Robotic Surgical Procedures for Male Infertility



Fig. 27.1
Operative setup for male infertility robotic procedures





Patient Positioning and Preparation


Figure 27.2 illustrates patient positioning for robotic male infertility procedures. The patient is placed in the supine position. The table is placed level (there is no Trendelenberg). The robot is brought in from the right side of the patient after skin incisions are made and the operative tissues exposed. The arms of the patient may be placed alongside (gently wrapped in the draw sheets) or apart on arm boards with adequate padding to prevent any nerve compression injuries. Sequential compression devices are placed on the lower extremities to reduce the risk of deep venous thrombus formation. A urethral catheter is generally not utilized, however, if the procedure lasts more than 2 h, the patient is usually straight catheterized at the end of the procedure to drain the bladder (before recovering the patient from anesthesia).

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Fig. 27.2
Patient positioning for robotic male infertility procedures


Trocar Configuration


The robot is positioned after skin incisions are made and operative tissues are exposed. The robot is used to perform the microsurgical components of the procedure. Since this is an open case, the trocars are loaded only to allow the instruments to function and to stabilize their movements outside the patient’s body. Figures 27.2 and 27.3 illustrate the trocar placement and robotic arm placement. It is important to advance the instruments at least 4–5 cm beyond the tip of the trocar when positioning the robotic arms to optimize range of motion. The fourth robotic arm may be placed lateral to the left robotic arm to minimize instrument clashes. The 0° camera lens is used to optimize the visual field during procedures.

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Fig. 27.3
Intraoperative trocar placement and robotic arm placement


Instrumentation and Equipment List



Equipment






  • da Vinci® Si Surgical System (four arm system; Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Black Diamond micro needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Micro Potts Scissors (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Micro bipolar forceps (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® curved monopolar scissors (Intuitive Surgical, Inc., Sunnyvale, CA)


  • EndoWrist® Black Diamond micro needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)


  • InSite® Vision System with 0o lens (Intuitive Surgical, Inc., Sunnyvale, CA)


Trocars






  • 12 mm trocar (2)


  • 8 mm robotic trocars (3)


Recommended Sutures






  • 10-0 nylon suture on double-armed fish-hook needles for vasal mucosal lumen anastomosis


  • 9-0 nylon suture on micro needles for vasal muscularis and adventitial lumen anastomosis


  • 6-0 prolene suture on micro needle for vasal adventitial anastomosis and testicular tunical closure in microscopic TESE


  • 3-0 silk suture ties (1.5 in. long) for vein ligation in varicocelectomy

Distal vas deferens is grasped (Fig. 27.4)

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Fig. 27.4
Distal vas deferens is grasped




  • 3-0 chromic suture for dartos layer and subcutaneous skin closure


  • 4-0 chromic suture for scrotal skin closure


  • 4-0 monocryl suture for subinguinal skin closure


Instruments Used by the Surgical Assistant






  • Micro Doppler Probe (Vascular Technology, Nashua, NH)


  • 18-guage angiocatheter on a 10 cm3 syringe for saline irrigation


  • Weck micro sponge sticks


  • Colored vessel loops for vessel identification during varicocelectomy


  • Titanium or Metal small clips via automatic stapler to hold vessel loops during varicocelectomy


Step-by-Step Technique (Video 27.1)



Robot-Assisted Microsurgical Vasovasostomy



Step 1: Identifying the Distal Vas Deferens


The proximal (testicular side) and distal (beyond vasectomy site) vas deferens around the previous vasectomy site is palpated through the scrotal skin. The distal vas just above the vasectomy site is fixed with a towel clip through the scrotal skin (Fig. 27.4).


Step 2: Incising the Scrotum Over the Vas Deferens


A 1–2 cm vertical incision is made with a #15 blade scalpel inferiorly from the towel clip over the vas (Fig. 27.5).

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Fig. 27.5
Scrotal incision made over vas deferens


Step 3: Dissection of the Vas Deferens


The distal and proximal vas ends are dissected free using fine electrocautery and sharp dissection (Fig. 27.6).

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Fig. 27.6
Dissection of the vas deferens


Step 4: Transection of the Proximal Vas and Examining Fluid Efflux


The proximal vas is carefully transected with an 11 blade scalpel and the fluid effluxing from the lumen is collected on a glass slide and examined under phase contrast microscopy to assess for the presence of any sperm (Fig. 27.7). If there is sperm found or the efflux is copious and clear or milky, then a vasovasostomy is performed on this side. If the efflux has no sperm and is thick and pasty, then a vasoepididymostomy is performed (described in the next section).

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Fig. 27.7
Proximal vas is carefully transected and fluid examined


Step 5: Preparing the Ends of the Vasa for Vasovasostomy


The distal end of the vas is also transected and the two clean ends of the vas are now approximated to each other to allow a tension-free anastomosis. Small hemostats are placed on the adventitia next to each end of the vas to avoid any direct manipulation of the vas (Fig. 27.8). The same procedure is performed on the contralateral scrotal side through the same skin incision. The robot is now positioned to perform the microsurgical vasovasostomy as described in the patient and trocar positioning sections above.

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Fig. 27.8
Both ends of the vas brought up to prevent any tension


Step 6: Robot-Assisted Microsurgical Vasovasostomy and Vasal Dilation (Table 27.1)





Table 27.1
Robot-assisted microsurgical vasovasostomy and vasal dilation : surgeon and assistant instrumentation
























Surgeon instrumentation
Assistant instrumentation

Right arm

Left arm

Fourth arm

• Irrigation syringe

• Black diamond micro needle driver
• Black diamond micro needle driver
Micro potts scissors
• Weck sponge sticks

Endoscope lens: 0°

The left side vasovasostomy is performed first. The black diamond micro forceps are loaded on the right and left surgical robot arms. The 0° camera lens is loaded onto the robot camera arm. The micro Potts scissors are loaded onto the fourth robot arm. The two vas ends are placed over a 1/4″ Penrose drain. The assistant now irrigates the field with saline using a 10 cm3 syringe with an 18-gauge angiocatheter tip. Weck sponge sticks are used to dry the field. Each of the lumen of the vas is dilated with the black diamond forceps (Fig. 27.9).

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Fig. 27.9
Vas lumen dilated


Step 7: Passing the Suture to the Surgeon


The assistant now passes the 9-0 nylon suture in its inner packaging to the surgical field to allow the robot console surgeon to grasp the suture (using the black diamond right hand grasper) and cut it at about 2 in. length using the micro Potts scissors (left hand fourth arm) (Fig. 27.10).

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Fig. 27.10
Suture delivered to surgeon


Step 8: Posterior Vasal Muscularis Anastomosis


The 9-0 nylon suture is used to approximate the posterior muscularis layer of the two ends of the vas. The surgeon uses the black diamond forceps in both left and right arms as needle drivers. The fourth arm is used by toggling the surgeons left arm to use the micro Potts scissors whenever suture needs to be cut (Fig. 27.11).

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Fig. 27.11
Posterior 9-0 nylon muscularis suture placed


Step 9: Posterior Vasal Mucosal Lumen Anastomosis


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Jul 17, 2017 | Posted by in UROLOGY | Comments Off on Robotic Surgical Procedures for Male Infertility

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