The operating room setup is as shown in Fig. 10.1. The robotic surgeons sit on the console. The patient cart is positioned behind the patient. The bedside surgeon and nurse assistant are at patient’s side opposite to the patient cart. The nurse assistant has access to the back trolley of the instruments which are positioned adjacent to him. Anaesthesia team and trolley are at head end of the table. There are multiple HD screens positioned in the operative room which can be seen by bedside surgeons, nurse assistant, anaesthetist and observers. It is important that the screen which bedside surgeon focuses is at his eye level. The robotic arms do not cover any part of this screen even temporarily so that the bedside surgeon has uninterrupted vision of ongoing surgery and is in position to assist efficiently.

The surgical table should have good cushioning to ensure that the pressure points are not compressed. Initially living-related voluntary kidney donor (VKD) is positioned in supine position on table. VKD is anaesthetised and intubated with endotracheal tube. VKD is catheterised with Foley catheter 14 Fr under all aseptic precautions, and uro bag is connected to catheter. Uro bag is kept dependent on the bedside surgeon side of the table. The pneumatic compression device is applied to lower limbs of VKD.

Then, the VKD is turned to the lateral decubitus position. The position can be 20 ° less than absolute lateral decubitus position also. For right RDN, the position is left lateral, and for left RDN, it should be right lateral. The abdominal wall of VKD should be at lateral edge of the table. After turning the patient, it is ensured by anaesthetist that the endotracheal tube is properly positioned and monitor probes are properly connected. Surgical team ensures that the Foley catheter and tubing are not compressed and draining urine freely.

The back of the VKD is supported with cushioned packs. The position of inferior lower limb of patient is important. The contralateral limb (left lower limb in case of right RDN and right lower limb in case of left LDN) should be flexed at the knee and positioned in such a way that the knee should not project beyond the edge of the table as this may restrict the movement of instrument and bedside surgeon working space. The ipsilateral lower limb (left in case of left LDN and right in case of right LDN) should be in complete extension position. A cushion is placed between the lower limbs.

Few centres recommend extension of kidney bridge for increasing the distance between the ipsilateral iliac crest and subcostal margin. Theoretically, this may assist the dissection, but at our centre, we did not find this manoeuvre necessary as the pneumoperitoneum itself creates enough space for dissection. However, as discussed later in the procedure part, if the movement of fourth arm is getting restricted, then the table may be extended to raise the kidney bridge. Once positioning of patient is acceptable, then the straps are put at nipple level and at buttock level of the patient with sufficient padding to prevent pressure injury. The straps at nipple level should be loose enough to allow the respiratory excursion. This can be achieved by placing surgeon’s hand on lateral aspect of chest over which the straps are tightened.

It is advisable to do surface marking prior to the port placement at least in early learning curve. The midline of abdominal wall should be marked. The lateral wall of the rectus should be marked. Anterior superior iliac spine, iliac crest, subcostal margin and 11th rib tip should be marked. These surface markings allow the orientation to be maintained during the port placement.

A small 2 mm stab is done on ipsilateral midpoint of spinoumbilical line, and pneumoperitoneum is induced with Veress needle (Fig. 10.2). The approximate relation of renal hilum in reference to 11th rib is noted with help of renal CT angiography which is done as preoperative workup. The fist port is camera port. It is 12 mm dilating port placed at lateral border of rectus at level of renal hilum (Fig. 10.3). Laparoscopy is done and the abdominal cavity is reviewed for adhesions at the abdominal wall, bleeding if any into peritoneal cavity during port placement or at time of Veress needle insertion. It is reinsured that there are no adhesions at Pfannenstiel incision site which is proposed site of retrieval incision. This is particularly important post-Caesarian sections and gynaecological surgeries.

Pfannenstiel incision is marked and incision is deepened through the skin and subcutaneous tissue (Fig. 10.4). The anterior rectus sheath is incised transversely and both recti are seen. Pneumoperitoneum is deflated and plane is created between anterior rectus sheath and recti cranially as well as caudally sufficient enough to allow the lateral retraction of recti. Both recti are retracted away from each other laterally, and properitoneal pad of fat is noted. The pneumoperitoneum is reinduced; it helps in proper dissection of properitoneal pad of fat and visualisation of parietal peritoneum. After careful dissection, transparent parietal peritoneum is noted which is preserved for incision at the time of final graft retrieval. These steps are necessary to ensure that the retrieval is fast and warm ischaemia time is minimum, and it is to be insisted that care has to be taken not to damage the parietal peritoneum at this time because it may lead to the leaking of pneumoperitoneum throughout the procedure.

Just like in laparoscopic surgery, the appropriate port placement is important in robotic surgery as well, but it is not as critical in robotic surgery. However, the care has to be taken in robotic surgery to ensure that the ports are at least four fingerbreadths away from each other in inflated abdominal wall. This is necessary for ensuring the proper functioning of robotic arms. If the ports are very closely placed, the clashing of robotic arms compromises its manoeuvrability.

One 8 mm robotic port is placed just below the subcostal border at the level of or little lateral to the mid-clavicular line. This is port for right robotic arm. Another 8 mm robotic port is placed few centimetres lateral to the midpoint of the spinoumbilical line. This is port for left robotic arm. The port used for fourth arm should be 8 mm long metal port; it is placed cranial and lateral to ipsilateral end of Pfannenstiel incision, and it should be caudal and medial to the midpoint of the spinoumbilical line. This port should be long port so that the fourth arm can be manoeuvred easily. If there is difficulty in manoeuvrability of fourth arm after docking, then as discussed earlier, the table may be broken to raise the kidney bridge or to lower the lower limbs of patient. It is necessary to ensure that the robotic fourth arm does not directly put pressure over patient’s lower limb.

Additional bedside surgeon working port is placed medial and cranial to the camera port. It should be 12 mm dilating port (Fig. 10.5).

Five millimetre port is placed in the midline or on the left side of midline below the xiphisternum for inserting the Allis forceps for liver retraction. Allis forceps is passed through this port fixed to lateral aspect of the diaphragmatic muscles to ensure good liver retraction. This is done after releasing adhesion of inferior border of liver surface if there are any (Fig. 10.6).

Another 12 mm dilating port is placed from Pfannenstiel incision through the ipsilateral rectus sheath and muscle. This port is for insertion of vascular stapler for clamping the graft renal vein.

Then the motorised patient cart is moved towards the patient, and the robotic arms are connected to corresponding robotic ports and camera port (Fig. 10.7), taking care of fourth arm as described above. After connecting the robotic camera in camera port, all the robotic instruments are inserted and docked under vision to ensure that the instrument is inserted in correct path without damaging any intervening structure.

Right robotic instrument monopolar curved scissors are inserted and connected to the monopolar cautery. Left robotic arm instrument is Maryland forceps, and it is connected to bipolar cautery (Fig. 10.8). Fourth arm instrument is ProGrasp forceps. Robot is docked, and now the console surgeon starts operating from console.