Fig. 30.1
Operating room setup for right partial nephrectomy demonstrating standard configuration of operating room personnel and equipment
Fig. 30.2
Operating room setup for left partial nephrectomy demonstrating standard configuration of operating room personnel and equipment
Patient Positioning and Preparation
Place the patient in modified flank position with a 30° wedge under the ipsilateral side where the partial nephrectomy will be performed with padding and tape across chest and thighs. Also, place folded towels and tape over the patient’s arms but under abdomen (Fig. 30.3). Rotate the table so that the patient’s abdomen is flat while obtaining trocar access, then rotate to 60° (30° wedge plus 30° table rotation) just prior to docking the robot. The anesthesia team should place an NG or OG tube prior to access.
Fig. 30.3
Patient positioning shown for a left partial nephrectomy
Trocar Configuration
Trocar configurations for left and right partial nephrectomies are shown in Figs. 30.4 and 30.5. One notable difference is the possibility of needing an extra trocar for liver retraction during a right partial nephrectomy. Again, we typically use the 5 mm trocars when the patient is younger than 8–10; otherwise, the 8 mm trocars are used.
Fig. 30.4
Trocar configuration for right partial nephrectomy. (A) Working port is roughly half the distance between the umbilicus and the xiphoid. (B) Working port is roughly 2/3 the distance between the umbilicus and the anterior superior iliac spine (ASIS), but if the area of interest is in the lower retroperitoneum or the child is small, may be adjusted medially and inferiorly. (C) Working port is for retraction of the liver
Fig. 30.5
Trocar configuration for left partial nephrectomy. (A) Working port is roughly half the distance between the umbilicus and the xiphoid. (B) Working port is roughly 2/3 the distance between the umbilicus and the anterior superior iliac spine (ASIS), but if the area of interest is in the lower retroperitoneum or the child is small, may be adjusted medially and inferiorly
Instrumentation and Equipment List
Equipment
Da Vinci® Surgical System (3-arm system; Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist® Monopolar Hook Electrocautery, 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist® Maryland Dissector, 5 mm or Bipolar Maryland Dissector, 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist® Curved Monopolar Scissors, 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist® Round Tip Scissors, 5 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist® Needle Driver , 5 or 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
Articulated Suction device, 8 mm (Intuitive Surgical, Inc., Sunnyvale, CA)
InSite® Vision System with 30° lens (Intuitive Surgical, Inc., Sunnyvale, CA)
Trocars
10 mm trocar—camera port
8 mm robotic trocars (2, if child is older than 8 years)
5 mm trocar (usually 2, if you need liver retraction during a right partial nephrectomy then you will need a 3 mm or 5 mm port for a lifting/retraction device)
Recommended Sutures
Preplaced fascial box stitch: 2-0 or 3-0 polyglactin suture
Vessel ligation and closure of renal defect: 3-0 and/or 4-0 polyglactin suture, length 12–14 cm by age
Skin Closure : 4-0 or 5-0 monocryl suture
Instruments Used by the Surgical Assistant
Laparoscopic needle driver
Maryland grasper
Suction irrigator device
Laparoscopic Kittner
5 mm titanium clip applier, medium (two are always kept in room)
Step-by-Step Technique (Video 30.1)
Step 1: Abdominal Access and Trocar Placement
For a right partial nephrectomy , reposition the patient in a right modified flank position as noted above then, for trocar placement, rotate the table so the patient’s abdomen is 0°. The 12 mm camera trocar is placed in the area of the umbilicus, using the Hasson open technique with 2-0 polyglactin suture on a UR-6 needle or a 3-0 polyglactin suture on a CT-2 needle bent accordingly. These are pre-placed fascial box stitches (used later for closure). Working trocars are then placed sharply under direct vision after pre-placing the fascial box stitches. For right-sided operation, a fourth trocar is placed for liver retraction. This trocar is placed in the left upper quadrant to permit passing between the camera and upper working trocar without interference and to lift the liver for exposure. Either a blunt Kittner dissector or a grasping tool is passed under the liver edge, lifted and pushed against the opposite abdominal sidewall to stabilize the instrument and liver. Rotate the patient to approximately 60° (30° from table rotation and 30° from the wedge placed earlier) and dock the robot.
Step 2: Accessing the Nonfunctioning Moiety (Table 30.1)
Table 30.1
Accessing the nonfunctioning moiety : surgeon and assistant instrumentation
Surgeon instrumentation | Assistant instrumentation | |
|---|---|---|
Right arm | Left arm | • Suction-irrigator |
• Monopolar hook electrocautery | • Maryland dissector | • Laparoscopic Kittner |
Endoscope lens: 30° down
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