel preparation
Operating room setup
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