Figure 58.1
Port placement for robotic radical prostatectomy. Schematic representation
The port placement consists of:
Four Robotic Ports
1: 12 mm port – Camera
3: 8 mm ports – 4th arm, Right Arm, and Left Robotic Arm
One to Two Assistant Ports
1: 12 mm port
1: 5 mm port (optional)
The robotic ports are placed four fingerbreadths apart from each other while the assistant port is three fingerbreadths apart from the camera port. Robotic ports are also placed on a parallel plane slightly below the umbilicus. A 5 mm assistant port is optional and can be utilized for more difficult cases where additional assistance is required. This port placement facilitates optimal utilization of the robot and is an adequate configuration to minimize exterior robotic arm clashing.
Robotic Radical Cystectomy
The gold standard of care for muscle-invasive and refractory non muscle-invasive bladder cancer is radical cystectomy [7]. Like other robot-assisted surgeries, robotic radical cystectomy (RRC) is gaining in popularity. Population-based studies conducted in the US demonstrated that the proportion of RRCs has consistently increased from 0.6 % in 2004 to 12.8 % in 2010, and over 2,101 RRCs have been performed to date [5, 8]. We have previously reported on our technique for RRC [4].
Our port placement for RRC is similar to RRP, with a few differences (Fig. 58.2). The patient is once again placed in lithotomy and in steep Trendelenburg. The port placement consists of:
Figure 58.2
Port placement comparison for robotic radical cystectomy. Demonstrating difference in port placement position for robotic radical cystectomy versus robotic radical prostatectomy. Schematic representation
Four Robotic Ports
1: 12 mm port – Camera
3: 8 mm ports – 4th arm, Right arm, and Left robotic arm
Two Assistant Ports
1: 12 mm port
1: 15 mm port
In comparison to RRP, the port placement is considerably more cephalad for RRC; this is attributed to the necessary additional reach required during proximal lymph node dissection and ureteral mobilization. The camera port is placed a hands breadth above the umbilicus while the working robotic ports are in line with the umbilicus. The 15 mm assistant port is placed slightly more caudal and lateral; this positioning provides for improved angulation during stapling for the neobladder.
Port Placement for Robotic Kidney Surgery
Transperitoneal Approach
One benefit to our port placement for robotic transperitoneal renal surgery is that this configuration can be used to treat renal tumors located in upper pole, hilar region, and lower pole. We once again use a four-arm approach with 1–2 assistant ports (Fig. 58.3a, b). The patient is placed in lateral decubitus position. For our nephrectomy robotic surgeries, we utilize the use of 8 mm bariatric robotic ports, which are placed at the costal margin and just slightly cephalad and lateral to the pubic bone. An 8 mm “regular” robotic port is placed two fingerbreadths above the anterior superior iliac spine and the camera and assistant ports are placed in their traditional locations. To minimize instrument clashing, we aim for an equilateral triangle between the camera port, the lower bariatric port, and the lateral regular robotic port. For right nephrectomy surgery (Fig. 58.3b), the port placement is similar to the left nephrectomy surgical port placement. The difference is the addition of the liver retractor port, which is placed at the xiphoid sternum. An equilateral triangle configuration is once again desired between the lower bariatric robotic port, camera port, and lateral standard robotic port. This configuration allows for optimal use of the four robotic arms while minimizing intra-peritoneal instrument clashing and exterior robotic arm clashing.
