Entry to the abdomen is done in the manner most familiar for the surgeon. Optical trocar entry, Veress needle, or open Hasson technique are all safe ways to enter the abdomen and chosen per surgeon preference [5]. For entry into the abdomen, we rotate the patient to the left slightly and enter the abdomen using the optical trocar technique with a 10/12 mm port near the midclavicular line approximately two to three fingerbreadths below the costal margin as shown in Fig. 25.2. Once we have established pneumoperitoneum, a 10 mm 30° laparoscope is inserted to survey the abdomen. We then place our two 8 mm robotic trocars. One is placed medially and one laterally to the camera port at a similar distance from the costal margin as shown in Fig. 25.2. The splenic flexure and proximal left colon may need to be mobilized or adhesions taken down before the lateral trocar can be placed safely. To minimize collisions of the robot arms, at least 8–10 cm of space should be placed between the camera port and the working trocars. An optional fourth port is sometimes necessary for retraction or suction. This can be a standard laparoscopic 5 or 10 mm assistant port through which suction or other instruments can be introduced to the abdomen. The assistant port can also be useful for holding the colon mesentery and pancreas out of the way as one approaches the renal vein and adrenal vein. The best place for this port is typically halfway between the camera port and the lateral robot port .

After placement of the ports, mobilization of the splenic flexure and left colon to gain exposure to the retroperitoneum can be done quickly and easily with laparoscopic instruments. Once this is accomplished, the robot is docked. If the patient was rotated slightly to the left for entry into the abdomen, the operating table is positioned back to upright in the right lateral decubitus position. The entire bed is then placed in reverse Trendelenburg position to allow the bowel to fall out of the field with the aid of gravity. The robot is then guided into place along an imagined straight line connecting the camera port to the adrenal to the base of the robot. This allows for the camera arm to be positioned into an optimum configuration and allows the greatest camera freedom of movement. A 30-degree robot scope is then docked to the camera port in a downward facing orientation. The other two robot arms are similarly docked. Robot instruments are then introduced into the abdomen being sure to keep them under direct vision during the initial placement.

Through the medial robot port, a double fenestrated grasper is good to start the operation with. An endowrist cautery hook or scissor cautery can be used through the lateral robot port. Throughout the operation one may need a second double fenestrated grasper available as well as a Maryland bipolar or a curved bipolar forcep. The bipolar forceps can be used to stop most bleeding in this area. A robotic vessel sealer may be used but is often not necessary. As robotic instruments improve and vessel sealing energy devices advance, the bipolar forcep can be replaced. A medium or large locking polymer clips and clip applier will be used for adrenal vein ligation and robotic shears are used to cut the vein once sealed .

The left robotic adrenalectomy is approached using the previously described “open book” technique of laparoscopy [6]. After mobilization of the colon caudad, the spleen is then mobilized lateral to medial. This can be done by providing gentle medial retraction of the spleen with the medial robotic arm and dividing the avascular attachments of the spleen to the lateral abdomen with hook or scissor cautery (Fig. 25.3). Caution should be used when retracting the spleen due to the lack of haptic feedback with the robot. One should be diligent to not put too much pressure on the spleen while retracting as splenic capsular tears can easily occur. Staying in the avascular, filmy plane will allow mobilization of the spleen with minimal blood loss. This is continued up to the diaphragm cranially and at this point the superolateral aspect stomach will come into view. Continue mobilization of the spleen medially until the spleen will lie medially under its own weight without retraction. Often, when progressing through this avascular plane, the tail of the pancreas and splenic artery are encountered. These structures may need to be gently dissected free and mobilized in continuity with the spleen to allow adequate exposure to the adrenal gland. Great care should be taken not injure the tail of the pancreas in this maneuver. This entire mobilization can usually be done with the endowrist cautery hook or scissor cautery. If small vessels are encountered, they may be sealed with bipolar cautery.

Once the mobilization of the spleen is completed, exposing and identifying the adrenal vein is the next step. As the tail of the pancreas is swept medially, the adrenal gland should come into view as well as the left kidney. The left adrenal vein is typically found at the inferomedial aspect of the adrenal gland. Dissection along the medial plane in the groove between the adrenal and the pancreas as well as dissection along the lateral aspect of the adrenal gland near the kidney can help to isolate the area of the adrenal vein (Fig. 25.4). Careful dissection, both blunt and with cautery, will allow identification of the adrenal vein as it empties into the left renal vein. Once identified and dissected circumferentially as shown in Fig. 25.5, the locking polymer clips are loading on the robotic clip applier and used to doubly ligate the vein on the stay side and once on the adrenal side (Fig. 25.6). The vein is then divided with the robotic shears. After division of vein, the tissue overlying the adrenal gland is grasped and used to elevate the adrenal gland. Bipolar cautery can be used to divide the attachments posterior to the retroperitoneal fat. The lateral aspect of the adrenal gland is similarly dissected free from the kidney. This is continued up toward the diaphragm. One may encounter a branch of the phrenic vein through this dissection, and if necessary, can be sealed and taken with bipolar cautery. Once the specimen is free, it is placed in an endocatch bag and removed through the camera port. Depending on the size of the specimen, the camera port may need to be enlarged for removal .