Robotic Partial Nephrectomy: Transperitoneal Technique

Fig. 6.1

Operating room setup using a three-armed or four-armed robotic technique

Patient Preparation and Positioning

The patient is placed under general endotracheal anesthesia and all intravenous lines, arterial lines, and other monitoring equipment are established prior to patient positioning, as access to extremities will be limited once the procedure has commenced. An orogastric tube is inserted and placed on suction to deflate the stomach, thereby minimizing the likelihood of encountering the stomach intraoperatively and sustaining possible injury, particularly during a left-sided procedure. A urethral catheter is also placed with the drainage bag easily accessible by the anesthesia staff. Sequential compression devices are placed on the patient’s bilateral lower extremities. The patient is positioned over the table such that the table may be gently flexed at the level just above the anterior superior iliac spine, resulting in increased exposure of the flank for well-spaced trocar placement (Fig. 6.2). The kidney rest on the table is generally not required and may increase the risk of perioperative flank complications. The patient is then placed in the lateral decubitus position; a modified flank position is suitable for anterior renal lesions, whereas a full flank position is preferred for posterior renal lesions. For posterior lesions, where medial rotation of the kidney is expected in order to adequately visualize the renal tumor, the patient should be placed in a full flank (vs. modified) position in efforts to utilize gravity to optimize medial mobilization of the ipsilateral colon and spleen (left) or liver (right) and allow unimpeded medial rotation of the kidney. An axillary roll is utilized when the patient is placed in a full flank position to prevent brachial plexus injury. To assist with maintaining the flank position, a large gel roll is placed behind the patient, thus supporting the patient’s back and pelvis. Pillows are placed between the arms to hold the upper arm in an anatomically neutral position (Fig. 6.3). The pillows are carefully placed such that the endotracheal tube is not compromised. Prior to placing the pillows, the dependent arm is placed on an arm board in a neutral position and is secured with pressure points padded. The pillows are placed over this dependent arm and secured to the arm board. The patient’s second arm is placed gently over the pillows, covered with foam padding and secured to the arm board. A shoulder roll is placed such that the shoulder is pulled inferiorly toward the patient’s feet to help minimize the risk of brachial plexus injury. The hips are secured to the table with straps and heavy cloth tape placed over foam padding as are the legs with the dependent leg flexed. All pressure points in contact with the table or tape are padded. Pillows are placed between the legs prior to fastening the table strap over the superior leg, which is left extended. To confirm that the patient is adequately secured to the operating room table, the table is rotated from one extreme to the other, taking care to ensure the patient’s position does not shift.

Fig. 6.2

The operating table is flexed at the level just above the patient’s anterior superior iliac spine, resulting in increased exposure of the flank for well-spaced trocar placement

Fig. 6.3

Pillows are placed between the arms to hold the upper arm in an anatomically neutral position

Instrumentation and Equipment List

Conventional laparoscope with 0° lens (for entry into the abdominal cavity, trocar placement, specimen extraction, fascial closure)
EndoWrist^® curved monopolar scissors (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® curved bipolar Maryland forceps (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® ProGrasp™ forceps (Intuitive Surgical, Inc., Sunnyvale, CA) if using a fourth robotic arm
EndoWrist^® large suture cut needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)
EndoWrist^® large needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)
InSite Vision System with 30° (down) lens (Intuitive Surgical, Inc., Sunnyvale, CA)
Laparoscopic articulating or robotic drop-in Doppler ultrasound probe; e.g., Aloka (Hitachi Aloka Medical Ltd., Tokyo, Japan) or BK ultrasound probe (BK Ultrasound, Peabody, MA)

Trocars

12 mm camera trocar with direct vision obturator
12 mm Airseal^® System assistant trocar
2-3 (depending on whether a three or four-arm technique is performed) × 8 mm robotic standard or extra-long trocars (in case of obese patients)

Instruments Used by the Surgical Assistant

Suction-irrigator device
Laparoscopic needle driver
Laparoscopic blunt tip grasper
Laparoscopic scissors
Hem-o-lok^® clip applier (Teleflex Medical, Research Triangle Park, NC)
Large (purple) Hem-o-lok^® clips (Teleflex Medical, Research Triangle Park, NC)
Lapra-Ty^® clip applier (Ethicon, Somerville, NJ)
Lapra-Ty^® absorbable suture clips (Ethicon, Somerville, NJ)
Atraumatic laparoscopic bulldog vascular clamps (six available: three short, three long), or alternatively, robotic bulldog vascular clamps and applicator (Scanlan International, St. Paul, MN)
Surgicel^® hemostatic gauze (Ethicon, Inc., Cincinnati, OH)
FloSeal^® (Baxter Int. Inc., Fremont, CA, USA)
10 mm Endocatch^® specimen retrieval bag (Covidien, Irvine, CA, USA)
8 French Blake round closed suction drain
Airseal^® System and tubing for insufflation (Conmed, Surgiquest Inc., Milford, USA)

Sutures

3-0 Polyglactin suture on an SH needle × 5; cut to 7″-secured at distal end with Lapra-Ty^® clip and knot (Fig. 6.4a)

Fig. 6.4

(a) 3-0 Polyglactin suture on an SH needle × 5; cut to 7″-secured at distal end with Lapra-Ty^® clip and knot. (b) 0 Polyglactin suture on CT-1 needle × 7; cut to 8″-secured at distal end with Hem-o-lok^® clip, Lapra-Ty^® clip, and knot
0 Polyglactin suture on CT-1 needle × 7; cut to 8″-secured at distal end with Hem-o-lok^® clip, Lapra-Ty^® clip, and knot (Fig. 6.4b)
0 Polydiaxanone suture on a CT-1 needle
4-0 Monofilament absorbable suture on a PS-2 needle
2-0 Monofilament non-absorbable suture on an FS needle

Available and in the Room

Laparoscopic reticulating Endo GIA™ (Covidien, Irvine, CA, USA) stapling device with a 30 mm cartridge length and vascular load
Laparoscopic Satinsky vascular clamp

Step-by-Step Technique

Step 1: Insufflation

Prior to placing the Veress needle, with the surgeon facing the patient’s abdomen, the operating table is rotated away from the surgeon, placing the patient in a relatively supine and horizontal position. A Veress needle is placed in a standard fashion within the umbilicus, penetrating the skin and abdominal fascia. Once satisfied with Veress placement, a drop test is performed and insufflation is commenced with CO₂ to a maximum pressure of 12–15 mmHg. We routinely use the Airseal^® System for insufflation. Once four-quadrant pneumoperitoneum is achieved, we commence placement of the trocars.

Step 2: Trocar Placement

Given the high variability of trocar placement, three- vs. four-arm approach, lateral vs. medial camera port placement, daVinci Si vs. Xi robot, tumor location, and body habitus, a number of trocar configurations can be used. Several literature reports document trocar placement. In general, it is important to place trocars at least 8 cm apart from one another to prevent internal and external instrument collision [2, 3]. With the advent of the daVinci Xi robot, the arms are much smaller in profile and more agile, making collisions minimal when compared to older model robots. As stated before, we will describe our institution’s technique using the daVinci Si robot, based upon a three-arm technique. Reference will be made to maneuvers using a four-arm technique when necessary.

We use a total of four trocars; a 12 mm trocar for the robotic camera, two 8 mm metallic robotic trocars, and a fourth 12 mm trocar to be used by the assistant (Fig. 6.5a, b). A fifth 5 mm trocar may also be placed, particularly for right-sided procedures to assist with liver retraction. Using a direct vision 12 mm trocar and 0° standard laparoscope, the robotic camera trocar is the first trocar to be placed once insufflation is achieved. Placement of this primary trocar for the endoscope is critical to the success of robotic partial nephrectomy and should be tailored according to the unique location of the renal tumor and not based on standard anatomic landmarks. Using the preoperative imaging films (both axial and coronal imaging) and the location of the renal tumor as a guide, the 12 mm camera trocar is placed so as to achieve a proper view of the tumor once dissected and fully exposed. It is critical not to have the camera trocar directly above or too far away from the tumor, compromising instrument maneuverability or visualization of the tumor base, respectively. Ideally, the camera trocar should be strategically placed to allow a 45° downward view of the renal tumor. For posterior renal lesions where the kidney and tumor will need to be rotated medially into view, the camera trocar should be placed further laterally to be able to peer along the posterior surface of the kidney. Once this primary trocar is placed into the abdomen, the Veress needle is identified and surrounding structures visualized to ensure no injury has been sustained. The Veress needle is then removed. At this point, the anterior abdominal wall can be inspected for adhesions, which if present are carefully lysed.

Fig. 6.5

(a) Three-arm trocar placement for daVinci Si. (b) Four-arm trocar placement for daVinci Si and Xi

Prior to secondary trocar placement, the operating room table is rotated to the abdominal side to achieve the final position that the patient will remain in for the duration of the operation. This allows for bowels to fall away from the affected renal unit. The approximate location of the kidney and tumor is estimated based upon visual landmarks such as the contour of the kidney, ipsilateral colon, spleen (on left), and liver (on right). On the outside of the body, with the camera pointing in the direction of the tumor, an “X” is marked on the skin as a rough guide to assist in placement of secondary trocars (Fig. 6.5a). Two 8 mm trocars are then placed under direct vision; these 8 mm trocars are placed in such a fashion that they form a broad-based triangle with the “X” (i.e., tumor) forming the apex of this imaginary triangle. The assistant’s 12 mm Airseal^® trocar is placed under direct vision in a plane that bisects an imaginary line between the camera trocar and the inferolateral 8 mm robotic trocar. Some surgeons opt to use a fourth robotic arm to assist with retraction that is placed through a trocar located dependent and inferior to the most inferior robotic trocar (Fig. 6.5b). Placement of these trocars may need to follow a different order depending on the nature of any adhesions encountered. With obese patients or patients with anatomy that will predispose to the robotic arms clashing externally, extra-long trocars (vs. standard size) can be used to decrease the likelihood of clashing. Occasionally, a fifth 5 mm trocar will need to be placed for right-sided procedures in order to aid with liver retraction (Fig. 6.5a).

The robot is then docked as described earlier. It is important to note that the robotic camera arm rests within the area of the “sweet spot” (a pre-determined area on the joint of the camera arm demarcated by a blue line), allowing for optimal range of motion. The 30° down robotic camera lens is then placed. The robotic instruments are then passed slowly into the abdomen under direct vision.

Step 3: Mobilization of Ipsilateral Colon (Table 6.1)

Table 6.1

Instrumentation for colon mobilization

Surgeon instrumentation		Assistant instrumentation
Right arm	Left arm	• Suction-irrigator
• Curved monopolar scissors	• Bipolar Maryland forceps	• Suction-irrigator

Dissection begins with identification and incision of the white line of Toldt, approximately 2 cm lateral to the ipsilateral colon. The colon is reflected medially and mobilized far enough inferiorly and superiorly so as not to create a “hammock” effect, whereby the extreme ends of the colon are still suspended to the lateral abdominal wall, impeding proper visualization and exposure of the renal hilum. For a left-sided dissection, the descending colon is mobilized from (and including) the spleen down to the pelvic inlet. For a right-sided dissection, the ascending colon is mobilized from (and including) the right lobe of the liver down to the pelvic inlet.

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