Robot-Assisted Retroperitoneal Lymph Node Dissection



Fig. 14.1
Operating room setup





Patient Positioning


Proper and safe patient positioning is of extreme importance in RARPLND. Most of these cases place the patient in a nonphysiological body position and can sometimes require a long operative times especially in post-chemotherapy patients. The patient is placed in low lithotomy, maximal Trendelenburg position with the left shoulder tilted downward (approximately 30o) as shown in Fig. 14.2. Placing the patient in this position will facilitate exposure as gravity will retract the bowel to the left upper quadrant of the abdomen. The patient should be secured to the table using 3-in. silk tape across the chest. The patient position should be tested prior to draping to ensure patient safety and stability on the table.

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Fig. 14.2
Patient positioning


Si postition


With the new robotic platform, the nurse and the bed side assistant can stand on the right side of the patient and the robot come from the left side for side-docking where the boom can be rotated to direct the instruments towards the head.

Given the lengthy nature of the procedure it is of paramount importance to pay special attention to pressure point padding in order to decrease the chances of neuropraxia, rhabdomyolysis, and compartment syndrome. Padding can be done with gel pads, eggcrate foams, or rolled sheets and blankets. The head should be secured in a neutral position with a head rest on the left side in order to avoid neck flexion once the patient is tilted. Arms are tucked by the sides and the legs are spread and fixed. The peroneal nerve on the “down-side” is prone to compression and the surgical team should try to have the legs relatively extended without full extension. This area should be padded as well as the medial side of the right leg. This will provide space in between legs to place a Mayo stand as discussed above and more importantly will prevent clashing of the third robotic arm with the legs.


Trocar Configuration


The pneumoperitoneum is established using a Veress needle technique. However, a Hasson technique can be used if intra-abdominal adhesions are expected from previous surgery. Establishing pneumoperitoneum can be performed while the patient is still in neutral position. However, trocar placement is best performed after changing to Trendelenburg position to move the bowel away and minimize the chances of injury. The trocar location varies based on surgical preference and several approaches have been described based on the template of dissection. However, when a full bilateral template is planned, we usually use the following template (Fig. 14.3) and trocar insertion takes place in the following order:

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Fig. 14.3
Trocar locations



  1. 1.


    A 12-mm trocar is placed 3–4 cm below the umbilicus for the robotic camera. In order to avoid inadvertent injury in this infraumbilical access, the bladder should be actively drained. Once the trocar is inserted, a 0o camera should be used to visualize the peritoneal cavity and guide the rest of trocar placement under direct vision.

     

  2. 2.


    Two 8-mm robotic trocars are then placed under direct vision on either side of the camera trocar. These are placed along the same horizontal line and one hand breadth from the camera on each side. These will be used for the first and the second robotic arms on the right and left side, respectively. Extra-long (bariatric) trocars should always be used.

     

  3. 3.


    The third robotic arm trocar is then placed in the left upper abdomen approximately 1–2 cm above the level of the umbilicus at the left anterior axillary line.

     

  4. 4.


    A 15-mm assistant trocar is placed in the right lower abdomen approximately 2–3 cm superomedial to the right anterior superior iliac spine.

     

  5. 5.


    An optional 5-mm assistant trocar is placed in a mirrored location to the third robotic trocar but in the right side of the abdomen.

     


Instrumentation List (Table 14.1)





Table 14.1
Robot-assisted retroperitoneal lymph node dissection: surgeon and assistant instrumentation








































Surgeon instrumentation
Assistant Instrumentation

Arm 1
Arm 2
Arm 3

• Curved monopolar scissors
• Maryland bipolar grasper
• Prograsp dissector
• Laparoscopic Suction-Irrigator

• Needle driver
• Needle driver
• Laparoscopic blunt tip grasper

• Hem-o-lock® clip applier
• Laparoscopic needle driver
 
• Laparoscopic scissors

• Robotic vessel sealer
• Laparoscopic vessel sealing device (LigaSureTM)

• Hem-o-lock® clip applier

• Laparoscopic vascular stapler (Endo-GIA 30-2.5)

• Reusable specimen retrieval bag





  • 0 Polyglactin suture on a CT needle for retraction stitches


  • Multiple 3-0 silk ties (4 in.) for lumbar vessel ligation


  • Multiple 5-0 polypropylene on a c-1 needle sutures (6 in.) for vascular injury repairs


  • Small abdominal laps/sponges to be used intra-abdominally


  • Multiple vessel loops to retract and occlude vessels


  • Multiple Hem-o-lock® clips of different sizes: ML (green), L (purple), and XL (gold)


Step-by-Step Technique (Videos 14.1, 14.2, 14.3, 14.4, 14.5, and 14.6)


We would like to highlight the following general principles :

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Jul 17, 2017 | Posted by in UROLOGY | Comments Off on Robot-Assisted Retroperitoneal Lymph Node Dissection

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