Editing Robotic Partial Nephrectomy (section)

=== Transperitoneal ===
* '''Position:''' Ipsilateral (tumor side up), modified flank/lateral decubitus at approximately 60-90° (if left sided, 90° so that spleen can fall; if <span style="color:#800080">right</span>-sided, less than 90°; alternatively, 45° has been described[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762997/]).
**Some surgeons prefer to flex operating table. If flexing table, position patient so that midpoint of inferior aspect of ribcage and superior aspect of pelvic bone is at break of bed
* '''Surgical plan:'''
** '''Number of ports: 5 (6 if <span style="color:#800080">right</span>-sided)''' (variations possible, depending on patient/tumour characteristics, surgeon preference, and institution equipment)
***4 robot ports + 1 assistant port +/- 1 liver retractor for <span style="color:#800080">right</span>-sided tumors
****Left hand: fenestrated bipolar graspers
****Camera
****Right hand: monopolar curved scissors (jaw length 1.1cm[https://r2surgical.com/products/470007-round-tip-scissors-new])
****Inferior port: Prograsp graspers
** '''Location of ports:'''
*** General considerations for robotic port placement
**** Port placement through the rectus muscle risks damage to the epigastric vessels.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***** The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***** Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[12]
**** 8-10 cm distance is recommended between robotic ports[https://fcc.report/FCC-ID/2AAZF-CHB01/2607925.pdf][https://www.auanet.org/documents/education/blus-handbook.pdf]
***** 10-20 cm distance should be maintained between the ports and target anatomy[https://fcc.report/FCC-ID/2AAZF-CHB01/2607925.pdf]
****** 10 cm distance from TA is good but 20 cm distance is better
****For accessory ports, maintain at least 5 cm from the other ports[https://fcc.report/FCC-ID/2AAZF-CHB01/2607925.pdf]
***Configuration 1: Straight line configuration (if Xi)[https://pubmed.ncbi.nlm.nih.gov/2241039/]
****All robotic ports are placed in a straight line lateral to the the lateral border of the ipsilateral rectus abdominus muscle. This line may translate laterally (obese patient, lateral tumor) or medially (skinny patient, medial tumor), depending on patient and tumour characteristics
***# Superior robotic port (8 mm): 2 fingerbreadths below the costal margin
***#Camera robotic port (8 mm (12 mm if Si)): 6 cm inferior to Superior robotic port
***# Robotic Arm 3 port (8 mm): 6 cm inferior to Camera robotic port
***# Most inferior robotic port (8 mm): 6 cm inferior to Robotic Port 3
***# Assistant (12 mm): half-way between camera and Robotic Arm 1, medial to these ports, in midline
***'''If <span style="color:#800080">right</span>-sided, additional 5 mm trocar placed just inferior +/- lateral (depending on anatomy) to xiphoid process to retract liver.''' Use laparoscopic locking clamp to hold on abdominal wall/diaphragm and retract liver away from surgical field.
****Depending on liver anatomy, liver retractor may need to be placed in contralateral side.
** '''Step by step:'''
*** '''General anesthesia and insertion of lines.''' Use naso/orograstric tube for gastric decompression during case.
*** '''Patient positioning, antiseptic preparation, draping.'''
**** After induction of general anesthesia...
**** Trim hair overlying operative site, if needed.
****While patient is supine, outline midline in approximate area of assistant port.
**** Insert foley catheter and have tubing go over contralateral leg.
**** Optional (if flexing operating table): Slide patient up/down table so that ASIS is at/below the break.
**** Slide patient laterally to tumor side of table and roll patient so that the anterior abdomen is placed on the contralateral edge of the table. Position patient in ipsilateral (tumor side up), modified flank/lateral decubitus.
**** Axillary roll should be placed (under the upper chest, at a level inferior to the tip of the scapula, rather than under the axillary region[https://pubmed.ncbi.nlm.nih.gov/2241039/]) to prevent neuropraxia.
***** Should be placed so that a palm can be placed vertically between armpit and axillary roll.
*****An axillary roll is not required if the patient is tilted at the 45° angle and not lying directly on his or her axilla[https://pubmed.ncbi.nlm.nih.gov/27109204/].
**** Use gel rolls, rolled blankets, or a bean bag to support the back.
**** Bottom leg flexed. Top leg straight. Pillows between legs.
****Optional: Flex table approximately 30 degrees. Slight Trendelenburg to level table parallel to floor.
**** Secure the patient to the table with wide cloth tape under axilla and at hip. Secure tape to underside of metal sidebars of table.
**** Contralateral arm is placed on a padded arm rest, and the ipsilateral arm is rested over the side of the body. Place foam padding to support ipsilateral wrist and elbow.
**** Meticulously apply foam pad soft tissue and bony sites, including the head and neck, axilla, hip, knee, and ankle, along with careful ergonomically neutral positioning of the neck, arms, and legs
**** Prepare surgical area and drape to expose umbilicus, xiphoid, costal margin, and ASIS.
*** '''Abdominal access with transumbilical Veress needle.''' Apply penetrating towel clamps superior and inferior to umbilicus. With fingers under clamp, gently lift (as excessive elevation can cause separation of the abdominal layers and increase risk of pre-peritoneal placement). Insert Veress needle at 90 degrees. Feel or hear (usually) 2 (corresponding to the penetration of the abdominal fascia and parietal peritoneum) clicks/pops (the protective sheath clicking when it recoils), indicating that the abdominal cavity has been entered.
****If transumbilical unsuccessful (3 attempts) or contraindicated (presence of umbilical pathology such as adhesions or herniations, peri-umbilical scars, aortic pulsations, thin patient), consider left upper quadrant (also known as Palmer’s point) entry.
*****Palmer’s point: 3cm below the left subcostal border in the mid-clavicular line
******Contraindications to Palmer’s entry include splenomegaly, hepatomegaly, portal hypertension, gastric or pancreatic masses, history of a splenic or gastric surgery and presence or suspicion of left upper quadrant adhesions.
******If Palmer’s point contraindicated, consider a point that is in middle of ASIS and umbilicus and translate this point superiorly to the level of the umbilicus
******If not transumbilical entry, use cautery/knife to make incision at planned entry point. Dissect down through fat to expose fascia. Use Kocher clamp to lift up on fascia. Insert Veress needle.
******In patients with potential of significant abdominal adhesions, consider open (Hassan) entry
***'''Test Veress needle and insufflate, if appropriate.''' Aspirate and inspect for blood or fecal content. If negative, inject saline for drop test (though not reliable). Aspirate the needle again. If successful on initial testing, gently advance the needle 0.5cm. Turn on insufflation to high flow (no need to begin at low flow because the size of the Veress needle limits flow to 1.5-2L/min) and evacuate initial air in tubing that is not CO2. Connect gas tubing to needle. Check for 3 consecutive pressure readings below 10mmHg. 
****If pressure >10 mm, withdraw needle slightly. If pressure decreases to <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed. 
***'''Achieve pneumoperitoneum''' to 15 (or 20; 20 facilitates port placement by increasing abdominal resistance, but have to remember to decrease after ports inserted) mm Hg.
*** '''Outline landmarks.''' Use a marking pen to outline costal margin, iliac crest, and lateral border of rectus.
***'''Outline port sites.''' Use marking pen to denote transverse incisions for robotic (8mm) and assistant (12mm) ports. Robotic ports should be at least 6cm (approx. 3 fingerbreadths; 8cm if Si[https://pubmed.ncbi.nlm.nih.gov/2241039/]) from each other and, within appropriate distance to target anatomy (15-20cm). Make sure assistant has good access to field from assistant port.
*** '''Insert midline assistant port using visual obturator.''' Twist assistant port into abdomen. Twisting is more important than pushing. Once in, remove trocar (should hear air coming out when opening valve on port), and insert camera (30 degrees). Switch gas to this port.
***'''Inspect abdomen.''' Check that no injury made to the bowel during insertion of Veress needle. Check for adhesions that may interfere with port placement.
***'''Insert remaining ports.''' Transilluminate abdominal wall to avoid large abdominal wall vessels. Begin insertion of most superior port (facilitates visualization). Use knife to make an 8mm transverse incision in this area. Twist port into incision under vision. Take out obturator and advance trocar until black line. Repeat steps for other ports. On <span style="color:#800080">right</span> side, setup liver retractor with Allis clamp through 5-mm subxiphoid port.
***'''Dock robot and insert instruments.''' Attach camera port to robot. Insert and attach camera. Target camera to renal hilum; use external cues (subcostal region) in addition to internal cues (posterior to lower liver on the right side, or several inches caudad to the spleen on the left). Hold camera port steady and allow robot to adjust. Adjust [https://vimeo.com/544900363 boom rotation], as needed. Attach remaining ports to robot. Insert monopolar scissors in right robot arm, bipolar fenestrated graspers in left robotic arm, and Prograsp graspers in inferior robotic arm. Connect monopolar and bipolar electric cords. Advance instruments under direct vision. Rotate the patient [https://www.youtube.com/watch?v=Bj_NjtsjUsI&t=164 clearance] joints on arms #1 and #4 toward the patient to maximize arm movement[https://pubmed.ncbi.nlm.nih.gov/2241039/].
****Alternatively, if more space between the arm and the patient is desired, rotate the patient clearance joints clockwise away from the patient and the preceding arm, resulting in the external arms assuming a steeper angle[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193435/]
***'''Lysis of adhesions, if needed.''' Check for adhesions and take any down if needed.
*** '''Medialize bowel to expose retroperitoneum.''' Use 30 degrees down camera. Incise peritoneum lateral to the white line of Toldt. The bowel mesentery is bright yellow in color while the retroperitoneal fat is dull yellow. Use blunt and sharp dissection to develop plane anterior to Gerota fascia and posterior to the mesocolon. Release attachments to the spleen and liver as needed.
**** Medial retraction by the assistant facilitates this step.
**** Line of Toldt should be divided at the junction between mesocolon and Gerota's fascia.
***** Take care to leave the kidney attached laterally to avoid unnecessary mobilization into the operative field.
***** If hole made in mesocolon, repair with absorbable suture
**** Thin pulsatile vessels belong to the mesentery and should not be divided. If there is undue bleeding, the plane is most likely wrong and needs revision
****'''On the <span style="color:#800080">right</span> side, goal is to identify the IVC;''' there is no need for extensive mobilization of the bowel to expose the renal hilum. 
*****'''Caution: To avoid duodenal injury, use minimal cautery during the medialization of the duodenum.'''
***'''Mobilize upper pole.'''
****'''On the left side, mobilize the spleen completely to avoid potential splenic injury.''' Be careful of splenic artery and pancreas. When developing space between spleen and kidney, use left hand under spleen to protect spleen. Use hand over hand motion. For efficiency, develop this space completely, before continuing to mobilize the colon.
**** '''On the <span style="color:#800080">right</span> side, the right triangular ligament may be divided to lift the liver off the upper pole.'''
***** On the right lobe of the liver, the anterior and posterior layers of the coronary ligament of the liver join to form the right triangular ligament.[https://www.kenhub.com/en/library/anatomy/liver-ligaments]
***** [[wikipedia:Falciform_ligament|Falciform ligament]] runs along the anterior surface of the liver and is attached on one end to the peritoneum behind the right rectus abdominis muscle and the diaphragm.
*** '''Identify ureter and gonadal vein'''. Use 30 degrees up camera. Use the 4th arm to retract the kidney laterally after sufficient medialization of the bowel. The mid-ureter is identified along the anterior aspect of the psoas, just inferior to the lower pole of the kidney. If too inferior, ureter will be medial and goal is to get under it so better to approach closer to lower pole. Once the ureter is identified, dissect a plane medial and parallel to the ureter +/- gonadal vein.
**** At times, especially early in the experience, the psoas tendon or the iliac artery may be confused with the ureter. It is important to look for the peristalsis of the ureter in case of confusion.
**** '''The gonadal vein is an important anatomic landmark when proceeding toward the renal hilum;''' the renal vein can be identified by tracing the gonadal vein proximally to its insertion in the
***** Renal vein, on the left side
***** Inferior vena cava just caudal to the hilum, on the right side
**** '''On the <span style="color:#800080">right</span> side, the gonadal vein is kept medially toward the vena cava, whereas on the left side, the gonadal vein is lifted along with the left ureter to expose the lower margin of the left renal hilum.'''
**** '''Proximally, the gonadal vessels are medial to the ureter. The gonadal vessels descend laterally and cross anterior to the ureter, “water under the bridge”''', '''a third of the way to the bladder.'''
***** '''On the left side, the gonadal vessels cross the left ureter after running parallel to it for a small distance'''
***** On the left side, be careful not to confuse the IMV for the gonadal vein. The IMV will be in the mesocolon, the gonadal vein will be in the retroperitoneal space
**** The gonadal artery is usually found just below the lower pole and if needed, can be ligated and divided.
*** '''Dissect along psoas towards renal hilum.''' Use the 4th arm to elevate the ureter +/- gonadal vein. Develop the plane superiorly towards the renal hilum, anterior to the psoas muscle. A few small ureteric vessels may be encountered which can be divided by the use of energy devices. The traction on the ureter is constantly re-positioned as one works towards the hilum.
***'''Identify and dissect renal hilum'''. During hilar dissection it is important to place the kidney on stretch, to improve identification and to facilitate dissection of the hilar vessels. Identify renal artery. The renal artery is posterior to the renal vein. The renal artery only needs enough dissection to allow bulldog to clamp it i.e. circumferential dissection is not needed. Place clamp(s) in the vicinity of the renal artery.
**** '''Caution: be careful not to miss early arterial branching''' that is more common on the right side, especially if a venous occlusion is planned, as this may lead to kidney congestion and may result in more bleeding.
**** '''Consider renal vein clamping for (3) <span style="color:#800080">right</span>-sided tumors, central tumors, and large tumors.'''
*****Advantages of renal vein clamping: decreased bleeding during tumor resection
*****Disadvantage of renal vein clamping: more dissection needed, potentially increasing risk.
**** If needed, the left gonadal vein can be ligated and divided to increase mobility of the renal vein and potentially improve exposure of the renal artery.
**** If left side, lumbar veins may be seen and these should be preserved, if possible.
*** '''Identify tumour and defat kidney.''' Make an incision in Gerota's fascia and dissect through fat in an area far from the tumor to find the kidney capsule. When near capsule, grasp fat and use cautery on edge of fat plane, not kidney edge. Continue to clear fat off renal surface, aiming to work in fat planes. A clue that the tumor area is approaching is the presence of adhesions. Stay superficial to capsule since capsule is strength layer of repair. Sticky fat can be tedious. Bipolar helpful for vessels in fat. Use ultrasound to confirm location of tumor (green dot indicates proximal aspect of probe).
***'''Use ultrasound to identify location, depth, and borders of tumor.''' Orient the ultrasound probe parallel to the tumor border to define the borders of the tumor. The fat is then cleared circumferentially around the mass, allowing for visualization of 1–2 cm of normal parenchyma for future renal reconstruction. All attempts should be made to leave the overlying Gerota’s fascia atop the mass to assist in histopathologic staging and also to use as a handle for retraction. Increase cautery settings to 50/50 and score edges of tumor + margin with scissors intermittently, not circumferentially. Check with doppler ultrasound that there is flow in multiple places. Consider how 4th arm will be used to keep the kidney in position during tumour excision and renorrhaphy.
*** '''Pre-clamp checklist''' 
****Confirm cautery settings (usually 40/40)
****Confirm stable patient status with anesthesia
****Confirm sufficient gas in tank
****Ensure bedside assist has access to field and all ports are not displaced
****Confirm all sutures/rescue sutures are available
****Get all sutures in the field (Two 22 or 15 cm (depending on defect size) 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture)
****Increase pneumoperitoneum to 20 mm Hg
****Announce sequence of steps to team
****#Apply bulldogs
****#Confirm absence of flow with ultrasound
****#Cut the tumor
****#Place the tumor in the bag
****#2-layer renorrhaphy
****#Remove clamps from artery to assess hemostasis
****#Remove clamps from body
*** '''Cut tumour''' 
****Apply bulldog(s), not at fulcrum[https://pubmed.ncbi.nlm.nih.gov/26417645/]
****Reposition 4th arm to optimize tumour excision and renorrhaphy.
****Use ultrasound with Doppler to confirm absence of flow in multiple places. 
*****If still flow, need to identify additional arterial inflow. 
*****After confirming absence of flow, assistant removes doppler and replaces with suction.
****Start cutting tumor around 5-6 o clock with cold scissors (may need to use heat over fat that covers edge). Use one scissor length excursions. Use left hand to retract the tumour. If excessive bleeding, may have missed an artery. Continue cutting tumor circumferentially, if possible, as allows more mobility. Initially, closer to edge, cut with cold scissors to enter enucleation plane. Be careful not to remove too much capsule, as this is the strength layer for repair. Once plane entered, use peel and lift. Some attachments/vessels may need bipolar/coagulation and then cut with scissors. Use left hand to retract tumor. The bedside assistant uses suction to clear the resection bed, enabling improved visualization while applying slight counter retraction, as needed.
****After excising tumor, place tumor in medial lower quadrant or immediately in bag.
****Use bipolar or hot scissors for any active vessels. 
***'''Renorrhaphy'''
****'''Switch to needle drivers.''' Use one hand to compress bleeding while other hand is changed to needle driver. When needle driver in, replace compression and switch other hand to needle driver.
****'''Consider renorrhaphy approach.''' Which direction will you want to place Hem-o-lok Weck clips for superficial layer? Want them to be placed easily by assistant and away from ureter. Which direction should needles travel to avoid injury to blood vessels? Which direction is most ergonomic for the deep layer?
****'''Deep layer closure.''' Use 22 cm (or 15 cm if smaller defect) 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture. Anchor on the renal capsule outside of the defect by taking outside-in bite. Inside bite should be at the distal apex of deeper bed.
*****Using same stitch, perform deep layer closure by passing suture through medullary layer of the renal defect. Bite is with right hand from one side to another, big bites taken in 1 (some situations may require this to be done backhand). Use right hand to first anchor stitch in position, then regrab proximally to manipulate in good direction. Slow, controlled movements avoid tearing. Use left hand to lift prior suture but not too tight. DO NOT TIGHTEN. Keep running until proximal aspect of deep defect. 2-3mm travel. If entry into collecting system, incorporate these into the bites. Exit the contralateral side of anchor. Secure with a Hem-o-lok Weck clip. Tighten slightly and break needle and ensure assistant removes needle.
****'''Superficial layer closure.''' Use 22cm 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture. Anchor on the renal capsule, contralateral to distal deep layer anchor, outside of the defect by taking outside-in bite. Then inside-out bite. Enter and exit outside the renal defect beyond the distal apex of defect. Place hem-o lock. Cinch slightly. Take next bite (taken in two, outside-in, inside-out), and place hem-o-lock. Put aside superficial stitch. All superficial layer bites should include capsule, as this is the strength layer.
****'''Tighten deep layer.''' Gradually tighten deep layer suture. When tightening, advance suture with right hand, hold in place with left. Direction of advancing suture should be in opposite direction throws (if taking right to left throws then tightening will be advancing suture from left to right). Repeat then move onto next suture. Tighten hemolock on exit +/- entry of deep layer. Consider placing additional hemolock on tightened tails.
****'''Continue superficial layer.''' Tighten superficial layer. When tightening hem-o-locks, advance suture so that it slides in middle. The ultimate (last) hem-o-lok may be held in place by spreading the needle driver tips, but for all penultimate ones the hem-o-lock should be held in center with grasp of needle driver. Subsequent bites should be taken in two, outside-in, inside-out. Ensure bites are not superficial as this suture should close both the cortical and medullary layers. After existing parenchyma, secure layer with Hem-o-lok Weck clips. Slightly tighten ultimate suture, but only cinch penultimate suture. Continue running to proximal edge of defect and exit on contralateral side.
****Tighten superficial layer.
****Tighten further.
****Tighten deep layer Hem-o-Loks at distal ends of renorrhaphy  
****Remove clamp. Assess kidney for bleeding and obtain additional hemostasis as needed.
*****If bleeding after unclamping, apply direct pressure immediately and increase the insufflation pressure to 20 mm Hg. Re-tighten and cinch down the renorrhaphy clips.
*****Open conversion is usually indicated for uncontrolled bleeding and the surgical team should be ready for such an eventuality.
****Decrease pneumoperitoneum 10 mm Hg and reassess for bleeding.
****Cut and remove remaining needles. Ensure assistant removes all needles.
****Remove bulldogs. Ensure assistant removes all bulldogs.
****Obtain further hemostasis, may need scissors to coagulate in some areas
***'''Closure'''
****'''Deliver specimen.''' A laparoscopic entrapment sac is introduced by the assistant; the specimen is placed in the sac and removed from camera port, if small, or assistant port, if larger. Care must be taken to make the extraction incision large enough to avoid fracturing the specimen, possibly preventing accurate histopathologic examination for margin status and staging.
****+/- insert drain through arm 4
****'''Undock robot.''' 
****'''Close port sites and extraction site.''' Close fascia of any port sites ≥12 mm.