Proper and safe patient positioning is of extreme importance in RARPLND. Most of these cases place the patient in a nonphysiological body position and sometimes require long operative times especially in post-chemotherapy patients. The patient is placed in low lithotomy, maximal Trendelenburg position and in some cases the left shoulder is tilted to the left slightly (approximately 30°), as shown in Fig. 23.1. 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. All potential pressure points should be padded. 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 is prone to compression and the surgical team should try to have the legs relatively extended without full extension. In most cases, standard Trendelenburg that is used for robotic pelvic procedures is all that is needed.

Neurapraxia is one of the most commonly encountered complications after any procedure with extreme positioning and is usually self-limiting and resolves with conservative management and physical therapy [12]. Early in one’s experience, the procedures may be long and being aware of the time the patient is in extreme positioning is critical. Complications such as rhabdomyolysis are of significant concern when the patient is in extreme positioning greater than 4–6 h. Patients should be assessed in the recovery room once they are fully awake where a vigilant neurovascular examination of the extremities can be conducted. Early detection and treatment of ischemia is important to prevent consequences of this complication . Follow-up of immediate postoperative labs, physical exam, and urine output will unveil any signs of rhabdomyolysis, which can be treated with aggressive hydration [13]. If rhabdomyolysis is suspected, the extremities should be assessed with compartment pressures and consultation to orthopedics or plastic surgery.

As in any laparoscopic intervention , visceral injuries can take place during access or trocar placement and standard measures should be taken to avoid these injuries [14]. In RARPLND, the pneumoperitoneum is established using either a Veress needle technique or a Hasson technique if intraabdominal adhesions are expected from previous surgery. This can be performed while the patient is still in a 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. 23.2). As the midline camera port is below the umbilicus, the bladder should be maximally drained with a catheter-tipped syringe prior to trocar placement.

An orogastric tube is inserted to completely deflate the stomach. A urethral catheter should be inserted to monitor urine output and to deflate the bladder. The bladder should be actively drained as mentioned previously. One of the most helpful maneuvers that were developed during the evolution of this technique is the bowel retraction sutures. Once the robot is docked, the bowel is retracted toward the upper abdomen and a wide incision is made in the posterior peritoneum below the bifurcation of the great vessels. This incision is the same one that is performed during open RPLND and is started caudal to the cecum and appendix and extended medially to the root of the small bowel mesentery. The peritoneum is then lifted off the underlying great vessels and space is dissected as superiorly as possible. This will be done by lifting the peritoneum with the left hand and blunt dissection will be done with the back of the scissors on the right hand. It should be noted that the inferior mesenteric artery (IMA) can be divided with impunity without any sequelae in this young group of patients if this will facilitate paraaortic dissection. Ligation of the IMA is usually done in post-chemotherapy cases in order to perform a thorough paraaortic dissection; it greatly facilitates the mobilization of the peritoneum and retraction of the bowel and mesentery [15]. The free edge of the peritoneum is then sutured to the anterior abdominal wall at multiple locations using 0 polyglactin suture on a curved needle (Fig. 23.3). This will help keep the bowel retracted in the upper abdomen and prevent its falling into the surgical field during later dissection, as shown in (Fig. 23.4). Care should be taken to avoid injury to the bowel and the epigastric vessels when these sutures are placed. A small abdominal lap sponge (“baby lap” – “e-tape”) should be inserted and used to pack the uppermost part of the retroperitoneum where the duodenum is commonly encountered to avoid injury to the duodenum during retraction. This is very important since there will be anterior retraction on the posterior aspect of the duodenum and it will prevent serosal injury. The duodenum is very susceptible to injury from minimal traction and only sharp dissection should be used when dissecting around it.

Although not a common complication in RARPLND, bowel injuries can still occur and is a devastating complication. One should be careful with electrocautery application near the peritoneum and off-field movements as energy may be transmitted and result in delayed bowel injury. In long cases, the bowel frequently slides back into the field in the left lower quadrant and surgeon should ensure that the bowel is adequately retracted whenever this happen again. The bowel retraction/suspension stitches should help prevent these complications.

Meticulous examination of preoperative cross-sectional imaging is important to ensure absence of congenital anomalies of the blood vessels or urinary system such as accessory renal vessels or duplicated urinary systems. Most commonly encountered vascular anomalies include lower pole renal accessary vessels. The location and size of the retroperitoneal lymph nodes/masses should be taken in consideration to plan dissection.

It should be realized that intraoperative vascular injuries (especially venous) injuries are not uncommonly encountered in post-chemotherapy RARPLND and the surgeon should be competent in achieving vascular control robotically. Moreover, it is of great benefit to have an experienced laparoscopic surgeon to assist at the bedside to help temporize and control any bleeders in case of conversion to open. Most common bleeders are small veins that can be almost always controlled. In our experience, the most commonly encountered bleeders are lumbar veins and a small vein that commonly arises from the anterior surface of the IVC just above its bifurcation. During all the steps of vascular dissection the principles of vascular proximal and distal control with a vessel loop should be considered as early as possible to promptly control bleeding. Once the IVC is circumferentially dissected, a vessel loop can be passed around it twice and a Hem-o-lock® is applied at the free end the loop. This will fix the loop in place. If bleeding is encountered in that vessel, the loop can be used to control the vessel. This is most commonly performed on the IVC and allows for retraction of the IVC and exposure of the posterior structures (Fig. 23.5).