Robotic Partial Nephrectomy

Videos

Transperitoneal

• Robotic transperitoneal, partial nephrectomy port placement (Dr. Ketan Badani)
• Robotic transperitoneal, right partial nephrectomy (Dr. Craig Rogers, Si robot)
• Robotic transperitoneal, right partial nephrectomy (Dr. Inderbir Gill)
• Robotic transperitoneal, right partial nephrectomy (Dr. Andrea Minervini)
• Robotic transperitoneal, right partial nephrectomy (Dr. Ronney Abaza, no use of robotic 4th arm)
• Robotic transperitoneal, right partial nephrectomy (Dr. Ronney Abaza, no use of robotic 4th arm)
• Robotic transperitoneal, right partial nephrectomy (Dr. Ronney Abaza, no use of robotic 4th arm)
• Robotic transperitoneal, right partial nephrectomy abbreviated (Dr. Andrea Minervini)
• Robotic transperitoneal, right partial nephrectomy abbreviated (Dr. Riccardo Autorino)
• Robotic transperitoneal, left partial nephrectomy (Dr. Andrea Minervini)
• Robotic transperitoneal, left partial nephrectomy (Dr. Xu Zhang)
• Robotic transperitoneal, left partial nephrectomy abbreviated (Dr. Craig Rogers)
• Robotic transperitoneal, left partial nephrectomy abbreviated (Dr. Tibet Erdogru)
• Robotic transperitoneal, left partial nephrectomy not annotated (Dr. Lance Hampton)
• Robotic transperitoneal, left partial nephrectomy not annotated (Dr. Boon Kua)

Retroperitoneal

• Robotic retroperitoneal, left partial nephrectomy (Dr. James Porter)
• Robotic retroperitoneal, left partial nephrectomy (Dr. James Porter)
• Robotic retroperitoneal, left partial nephrectomy (Dr. James Porter)
• Robotic retroperitoneal, right partial nephrectomy (Dr. James Porter)
• Robotic retroperitoneal partial nephrectomy abbreviated (Dr. Craig Rogers)

Other videos

• Renorrhaphy annotated video (Dr. Steven Chang)
• Managing complications (Dr. Ronney Abaza)

Contraindications

1. Contraindications to laparoscopic surgery
2. History of extensive abdominal surgery (contraindication for transperitoneal approach)
3. Morbid obesity
4. Extremely large tumor

Advantages of Robotic Approach

• Compared to laparoscopic approach (2014 meta-analysis[1])
  • Significantly lower rate of conversion to open surgery, conversion to radical surgery, shorter warm ischemia time, smaller change of estimated glomerular filtration rate, and shorter length of stay
  • No significant differences in complications of Clavien-Dindo classification grades 1-2, Clavien-Dindo classification grades 3-5, change of serum creatinine, operative time, estimated blood loss, and positive surgical margins
• Compared to open approach (2022 meta-analysis [2])
  • Significantly lower rates of blood loos, length of stay, and postoperative complications
  • No significant differences in operative time, warm ischemia time, positive surgical margins, preoperative eGFR, postoperative eGFR and intraoperative complications

Pre-operative Preparation

• Pre-operative imaging
  • Primary tumor
    • Size
    • Location
      • Tumor position on CT will correspond to direction of hilum during surgery i.e. a posterolateral tumor on imaging that is in direct line with the hilum will be a lateral tumor during transperitoneal partial.
    • Endophytic vs. exophytic
      • If endophytic tumor, obtain pre-operative ultrasound.
        • If tumour not visible on pre-operative ultrasound, consider radical nephrectomy as intra-operative ultrasound to identify tumour will unlikely be successful.
    • Proximity to collecting system
    • Vasculature
  • Metastatic staging
• Hold/bridge anticoagulation medications prior to surgery
  • ASA 7 days
  • Clopidogrel 5 days
  • Apixaban 2 days
• Pre-operative testing
  • Urinalysis +/- culture
  • CBC
  • Serum creatinine/GFR

• Venous thromboembolism prophylaxis
  • Compression stockings
  • Heparin[3]
• Antibiotics
  • 2g cefazolin (900 mg clindamycin, if penicillin allergic)[4]

Equipment

• Ultrasound with doppler
• Sutures/staplers[5]
  • Renorrhaphy
    • 2-0 Stratafix on CT-1 needle, cut to 23 cm (or 15 cm if smaller defect), with Hem-o-lok Weck clip in the loop perpendicular to the suture tail, x2
      • 23cm 2-0 Stratafix on CT-1: SXPP1B409
      • 15cm 2-0 Stratafix on CT-1: SXPP1B456
    • 3-0 monocryl on RB1 for collecting system or larger vessels
    • Alternatively[6]
      • 3-0 V-loc suture on a V-20 needle for the deep layer
      • 2-0 V-loc on a GS-21 needle for the outer capsular layer
  • Closing
    • 0 Vicryl on UR6 x 2
    • 4-0 monocryl on PS-Z
    • 0 silk for drain
  • Rescue sutures/staplers
    • If persistent bleeding from renorrhaphy
      • 0 Vicryl on CT-1 needle, cut to 10cm, tail on knots with two Hem-o-lok Weck clips before the knots, perpendicular to each other, x3
      • 2-0 Vicryl on CT-1 needle, cut to 10cm
    • If vascular injury
      • 4-0 Prolene on RB1 (in case of vascular injury), cut to 10cm with Weck clip applied at the end[7]
        • A knot is tied at the end of the suture (see Figure) and Weck clip is applied proximal to it; the thread is now again tied over the clip, this prevents slipping of the clip and helps it in sinching the opening in the vessel.
    • If converting to radical nephrectomy
      • Vascular staplers
      • White, open staple height of 2.5mm, 45mm or 60mm depending on length of vessel[8]
• Bolster
  • Surgicel, rolled, and tied in a roll using colorless suture (to contrast renorrhaphy sutures)
• Lapra-Ty and clip appliers
• Hem-O-Lock clips and applier
• Specimen Retrieval Pouch
  • Endo Catch™ Gold device 10 mm
    • Volume 220mL
• If retroperitoneal
  • S-curve retractors
  • Tonsil clamp
  • Spacemaker dissection balloon
    • Kidney shaped
      • If using Medtronic Spacemaker Dissection Balloon PDB2 product, the maximum number of pumps is 50. However, the actual number of pumps required to dissect the space will vary from patient to patient.[9]
  • 12 mm blunt tip balloon trocar[10]
    • Consists of a blunt obturator and a valve body/cannula assembly.
      • The valve body/cannula assembly contains an internal flapper valve and seal to prevent gas leakage when instruments are inserted or withdrawn. The Blunt Tip Trocar includes built-in converters to allow insertion of instruments of various diameters. In addition, the device has an external one-way valve for gas insufflation.
    • To minimize leakage and secure the trocar, the distal end of the sleeve has a balloon which is complemented by the proximal foam sponge/collar assembly. A syringe is provided for inflation/deflation of the balloon.

Steps of procedure

Transperitoneal

• Position: Ipsilateral (tumor side up), modified flank/lateral decubitus at approximately 60-90° (if left sided, 90° so that spleen can fall; if right-sided, less than 90°; alternatively, 45° has been described[11]).
  • 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 right-sided) (variations possible, depending on patient/tumour characteristics, surgeon preference, and institution equipment)
    • 4 robot ports + 1 assistant port +/- 1 liver retractor for right-sided tumors
      • Left hand: fenestrated bipolar graspers
      • Camera
      • Right hand: monopolar curved scissors (jaw length 1.1cm[12])
      • 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.[13]
        • 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.[14]
        • 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[15][16]
        • 10-20 cm distance should be maintained between the ports and target anatomy[17]
          • 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[18]
    • Configuration 1: Straight line configuration (if Xi)[19]
      • 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
      1. Superior robotic port (8 mm): 2 fingerbreadths below the costal margin
      2. Camera robotic port (8 mm (12 mm if Si)): 6 cm inferior to Superior robotic port
      3. Robotic Arm 3 port (8 mm): 6 cm inferior to Camera robotic port
      4. Most inferior robotic port (8 mm): 6 cm inferior to Robotic Port 3
      5. Assistant (12 mm): half-way between camera and Robotic Arm 1, medial to these ports, in midline
    • If right-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[20]) 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[21].
      • 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[22]) 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 right 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 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 clearance joints on arms #1 and #4 toward the patient to maximize arm movement[23].
      • 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[24]
    • 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 right 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 right 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.[25]
        • 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 right 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) 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.
      • 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
        1. Apply bulldogs
        2. Confirm absence of flow with ultrasound
        3. Cut the tumor
        4. Place the tumor in the bag
        5. 2-layer renorrhaphy
        6. Remove clamps from artery to assess hemostasis
        7. Remove clamps from body
    • Cut tumour
      • Apply bulldog(s), not at fulcrum[26]
      • 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.

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[27])
      • 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[28]) 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 boom rotation so that laser is aligned with camera and two anterior ports.
      • Rotate the patient clearance joints on arms #1 and #4 toward the patient to maximize arm movement[29].
        • 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[30]
      • 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^th 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.

Special Scenarios

Intraoperative bleeding[31]

• First step is anticipation: hemorrhage tray should always be available on request
• In case of bleeding:

1. Apply compression
2. Increase pneumoperitoneum to 20 mm hg (particularly helpful to reduce venous bleeding)
3. Can use a rolled gauze sponge to tamponade or to grasp the arterial stump
4. Improve exposure and use careful suction (venous bleeding will increase with loss of pneumoperitoneum)
5. Determine whether minimally-invasive repair is still possible or not. If it is not possible, conversion to open surgery should be done as soon as possible

Complications

Population-based data is preferentially described, rather than data from few surgeons.

• Overall rate of any complications: ≈10-25%[32][33]
  • Rates of major complications (Clavien grades 3-5): ≈4%[34]
• Median length of stay: ≈3 days[35]
  • ≈25% have LOS > 4 days[36]

Intra-operative

• Bleeding
  • ≈6-20% transfusion rate[37][38]
• Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas, ureter, bladder)
  • Bowel injury
    • Intraoperative intestinal injury rates: ≈4%
    • May occur during trocar placement or from cautery injury
    • All injuries recognized intraoperatively require immediate repair and intraoperative general surgery consultation should be considered
    • In the postoperative period, signs of a bowel injury could include port-site pain, nausea, vomiting, abdominal distension, fever and leucocytosis.
  • Intraoperative ureteral or bladder injury rates: ≈4%
• Conversion to open surgery
• Conversion to radical nephrectomy
• Risks of general anesthesia
  • DVT/PE rates: ≈1%

Early post-operative

• Infection
• Re-operation due to
  • Bleeding
  • Wound dehiscence
• Urine leak
  • Should be suspected postoperatively if the drain output is elevated with elevated drain creatinine levels. The drain should be left in place and the urine output monitored.
  • A CT urogram may be ordered for continued leakage or symptoms to assess for a urinoma.
  • A percutaneous drain may need to be placed if there is a collection or the existing drain may need to be adjusted.
  • Resolution of the urinoma should be confirmed with follow-up imaging.
  • Retrograde placement of a ureteric stent should be an option if there is continued output or evidence of obstruction.

Late post-operative

• Incisional hernia
• Pseudoaneurysm
• Failure to cure
  • Positive surgical margin ≈10%[39]
• Need for secondary procedure e.g. to manage urine leak or pseudoaneurysm

References

• Davila, Hugo H., Raul E. Storey, and Marc C. Rose. "Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique." Journal of robotic surgery 10.3 (2016): 285-288.
• Caputo, Peter A., et al. "Robotic‐assisted laparoscopic nephrectomy." Journal of surgical oncology 112.7 (2015): 723-727.
• Sukumar, Shyam, and Craig G. Rogers. "Robotic partial nephrectomy: surgical technique." BJU international 108.6b (2011): 942-947.
• Kallingal, George JS, et al. "Robotic partial nephrectomy with the Da Vinci Xi." Advances in urology 2016 (2016).