Pediatric Robotic Anti-reflux Procedures



Fig. 31.1
Operating room setup for extravesical ureteral reimplant demonstrating standard configuration of operating room personnel and equipment





Patient Positioning and Preparation


Initially, frog leg the patient (Fig. 31.2) to prep and place urethral catheter in the sterile field. Placement of a rectal tube for decompression may also be helpful. Then adjust legs to have patient in supine position for obtaining access (Fig. 31.3). Place padding and tape across chest and lower thighs and place a folded towel and tape over arms but under abdomen. The anesthesia team should place an NG or OG tube prior to access.

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Fig. 31.2
Initial positioning for reimplant. “Frog leg” positioning helps with initial placement of urethral catheter on the sterile field in female patients


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Fig. 31.3
Final positioning for reimplant. After catheter is placed, the patient is readjusted to the supine position


Trocar Configuration


Trocar configuration for an extravesical ureteral reimplant is shown in Fig. 31.4. The 5 mm trocars can be used when the patient is younger than 8–10 years, otherwise the 8 mm trocars are used. Adjust the patient to moderate Trendelenburg position prior to docking robot.

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Fig. 31.4
Trocar configuration for extravesical ureteral reimplant


Instrumentation and Equipment  List



Equipment






  • da Vinci® Si Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Monopolar Hook Electrocautery, 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Maryland Dissector, 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® DeBakey Forceps , 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Curved Monopolar Scissors, 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Round Tip Scissors, 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Needle Driver, 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • Articulated irrigation device, 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)


  • InSite® Vision System with 30° lens (Intuitive Surgical, Inc., Sunnyvale, CA)


Trocars






  • 8.5/10 mm Camera trocar


  • 8 mm Robotic trocars (2, only if child is older than 8–10)


  • 5 mm Trocar (2)


Recommended Sutures






  • Preplaced fascial box stitch: 2-0 or 3-0 polyglactin suture


  • Hitch stitch: 3-0 or 4-0 polyglactin


  • Bladder mucosal tears: 6–0 chromic, 14 cm length


  • Detrusor tunnel: 4-0 polyglactin, 14 cm length


  • Skin closure: 4-0 or 5-0 monocryl suture


Instruments Used by the Surgical Assistant






  • Maryland grasper


  • Suction irrigator device


Step-by-Step Technique (Video 31.1)



Step 1: Abdominal Access and Trocar Placement


As noted above, the urethral catheter may be easily placed on the sterile field prior to adjusting the patient from frog-legged to supine position. The 12 or 8.5 mm camera trocar is placed in the area of the umbilicus, using the Hasson open technique with 2-0 polyglactin suture on a UR-6 needle or a 3-0 polyglactin suture on a CT-2 needle bent accordingly. These are pre-placed fascial box stitches (used later for closure). Working trocars are then placed sharply under direct vision after pre-placing the fascial box stitches. Dock the robot.


Step 2: Ureteral Mobilization (Table 31.1)





Table 31.1
Ureteral mobilization: surgeon and assistant instrumentation




















Surgeon instrumentation
Assistant instrumentation

Right arm

Left arm
• Suction-irrigator

• Monopolar hook electrocautery (or monopolar scissors)
• Maryland dissector

Endoscope lens: 30° down

Access is transperitoneal to the posterior aspect of the bladder . The ureter is identified through the peritoneum, exposed by incising the peritoneum transversely lateral to the midline, posterior to bladder and anterior to uterus in girls (Fig. 31.5). The ureter is mobilized for about 5–6 cm proximal to UVJ (Fig. 31.6a, b), staying close to the ureter without disrupting its adventitia. A combination of blunt and electrocautery dissection is used. If there is difficulty in identifying the ureter anterior to the uterus, this can be accomplished more proximally and dissected down toward the bladder.

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Fig. 31.5
Transperitoneal access to bladder. The peritoneum is incised just over the ureter of interest (red line), along the vesico-uterine fold of the peritoneum

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Jul 17, 2017 | Posted by in UROLOGY | Comments Off on Pediatric Robotic Anti-reflux Procedures

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