Renal cancer. Contemporary management. Editor John A. Libertino. Springer New York, 2013
The techniques described for transperitoneal laparoscopic partial nephrectomy can be translated for use with the da Vinci (Intuitive Surgical, Sunnyvale, CA, USA) robotic surgical system. The use of articulating arms may decrease challenging angles necessary during renal surgery, such as closing the collecting system or placing renal parenchymal sutures. Patient positioning is the same as for the transperitoneal laparoscopic approach with patients placed in the 45° modified flank position with the table maximally flexed. Rather than being centered on the table, the patient’s posterior is closer to the side where the robot is docked so as to decrease the reach of the robotic arms over the patient’s torso. Typically there are four robotic ports and an assistant port placed between the camera trocar and the left robotic working trocar, with an additional subxiphoid liver retractor for right-sided tumors.
Фиг. 14.4. (a) Placement of Surgicel bolster under 0 Vicryl mattress parenchymal sutures. Early unclamping has been performed, hence perfused renal parenchyma. (b) Bolster sutures are cinched down using slip technique of Hem-o-lok (Image courtesy of use, www.urologybook. com)
Фиг. 14.5. Trocar placement for robotic-assisted laparoscopic partial nephrectomy. LR 5 mm liver retractor port, R robotic right arm, C robotic camera, L robotic left arm, LT robotic lateral trocar
When selecting trocar sites, attention must be paid to ensuring adequate distance between sites so that there is sufficient working room for the instruments. Robotic trocars and the camera should be placed at least 8 cm away from each other. Initially, a 12 mm incision is made lateral and cephalad to the umbilicus, where the 30°down laparoscope is placed. Three additional 8 mm ports are placed at the ipsilateral edge of the rectus muscle, midline about 3 cm below the umbilicus (robotic left arm for right-sided renal tumors), and cephalad to the camera port (robotic right arm for right-sided renal tumors). The robot is docked at nearly 90° to the table. We place one robotic arm in the later almost position on the abdomen during transperitoneal cases. The ideal location for this arm is determined after the robot has been docked. In this way, the least amount of arm clashing can be determined. The fourth arm with a prograsper may be used to provide counter retraction during bowel takedown and hilar dissection. With alternative instruments, the fourth arm may be used for kidney and tumor dissection. The bedside assistant is responsible for suctioning, retraction when needed, delivery of sutures, and placement of clips on sutures. Depending on the method of hilar clamping, this may also be the assistant’s responsibility (Фиг. 14.5).