(a) Right-sided port configuration for laparoscopic pyeloplasty (b) Left-sided port configuration for laparoscopic pyeloplasty
(a) Right-sided port configuration for robotic pyeloplasty (b) Left-sided port configuration for robotic pyeloplasty
For laparoscopy we usually gain access with a Veress needle and subsequent 12 mm port at the junction of the line between the umbilicus and anterior superior iliac spine (ASIS) and the lateral edge of the rectus muscle. A 5 mm port is placed two fingerbreadths below the costal margin on the lateral rectus line and a 5 mm camera port is placed four fingerbreadths below this. A 5 mm assistant port is placed laterally after the ureter is identified. A closed bowel grasping instrument is introduced through the assistant port and is used to retract the lower pole of the kidney while the UPJ and renal pelvis are dissected.
For robotic procedures access and initial 12 mm port placement for the camera is gained at the lateral rectus line at the level of the 11th rib. A robotic port is placed two fingerbreadths below the costal margin and the second robotic port is placed 4 fingerbreadths above and medial to the ASIS. A 12 mm assistant port is placed medially. The robot is then docked over the patient’s back and directly perpendicular to the operating table. (Fig. 70.3).
Room setup and robot positioning
Robotic and Laparoscopic Instrumentation
For robotic procedures, in order to limit costs, we only utilize three robotic arms and typically use 1 each of an 8 mm ProGrasp forcep, a Hot Shears monopolar curved scissor, and a Large Needle Driver. We have found that use of only one needle driver is sufficient for precise completion of the anastomosis.
For laparoscopic procedures we typically utilize a small bowel grasper, laparoscopic shears, laparoscopic hook, and needle drivers. A laparoscopic suction-irrigator can be used for dissection in addition to keeping the surgical field clear. We use 1 each of a dyed and undyed 4-0 vicryl suture on an RB-1 needle cut to 5 inches to complete the anastomosis. A 4.7 × 26 cm double-J ureteral stent is placed initially as described above and a closed suction drain is placed through the most caudal port site at the end of the procedure.
Dissection and Ureteral Identification
The colon is mobilized medially except in a rare case of a pediatric or extremely thin patient for which a transmesenteric approach can be elected. On the right side the duodenum is Kocherized. We then enter Gerota’s fascia just lateral to the inferior vena cava (IVC) on the right side or aorta on the left side. After identifying the psoas muscle, the edge of Gerota’s fascia is grasped and the ureter and gonadal vein are gently swept medially with the laparoscopic suction until both are noted. The gonadal vein is then allowed to drop medially and the ureter with some surrounding tissue is retracted laterally. During laparoscopic cases we usually place the lateral 5 mm assistant port at this point in order to allow an assistant to retract the ureter laterally with a bowel grasper. Robotically, we tend to use Hem-o-Lock clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC) in order to secure Gerota’s fascia to the sidewall for lateral retraction (Fig. 70.4).
Robotic pyeloplasty: retraction of Gerota’s fascia using a hem-o-lok clip
Laparoscopically we use hook cautery and robotically we use the Hot Shears in order to dissect Gerota’s fascia cranially to the UPJ. As the surgeon approaches the UPJ, great care must be taken to identify and carefully dissect any crossing vessels that may be present. As discussed earlier, usually crossing accessory lower pole vessels include both an artery and vein and we typically aim to preserve both. We then dissect all surrounding tissue and the rind from the proximal ureter, UPJ and renal pelvis (Fig. 70.5). If dissection of the renal pelvis is too aggressive or if tissue further from the renal pelvis is dissected, then the surgeon risks transecting a branch renal vessel.