Editing Robotic Partial Nephrectomy (section)

=== Retroperitoneal ===

*'''Factors to consider for retroperitoneal approach'''
**Tumor factors
***Tumor location
****In axial plane, bisect kidney obliquely resulting in two equal segments. Retroperitoneal approach favours tumours posterior to bisection while transperitoneal approach favours tumours anterior to bisection.
****Retroperitoneal approach may also be favoured for lateral posterior tumours (even if slightly anterior to bisection line), upper pole, and posteromedial 
****Lower pole tumours are harder with retroperitoneal approach, though may not be as much of a problem with Xi robot compared to Si
****Anteromedial tumours also difficult with retroperitoneal approach
**Patient factors
***Retroperitoneal fat
****In patients with significant retroperitoneal fat, retroperitoneal approach can be difficult to dissect through large quantities of fat without familiar anatomic landmarks
*Advantages
**Avoids potential injury of intraperitoneal contents
*'''Position:''' Ipsilateral (tumor side up), full flank (90°), flexed (30°), lateral decubitus. Patient should be straight, with shoulder in line with hips. Bottom leg flexed. Top leg straight. Pillows between legs.
* '''Surgical plan:'''
** '''Number of ports: 5'''
*** 4 robot ports (8 mm) + 1 assistant port (12 mm)
**** Left hand: fenestrated bipolar graspers
**** Right hand: monopolar curved scissors (jaw length 1.1cm[https://r2surgical.com/products/470007-round-tip-scissors-new])
**** Anterior port: Prograsp graspers
** '''Location of ports:'''
***All ports are based on location of camera port and are along a line of curvature that parallels the costovertebral angle
****Anterior most port is closest to the costal margin while the posterior most port is slightly away from the rib cage margin
***Camera port: along a coronal line of the flexed abdomen that denotes the 'summit' (12 o'clock or mid-axillary line)
****Closer towards tip of 12th rib for upper pole tumors
****Closer to midway between 12th rib and pelvic bone for interpolar/lower pole tumors
*****More inferior towards pelvic bone may result in collisions with pelvic bone
***Posterior robotic port: 4 fingerbreadths posterolateral to camera port, along line of curvature
***Anterior robotic  port: 3 fingers medial to camera port, along line of curvature
***Anterior most robotic port: 3 fingers medial to anterior port, along line of curvature
****Anterior most robotic port and posterior robotic port are at approximately the same axial level
***12mm Assistant port: along a straight line inferiorly from anterior most port, 1-2 fingerbreadths superomedial to the ASIS (further away for skinnier patients)
****Think about trajectory of assistant to minimize collisions with robotic arms/maximize space for assistant.
** '''Step by step:'''
***'''General anesthesia and insertion of lines.''' No need for 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
**** Insert foley catheter and have tubing go over contralateral leg.
**** Slide patient up/down table so that midpoint of inferior aspect of ribcage and superior aspect of pelvic bone at break. Goal is to open this space.
**** 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), full 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.
**** Bottom leg flexed. Top leg straight. Pillows between legs.
****Use taped folded blankets (preferred) to support the chest, upper back and proximal thigh. The abdomen, flank, and mid/lower back should be free.
*****Skinnier patients will need more folded blankets
****Ensure that patient is 90 degrees and straight (shoulders in line with hips). 
**** Flex table 30 degrees. Slight Trendelenburg to level table parallel to floor.
*****If kidney rest available, consider expanding space further, if needed.
*****Opening the space is paramount; therefore, reposition until flexion is optimal
*****If patient not at 90 degrees to table, this will become accentuated during flexion
**** Secure the patient to the table with wide cloth tape, one strip under axilla and one strip at hip/upper thigh. Tape should be secured to metal bars on bed.
****Contralateral arm is placed on a padded arm rest, and the ipsilateral arm on arm board or pillow.
*****Ipsilateral arm is tilted towards head as much as possible
****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
****Ensure again that patient is 90 degrees and straight (shoulders in line with hips).
**** Use marking pen to denote line of 'summit', 12th and 11th ribs, and pelvic bone.
****May need to turn the table for appropriate for robot to come in posteriorly.
*****Robot should come in posteriorly to increase working room for assistant.
****Prepare surgical area with care to avoid wiping out marked areas, and drape to expose anterior abdomen, 'summit', 12th and 11th ribs, pelvic bone, and as much of the spine as possible
*****Anterior abdomen exposure needed in case of conversion to transperitoneal approach
*****Spine exposure needed for insertion of right robotic arm
*** '''Outline ports'''
****Denote a 1.5 cm line, perpendicular to 'summit' line for access/camera site.
*****Choose site based on location of tumor (upper vs. lower pole)
****Use marking pen to denote remaining port sites. Make sure assistant has good access to field from assistant port.
***'''Retroperitoneal access''' 
****Use cautery to dissect straight down through skin and muscle to level of lumbodorsal fascia. Be slow with cautery to achieve hemostasis. Assistant uses S curve retractors for exposure.
****Use tonsil clamp/cautery to make enter lumbodorsal fascia
****Use a straight finger to feel space, which should be soft. Develop space slightly with digit.
****Insert space expander straight into space. When resistance (hitting psoas), tilt anteriorly to follow angle so that it is just over psoas. Will advance approximately 2-3cm after angling, with minimal resistance (should feel like fat, not muscle). Remove obturator. Insert robotic port and 30 degrees up camera. Attach orange pump to bottom hole. Inflate until bag is completely unfolded, should see psoas posteriorly and transversus abdominus and peritoneum anteriorly. Deflate space expander and remove.
*****Space expander may not have enough room to accommodate robotic port and inflate at the same time, may have to pull up on robot port to be able to pump it
*** '''Insert camera port'''
****Insert blunt tipped balloon trocar. Inflate balloon with 35cc of air. Lift up and close latch. Make seal tight. Insert robotic trocar. Insert 30 degree up camera. Connect insufflation to top hole on trocar.
****
***'''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.  
*** '''Insert posterior robotic port.''' Does not need to be under vision. Ensure that port is inserted perpendicular and does not skive. 
****If skin between posterior port and camera are bunched, there is skiving.
***'''Identify location of other ports and sweep peritoneum.''' Push on abdomen to identify approximate location of other ports. Use laparoscopic kitner from posterior robotic port to gradually push away peritoneum from muscle. Start more proximal than the edge of the peritoneum, do not directly push peritoneum. Use a rolling move to push the peritoneum. Should only see muscle ideally. 
****'''If hole in peritoneum,''' attempt to close defect with hem-o-lock. If unsuccessful, consider inserting port transperitoneal through hole to ventilate gas out from intraperitoneal space.
***'''Insert remaining ports under vision.''' Robotic ports 8mm incision, assistant port 12mm incision. Insert most anterior port first, followed by other anterior port, followed by assistant port. Use laparoscopic kitner to displace peritoneum. Assistant port should be inserted far in so that it does not risk displacement.
***'''Dock robot and insert instruments.''' Robot should come perpendicular and posterior to patient so that assistant has more room. 
****Adjust [https://vimeo.com/544900363 boom rotation] so that laser is aligned with camera and two anterior ports.
****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/]
****Insert camera port through assistant port. Attach remaining robotic ports to robot and adjust trocars so that the black line is at outside fascia (want port to be a little more than peaking into the body). This will improve mobility of the arms.
****Advance arms under vision. Fenestrated graspers (left arm), Camera (0 degrees or 30 degrees up), Monopolar scissors (right hand), Anterior arm (Prograsp).
****Arms should be at same FLEX level
****Burp instruments.
****Connect monopolar and bipolar electric cords. Setup sucker
****Insert camera through camera port.
*****Camera oriented vertically but slightly tilted to foot.
***'''Identify psoas muscle and Gerota’s fascia'''. View horizon should be such that psoas is horizontal (on left side, turn counter-clockwise, on right side turn clockwise). Use prograsps to retract kidney up and away. Gerota’s fascia should be in front of you. If lost, use psoas as a guide.
***'''Insert ultrasound and get a lay of the land.'''
***'''Make a transverse incision through Gerota’s fascia''', close to psoas. Develop plane above psoas facia. Does not have to be directly on psoas, can be in a fat plane above but close to psoas. If too inferior, will get under IVC/gonadal. Use 4<sup>th</sup> arm to lift kidney, gradually adjusting as needed. 
****'''Beware of lumbar veins medial to the psoas.''' 
****'''On right side, may encounter IVC; left side may encounter gonadal vein. IVC/gonadal can be used as guide towards renal hilum.''' 
***Continue to dissect along psoas muscle towards pulsations'''.''' 
****Note that you do not want to be too medial and end up at the pulsations of the aorta/IVC or ureter. 
***'''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) right-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.
****'''On right side, be sure to identify suprarenal IVC before ligating renal vein (if needed).'''
*** '''Identify tumour and defat kidney.''' Release kidney from 4th arm retraction. Dissect through fat in an area far from the tumor to find the kidney capsule. Don't defat completely, need some fat for retracting kidney. 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 one is approaching the tumor area 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.''' To define the border of the tumor, the ultrasound probe is oriented parallel to the tumor border. 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
*** '''Cut tumour''' 
****Apply bulldog(s). Ensure tips of clamps on vessels.
****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 cortical 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. (First throw is taken on opposite side of anchor). 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). 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 hem-o-lock on exit +/- entry of deep layer. Consider placing additional hemolock for vicryl, not needed for braided sutures such as stratafix.
****'''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 anterior port.
****'''Desufflate balloon trocar'''
****'''Undock robot.''' 
****'''Close port sites and extraction site.''' Close fascia any port sites ≥12 mm.