Robotic Partial Nephrectomy: Difference between revisions

***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

***If vascular injury

***If converting to radical nephrectomy

****Vascular staplers

****White, open staple height of 2.5mm, 45mm or 60mm depending on length of vessel[https://pmc.ncbi.nlm.nih.gov/articles/PMC8325431/]

**Surgicel, rolled, and tied in a roll using colorless suture (to contrast renorrhaphy sutures)

*Specimen Retrieval Pouch

**Endo Catch™ Gold device 10 mm

=== Transperitoneal ===

**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:'''

****Left hand: fenestrated bipolar graspers

****Camera

****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

****Depending on liver anatomy, liver retractor may need to be placed in contralateral side.

** '''Step by step:'''

**** After induction of general anesthesia...

**** Trim hair overlying operative site, if needed.

**** 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.

**** 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.

***'''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.

*** '''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.

***'''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/]

**** Medial retraction by the assistant facilitates this step.

**** Line of Toldt should be divided at the junction between mesocolon and Gerota's fascia.

**** 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

*****'''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 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.

**** 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

**** '''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'''

***'''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.

*****Advantages of renal vein clamping: decreased bleeding during tumor resection

*****Disadvantage of renal vein clamping: more dissection needed, potentially increasing risk.

**** 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'''  

****#2-layer renorrhaphy

****#Remove clamps from artery to assess hemostasis

*** '''Cut tumour'''  

****Apply bulldog(s), not at fulcrum[https://pubmed.ncbi.nlm.nih.gov/26417645/]

****'''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.

****'''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.

*Risks of general anesthesia

**DVT/PE rates: ≈1%

=== Early post-operative ===