Editing Robot-assisted Laparoscopic Prostatectomy (section)

=== Abdominal Access and Robot Docking ===
*'''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.
**Insert 16F foley catheter and inflate balloon.
**Meticulously apply foam pad to soft tissue and bony sites, along with careful ergonomically neutral positioning of the neck, arms, and legs 
**Secure the patient to the table.
**Prepare surgical area and drape.

*'''Veress needle access.''' Apply penetrating towel clamps to lateral aspects of 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 in obese patients and 45 degrees in thin patients. Feel or hear (usually) 2 clicks/pops (corresponding to the penetration of the abdominal fascia and parietal peritoneum)(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.
**With the Veress needle (before abdominal insertion), low flow should register 1 L/min and at high flow should register 2 to 2.5 L/min.[https://link.springer.com/book/10.1007/978-3-642-88454-2]
**Regardless of the insufflator setting, maximal flow through a Veress needle is only about 2.5 L/min because it is only 14 gauge.[https://link.springer.com/book/10.1007/978-3-642-88454-2]
**A Hasson cannula has a much larger internal diameter and can immediately accommodate the maximum flow rate of most insufflators (Le., >6 L/min)[https://link.springer.com/book/10.1007/978-3-642-88454-2]
*'''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. As the pressure slowly rises to 20, the remaining port sites are marked.
*'''Outline port sites'''. Use marking pen to denote transverse incisions for robotic (8mm for camera port and 8mm for other robotic trocar sites) and assistant ports (12mm RLQ assistant port and 5mm RUQ assistant port). 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). For RUQ assistant port, draw a line from pubis and half-way between central and right medial incision; 5mm assistant port should be approx. 3cm superior and half-way in between the central and right medial incision. Make sure this port is not too close to the camera port otherwise will have lots of difficulty moving sucker laterally. The most lateral ports must be at least 3 fingers medial and 3 fingers superior to ASIS.
* '''Insert camera port.''' Once at 15mm Hg, make an incision overlying camera port. Use hemostat to dissect down through fat. Twist port into abdomen; twisting is more important than pushing. Once inside, remove obturator (should hear air coming out when opening valve on port), connect gas, and insert camera. Check that no injury made to the bowel during Varess or port access. Remove Veress needle. Check for adhesions that may interfere with port placement.
*'''Table in 30 degrees Trendelenburg.''' And then even more Trendelenburg. This moves bowel out of the way for subsequent ports.
*'''Insert remaining ports.''' For the remaining ports, inject local anesthetic to identify approximate location inside and then inject a supraperitoneal bleb for local anesthetic purposes. Insert all remaining ports under direct vision. All ports should be inserted perpendicular to the fascia. Port placement may have to be modified due to unexpected anatomy, or adhesions may need to be taken down prior to port insertion. Point camera towards patient’s left side. Begin insertion of most left lateral port (facilitates visualization of inserting left medial port). Use knife to make an 8mm transverse incision in this area. Twist port into incision under vision. Take out obturator and insert trocar until black line. Repeat steps for left medial port, taking care to avoid injury to epigastric vessels. Repeat on the right side. Note that right lateral port will be a 12mm incision for the bed-side assistant port. Once the bed-side assistant port is in, switch the gas to this port. Insert right medial robotic port. Insert 5mm assistant port.
*'''Dock robot and insert instruments.''' Attach camera port to robot. Insert and attach camera. Target camera to prostate. 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 Maryland graspers in left robotic arm, and Prograsp graspers in 4th 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/]
**See https://www.laparoscopyhospital.com/docking-in-robotic-surgery.html for detailed instructions
*'''Lysis of adhesions, if needed.''' Check for adhesions and take any down if needed.