Basic trocars providing the foundation for robotic nephrectomy include the camera port and at least two other trocars for the robotic left- and right hand instruments. Initially, a surgeon early in his or her experience will add additional trocars for the robotic fourth arm and/or assistant ports. More experience will allow reduction in the number of trocars needed, particularly for more straightforward nephrectomies. The minimum number of trocars with which robotic nephrectomy can be performed is only three (Fig. 9.1). This is particularly beneficial when a bedside assistant skilled in laparoscopy is not available as the procedure can be performed with only a scrub nurse able to change the robotic instruments. Newer surgeons should have a skilled bedside assistant even if this requires having another urologist when specialized assistants or residents/fellows are not available. This will maximize efficiency and aid in progression of the procedure with an additional level of safety.

For more complex nephrectomy procedures, such as caval thrombectomy , additional trocars allow retraction with the robotic fourth arm and/or one or more assistant ports for suction and retraction as well as introduction of needles, hemostatic agents, bulldog clamps, and the like. Surgeons who prefer to staple hilar vessels will need an assistant trocar large enough to introduce the laparoscopic stapler or can use the robotic stapling device available with the newer generation robots. Surgeons who use Hem-o-lok clips on the renal vessels can simply use the robotic clip appliers or can again place an assistant port of at least 12 mm in diameter for the handheld clip applier used by the bedside assistant.

A dedicated 5 mm trocar can be placed for a liver retractor if desired but is not necessary in straightforward right nephrectomies with experience. If a liver retractor is used, care should be taken to avoid external collisions between the robotic arms and the instrument outside the body being used for liver retraction, which will not be seen by the surgeon at the console. Surgeons avoiding a liver retractor can lift the liver edge and use the shaft of the right robotic arm to keep the liver elevated while they dissect the upper pole of the kidney.

The trocar for the camera has been used by some surgeons at the umbilicus or more laterally for those who prefer. The closer the camera trocar is placed to the midline, the wider the view possible and vice versa. Placing the camera trocar too laterally can cause a view that is too close to the kidney and other relevant anatomy, but a lateral camera port does provide additional room for the bedside assistant. An additional advantage of a periumbilical or midline camera trocar is that this can be extended at the end of the procedure to extract the specimen through the linea alba without any muscle cutting.

After placing the camera trocar at the umbilical level through the midline, the scope can be used to guide optimal positioning of the remaining ports with the goal of triangulating the robotic arms around the affected kidney for ideal access and minimization of external arm clashing. The patient side cart can be docked at an angle over the ipsilateral shoulder to create this angulation or the tower rotated on the da Vinci Xi robot to achieve the same goal. The 30° down lens should be used for midline camera trocar configurations while the 0° lens should be used the more lateral the camera trocar is positioned.

Some surgeons prefer to use ruler measurements and sometimes complex algorithms to decide on trocar positioning , but oftentimes one size does not fit all and an understanding of the individual patient’s anatomy is more useful than fixed measurements. Certainly, if measuring and marking the planned trocar sites is done, this is best done after insufflation of the abdomen since pneumoperitoneum will affect the final position and spacing of the trocars.

The working robotic instrument trocars are placed in the lower and upper quadrants ipsilateral to the affected kidney at least 8 in. from the camera trocar and never in line with the camera trocar and patient side cart as this will make docking to the trocars impossible. The exact position of these upper and lower quadrant trocars can be adjusted for better upper pole access when needing to reach high in the abdomen for a predominantly upper pole tumor, for example. In contrast, the trocars can be adjusted for better lower abdominal access, but regardless of minor adjustments in the triangulation of ports, planning must allow adequate access to the hilum for the most critical portion of the procedure.

Assistant ports can be placed before or after the robot is docked, which allows the surgeon to make sure the assistant will have adequate reach to the trocar and to make sure there will be less external collisions with any trocars to be used for static retraction (e.g., liver retractor). On the right side, a 5-mm trocar is adequate for suction or retraction and can be placed in the right upper quadrant for the liver or in the lower quadrant for the colon and/or duodenum.

On the left side, a lower quadrant assistant port is better for retraction of the colon when needed. If the surgeon uses the bedside assistant to clip or staple the renal vessels, a 12 mm port is best placed in the lower quadrant so that the angle of approach to the hilum will be more perpendicular. This way, when clipping or stapling a vessel, visibility will be better, including the back end of the clip or stapler just before deploying to make sure it is all the way across the vessel.

Our preference is to use the robotic cautery scissor and fenestrated Maryland bipolar for the entirety of the procedure, using the robotic Hemolock clips for the renal artery, renal vein, and ureter (and gonadal vein when appropriate). Other robotic energy instruments can be substituted, including hook cautery or other robotic bipolar energy instruments. Suction is typically not needed if hemostasis is maintained, but if no assistant port is being used and suction is needed, it can be accomplished through a robotic instrument port by temporarily removing the robotic instrument and applying the included reducer cap on the port valve.