Patient positioning and anesthetic considerations are similar to robotic-assisted laparoscopic prostatectomy (See Chap. 21). Patients are placed in dorsal lithotomy position utilizing Allen stirrups with both arms tucked to the patient’s side. The vagina , urethra, and abdomen should be prepared in the sterile operative field. Positioning should insure full intraoperative access to the vagina .

The patient is moved to the operative table in supine position with the buttock just superior to the removable foot portion of the table. Induction of general endotracheal anesthesia is performed by the anesthesiologist. Once anesthesia has released the patient for positioning by the operating room staff, the hands and elbows are padded bilaterally with egg-crate foam, ensuring that the intravenous access is still functioning accordingly. There are two draw sheets, one of which will remain on the table and one that will be used to tuck the arms. The patient is rolled by one operating room staff while another brings the upper draw sheet over the arm wrapping underneath the arm and tucked between the patient and bed. This is then repeated for the opposite arm. Care must be taken to ensure that the fingers are appropriately protected and the hands are in the thumb up position at their side. Thigh length sequential compression devices (SCDs ) are then placed on the patient. Allen stirrups are then secured to the operative table. A pillow case or sheet is placed in each Allen stirrup. Simultaneously, each leg is placed in its respective Allen stirrup ensuring that the heels are appropriately seated. Egg-crate foam is placed laterally just below the knee to protect the fibular nerve from any pressure. Egg-crate foam is also placed over the foot prior to securing the straps on the Allen stirrups. The SCDs are then attached to the pump. The foot end of the operative table is then removed. The stirrups are then manipulated to ensure a >90° angle about the knee, with the knees in line with the opposite shoulder. Stirrups are dropped to the low lithotomy split leg position as well as the high lithotomy position to ensure appropriate range of motion and positioning. They are then left in the low lithotomy position. Egg-crate foam is then placed across the patients’ chest superior to the xiphoid. Two strips of heavy silk tape are then brought across the patients’ chest over the foam and secured to the table . This should be snug but not too tight. Check with anesthesia to ensure the tidal volumes are still appropriate. A warming device or blanket may then be placed superior to the xiphoid per anesthesia preference. The patient is prepped from the xiphoid to below the perineum. The prep should be carried out laterally to the table and inferiorly to the mid-thigh bilaterally. The patient is then placed in 20° Trendelenburg for the initial portion of the case. A universal protocol time out is performed with all in attendance confirming correct patient, correct procedure, correct side (not applicable in this case), correct equipment, and any special considerations. All in attendance must verbally agree prior to the procedure start.

A total of five trocars are utilized for the robotic portion of the case (Fig. 26.2). A 12 mm camera port is placed in the supra-umbilical midline. The left-sided 8 mm robotic trocar is placed 15 cm from the mid portion of the pubic bone and 8 cm from the midline. The right-sided 8 mm robotic trocar is placed 15 cm from the mid portion of the pubic bone and 8 cm from the midline. A 12 mm assistant trocar is placed 7 cm superolateral to the right-sided 8 mm robotic trocar. A 5 mm assistant trocar is placed 7 cm superolateral to the camera trocar on the patients’ right-hand side. If a fourth arm is desired for the robot, a third 8 mm robotic trocar can be placed 10 cm lateral to the left 8 mm robotic trocar.

Surgical instrumentation is similar to robotic-assisted laparoscopic radical prostatectomy and is listed in Table 26.1.