Robotic Partial Nephrectomy: Difference between revisions
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***# Robotic Arm 3 port (8 mm): 8 cm inferior to Camera robotic port | ***# Robotic Arm 3 port (8 mm): 8 cm inferior to Camera robotic port | ||
***# Most inferior robotic port (8 mm): 8 cm inferior to Robotic Port 3 | ***# Most inferior robotic port (8 mm): 8 cm inferior to Robotic Port 3 | ||
***# Assistant (12 mm): half-way between camera and | ***# Assistant (12 mm): in midline, half-way between camera and superior port | ||
***'''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. | ***'''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. | ****Depending on liver anatomy, liver retractor may need to be placed in contralateral side. | ||
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**** Insert foley catheter and have tubing go over contralateral leg. | **** 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. | **** 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. | **** 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. This allows a greater degree of freedom for the robotic arms without interference from 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. | **** 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. | ***** Should be placed so that a palm can be placed vertically between armpit and axillary roll. | ||
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***** 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] | ***** 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. | ***** [[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. | *** '''Identify ureter and gonadal vein at lower pole of kidney'''. 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. | **** 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 | **** '''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 | ||