Fig. 7.1
(a) Operative room set-up for right partial nephrectomy; (b) Operative room set-up for left partial nephrectomy
Patient Positioning
Under general endotracheal anesthesia , the patient is placed in a modified (30°–70°) lateral decubitus position, with the umbilicus over a mild break in the table. An axillary roll is placed, the table is flexed as necessary (usually minimally compared with open flank surgery), and copious padding is used and positioned to support the buttocks and flank. Pillow(s) are placed between the flexed lower and straight upper leg. The upper arm rests on a well-padded arm board (or pillows) without tension on the brachial plexus. Tape is used to secure the patient around the hips, shoulders, and thighs to ensure stability when rolling the table to facilitate bowel retraction (Fig. 7.2). Care is taken to adequately pad all pressure points and place all limbs in neutral position to minimize positioning injuries. The abdominal skin is shaved with clippers and the patient is prepped and draped in standard sterile fashion for a trans-peritoneal robotic surgery. An 18-French urethral catheter is inserted and an orogastric tube is placed. A standard timeout is called prior to incision.
Fig. 7.2
Patient positioning
Instrumentation and Equipment List
Equipment
Da Vinci ® Si or Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA)
0° and 30° robotic scope (Intuitive Surgical, Inc., Sunnyvale, CA)
Monopolar Scissors (Intuitive Surgical, Inc., Sunnyvale, CA)
ProGrasp™ Forceps (Intuitive Surgical, Inc., Sunnyvale, CA)
Bipolar Grasper™ Forceps (Intuitive Surgical, Inc., Sunnyvale, CA)
Needle Drivers (Intuitive Surgical, Inc., Sunnyvale, CA)
Clip Appliers (Intuitive Surgical, Inc., Sunnyvale, CA)
Trocars
12-mm visual obturator trocar (Visiport, Medtronic Parkway, Minneapolis, Minnesota)
5-mm trocar × 2
8-mm trocar × 2
Bariatric 8-mm trocar × 2
Assistant Instruments
Suction irrigator device (Bariatric length)
Laparoscopic spoon forceps
5-mm locking atraumatic grasper
Hem-o-lok applier (Teleflex Medical, Research Triangle Park, NC)
Medium (purple) Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC)
Small (green) Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC)
10-mm LigaSure Atlas™ Sealer/Divider device (Valleylab, Tyco Healthcare Group LP, Boulder, CO)
Laparoscopic Needle driver
Laparoscopic scissor
0-mm specimen entrapment bag
Sponge on a stick
Laparoscopic Doppler ultrasound probe
Surgicel ® hemostatic gauze (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA)
Hemovac or Jackson Pratt
FloSeal hemostatic matrix (Baxter International, Deerfield, IL)
FloSeal laparoscopic applier with obturator (Bariatric length) (Baxter International, Deerfield, IL)
Laparoscopic bulldog clamps
Neurosurgical aneurysm micro bulldog clamps (Bear™ disposable vascular clamp, AROSurgical, Newport Beach, CA)
Mini-vessel loops (Devon Dev-o-loops, Tyco Healthcare, Mansfield, MA).
Indocyanine Dye (Akorn, Lake Forest, IL)
Recommended Sutures
4-0 Prolene suture or 3-0 Vicryl suture on a SH needle (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA)
4-0 Monocryl or V-Loc barbed suture (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA)
Step-by-Step Technique (Videos 7.1, 7.2 and 7.3)
Step 1: Pneumoperitoneum and Trocar Placement (Fig. 7.3)
Fig. 7.3
(a) Trocar placement for left partial nephrectomy. (b) Trocar placement for right partial nephrectomy
A transperitoneal ap proach is typically used for most tumors. Our standard trocar placement configuration allows for treatment of all renal tumors irrespective of location, whether upper pole, lower pole, or hilar. We employ four robotic trocars with 1–2 assistant ports. Veress needle pneumoperitoneum (13–15 mmHg) is established and the first trocar (12-mm for the Si robot; 8-mm for the Xi) is inserted on the same level as the 12th rib just lateral to the para-rectus line. The robotic camera is inserted and the peritoneal cavity inspected to ensure safe entry. Bariatric 8 mm trocar is placed at the costal margin just slightly cephalad and lateral to the pubic bone (just lateral to the medial umbilical ligament). A standard 8 mm trocar is placed two fingerbreadths above the anterior superior iliac spine. Assistant trocars are placed in their traditional locations: one trocar between the camera trocar site and upper-most robotic arm, another between the camera and the lower robotic arm. Both assistant trocars are placed slightly more medial than the other trocars.
To reduce instrument clashing, the trocar configuration should form an equilateral triangle between the camera port, the lower bariatric port, and the lateral traditional robotic port. For a right partial nephrectomy, an additional incision is made at the xiphoid sternum where the liver retractor is inserted. In this trocar configuration, the lower bariatric trocar is the most “active” arm, regardless of laterality. The use of a bariatric, and thus longer, trocar enhances our reach when treating upper pole tumors. Specimen retrieval typically occurs in the more caudal assistant port, though this is patient dependent. The surgical table is tilted, and the da Vinci® is docked posterior to the patient with the camera arm coming in to the patient at an angle of 15° in line with the camera port. Robotic instruments are inserted into the peritoneal cavity under direct vision.
Steps 2-3: Bowel Mobilization and Hilum Dissection
These steps are standard procedural steps for RAPN and have been discussed elsewhere. We present a brief summary of these steps. The Gerota’s fascia-covered kidney and the uretero-gonadal packet are visualized and retracted laterally. The main renal artery and vein are circumferentially mobilized and each is encircled with mini-vessel loops.
Steps 4–5: Hilar Micro-dissection and Super-Selective Arterial Clamping
Medially Located Tumors and Visible Confirmation of Interrupted Perfusion
The pre-operative CT-reconstructed 3D renal arterial images help guide and orient the surgeon during arterial micro-dissection. The main renal artery and vein remain unclamped during this procedure. Delicate and selective anatomical vascular micro-dissection of tumor feeding arterial branches (tertiary, quaternary or higher order) is performed deep into the renal hilum in a medial-to-lateral direction. Micro-dissection of tertiary renal arterial branches is advanced by dissecting into the renal sinus by developing the peri-pelvic plane of Gil-Vernet. A small radial nephrotomy incision is initiated on the concave, hilar edge of the kidney directly overlying the tumor-feeding arterial branch. Mini-vessel loops can be used to isolate and atraumatically retract higher-order arterial branches as the surgeon advances the micro-dissection toward the tumor; the small radial nephrotomy incision is extended to 2–3 cm to extend the micro-dissection intra-renally, if necessary. If a nephrotomy incision is deemed necessary, it should be made on the hilar edge of the kidney directly overlying the anterior surface of that specific arterial branch. Once the perceived terminal, tumor-feeding arterial branch is identified, a neuro-surgical aneurysm micro-bulldog is placed temporarily to confirm selective devascularization of the tumor. Visual (normal color and turgor), color-Doppler and “fire-fly” indigo-cyanine green fluorescence inspection of the surrounding normal kidney is performed to confirm that this super-selective clamping did not interrupt perfusion to the normal kidney. Topical papavarine can be applied onto the renal hilar vessels to counteract any vasospasm.
Related posts:
Complications and Management of Robotic Assisted Partial Nephrectomy
Complications in Pediatric Robotic Surgery
Single-Port Robotic Surgery: Current Status and Future Considerations
Pediatric Robotic Anti-reflux Procedures
Robot-Assisted Radical Nephroureterectomy
Transperitoneal Robot-Assisted Radical Prostatectomy: Posterior Approach
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