Retroperitoneal Robotic Partial Nephrectomy

Fig. 8.1

(a) Initial operating room setup for a right-sided retroperitoneal robotic partial nephrectomy. (b) Final operating room setup once the patient and operating table have been turned 135° to allow for the robot to be docked over the patient’s head

The Bovie electrocautery unit and insufflation tower are positioned next to the patient’s feet. The assistant is positioned on the anterior side of the patient and scrub technician is on the posterior side of the patient. Monitors are positioned such that the assistant, scrub technician, and anesthesiologist all have a clear direct view (Fig. 8.1b).

Patient Positioning and Preparation

After induction of general endotracheal anesthesia, the anesthesiologist places all necessary lines for monitoring and fluids, particularly as the subsequent lateral decubitus position may limit access to the extremities. No orogastric or nasogastric tube is required for the retroperitoneal approach. An 18 French urethral catheter is inserted. The patient is then placed in full 90° flank position with the side of the renal mass up, taking care to ensure that the hips are in line with the shoulder. Maintaining alignment of the hip and shoulder during patient flexion is essential for maximizing working space in the retroperitoneum . If the hips and shoulders are not in line however, flexion of the table will accentuate any rotation and will result in distortion and compression of the retroperitoneum. Some patients may have a prominent hipbone, in which case we make sure to place the hip below the break in the table.

To help maintain the full flank position, we use two rolled blankets folded in thirds, and rolled under the drawsheet to support the patient’s spine. One blanket (likewise folded in thirds) is rolled under the drawsheet in front of the patient so provide a low profile support to the patient’s abdomen (Fig. 8.2a). The rolled blankets allow for adequate exposure of both the retroperitoneal space as well as the whole abdomen in the event of a conversion to a transperitoneal approach. Blankets also allow stable patient positioning without the need for a hard surface such as a beanbag. The bottom leg is bent, and the top leg is left straight and resting on pillows. An axillary gel roll is placed. The dependent arm is supported by an arm board, tilted toward the head as much as possible, and secured with tape. Two or three pillows are then placed over the arm, and the ipsilateral arm placed over this pillow tower and secured. We use 2-in. cloth tape over the ipsilateral shoulder and arm, and another piece perpendicular to this to help prevent the arm from falling toward the patient’s head. The bed is then fully flexed to maximize the space between the 12th rib and iliac crest, and reverse Trendelenburg used to make sure that the flank is parallel to the floor. Lastly, we use cloth tape to secure the hips and legs. The final position is shown in Fig. 8.2b. An upper-body warming device is placed. Depending on the side of the mass, the bed is then rotated as described above to allow for the robot to be docked directly over the head.

Fig. 8.2

(a) The patient is placed in full flank position, with one rolled blanket anteriorly and two rolled blankets posteriorly to help maintain the body perpendicular to the bed. (b) The table is fully flexed with slight reverse Trendelenberg

Throughout the case, it is important to maintain clear and effective communication with the anesthesiologist. Once all the positioning has been completed, we verify that they are satisfied with their access to the airway, all IVs and monitoring lines. We request that they run intravenous fluids at a brisk rate as tolerated, and after 2 L of fluids have been given, to administer Furosemide 20 mg IV all prior to any ischemia time.

Trocar Configuration

A total of four trocars are used: a 12-mm camera trocar, two 8-mm robotic trocars for the right and left robotic arms, and a 12-mm assistant trocar. If the surgeon wishes to use the fourth robotic arm, an additional 8-mm robotic trocar is opened. The fourth arm is then draped and positioned such that it is the most medial trocar in relation to the patient’s midline (i.e., lateral to the left arm for a left-sided tumor, medial to the right arm for a right-sided tumor).

Trocar configurations for a right retroperitoneal robotic partial nephrectomy using the 3-arm technique is shown in Fig. 8.3.

Fig. 8.3

Trocar configuration for a right retroperitoneal robotic partial nephrectomy using a 3-arm technique. If needed, a fourth arm may be placed at the “X”

Instrument and Equipment List

Equipment

da Vinci^® Si Surgical System (4-arm system; Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® curved monopolar scissors (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® fenestrated bipolar grasper (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® ProGrasp™ forceps (Intuitive Surgical, Inc., Sunnyvale, CA) if using fourth arm
EndoWrist^® large suture cut needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)
InSite Vision System with 0° lens (Intuitive Surgical, Inc., Sunnyvale, CA)
Robotic flexible drop-in Doppler ultrasound probe (BK Ultrasound, Peabody, MA)
Balloon-dilating device (OMSPDBS2, Kidney Distension Balloon, Covidien, Mansfield, MA)
Laparoscope with 30° lens

Trocars

12-mm trocars (2)
- A 12-mm Hasson blunt-tip trocar with fixation balloon (OMS-T12BT, Covidien, Mansfield, MA) for the camera
- A 12-mm trocar for the assistant
8-mm robotic trocars (2, or 3 if using the fourth arm)

Recommended Sutures (Fig. 8.4)

Fig. 8.4

Prepared sutures prior to excision of the renal mass: (from left to right) Six 2-0 Polyglactin CT-2 sutures cut to 8 cm; One 2-armed pledgeted suture made from two 2-0 Polyglactin CT-1 needles clamped together at 12 cm; One 3-0 Monocryl SH cut to 15 cm; One 3-0 Monocryl SH cut to 18 cm

Retraction of perinephric fat as needed: 2-0 Polypropylene on a Keith needle, uncut (not shown)
Oversewing vessels and collecting system: 4-0 Polyglactin (undyed) on a RB-1 needle. Six sutures are cut to 12 cm, and one suture is cut to 15 cm (not shown).
Deep renorrhaphy layer: 3-0 Monocryl (dyed) on an SH needle, with a Hem-o-lok^® clip and LAPRA-TY^® clip on the distal end. One has the Hem-o-lok^® clip at 15 cm, and a second suture has the Hem-o-lok^® clip at 18 cm.
Cortical renorrhaphy layer: 2-0 Polyglactin on a CT-2 needle, with a Hem-o-lok^® clip and LAPRA-TY^® clip on the distal end at 8 cm. An additional 2-armed pledgeted suture is created using two 2-0 Polyglactin CT-1 needles clamped together at 12 cm with a Hem-o-lok^® clip and LAPRA-TY^® clip and tied together, and a 9.5 × 4.8 mm soft TFE polymer pledget passed through both needles.

Instruments Used by the Surgical Assistant

Suction irrigator device
Laparoscopic needle driver
Laparoscopic blunt tip grasper
Hem-o-lok^® clip applier (Teleflex Medical, Research Triangle Park, NC)
Large Hem-o-lok^® clips (Teleflex Medical, Research Triangle Park, NC)
LAPRA-TY^® suture clip applier (Ethicon, Somerville, NJ)
LAPRA-TY^® absorbable suture clips (Ethicon, Somerville, NJ)
10 mm titanium clip applier ML size (Covidien, Mansfield, MA)
Keith needle with 2-0 Polypropylene suture
Atraumatic bulldog vascular clamps (six available) (Scanlan International, St. Paul, MN)
SURGICEL^® hemostatic gauze (Ethicon, Inc., Cincinnati, OH)
10 mm Endocatch^® specimen retrieval bag
15 F Blake round closed suction drain
Available and in the room: Laparoscopic reticulating GIA stapling device with a 30 mm cartridge length and vascular load

Step-by-Step Technique (Videos 8.1, 8.2, 8.3, 8.4, and 8.5)

Step 1: Retroperitoneal Access and Trocar Placement

We begin by gaining access to the retroperitoneal space . To start, the bony landmarks are palpated and marked: the iliac crest, the 12th rib, and the costal margin. A 12 mm transverse incision is made in the midaxillary line, one fingerbreadth above the iliac crest, anterior to the Triangle of Petit [2]. Blunt dissection is carried down to the external oblique fascia. Blunt finger dissection is then used to penetrate the external and internal oblique fascia as well as the transversalis fascia. The finger should then enter the retroperitoneal space, and should be able to palpate the psoas muscle posteriorly, the tip of the 12th rib superiorly, and often the inferior cone of Gerota’s anteriorly. The finger is used to gently sweep the peritoneum away. The balloon-dilating device is then placed into this space, taking care to orient the device so that the dimension of maximal expansion is along the cephalo-caudal axis. A 30° laparoscope is inserted into the balloon dissector, and 40 pumps are performed under direct vision. Depending on the dissection of tissues and working space, one can give up to 60 pumps, taking care not to cause undue shearing that may accidentally breach the peritoneum. If the peritoneum is inadvertently entered, we will enlarge the incision and place the robotic fourth arm transperitoneally through this location to help retract the peritoneum and kidney. While pumping the balloon, the landmarks that we identify are the transversus abdominis muscle and anterior layer of peritoneum superiorly, Gerota’s fascia as it is pushed off the psoas muscle posteriorly, and the ureter inferiorly (Fig. 8.5). The balloon is then deflated and replaced with the 12 mm Hasson camera trocar.

Fig. 8.5

Anatomic landmarks during creation of the retroperitoneal space include the posterior layer of Gerota’s fascia on the psoas muscle (shown), as well as the ureter and the peritoneum as it is pushed medially off the tranversus abdominis

Once pneumo-retroperitoneum is established to 15 mmHg, the remaining trocars are marked with at least 7 cm (and preferably 8 cm) in between. The lateral robotic trocar site is marked at the apex formed by the erector spinae muscles and 12th rib. The medial robotic trocar site is marked along the anterior axillary line, 7–8 cm away from the camera trocar. The assistant trocar is marked in the anterior axillary line above the anterior superior iliac spine, and 7–8 cm caudal to the medial robotic trocar. If a fourth arm is anticipated to be used, it is placed 7–8 cm medially and ~2 cm inferiorly to the medial trocar. A spinal needle can be inserted under vision to confirm the marked sites. A laparoscopic Kittner can be used through the lateral robotic trocar to sweep away the peritoneum if more space is needed for the medial trocars (Fig. 8.6). All trocars are then placed under direct vision. The robot is then docked over the patient’s head, parallel to the spine. The robotic cart is positioned such that the robotic camera arm is in the far end of the “sweet spot” range, which allows for greater range of motion inferiorly in the limited working space. The robotic camera is inserted with a 0° lens, and robotic instruments are advanced into the working field under direct vision. The camera scope is rotated so that the psoas muscle appears horizontal.