Robotic Radical Nephrectomy

Contraindications

1. Contraindications to laparoscopic surgery
2. History of extensive abdominal or pelvic surgery
3. Morbid obesity
4. Extremely large tumor

Advantages of Robotic Approach

• Reduced blood loss, less pain, and shorter hospital stays

Pre-operative Preparation

• Hold/bridge anticoagulation medications prior to surgery
  • ASA 7 days
  • Clopidogrel 5 days
  • Apixaban 2 days
• Pre-operative testing
  • Pre-operative urinalysis +/- culture

Steps of procedure

• Venous thromboembolism prophylaxis
  • Compression stockings
  • Heparin
• Antibiotics
  • 2g cefazolin (900 mg clindamycin, if penicillin allergic)
• 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.
• Surgical plan:
  • Number of ports: 5 (6 if right-sided) (variations possible, depending on institution equipment and surgeon preference)
  • Location of ports:
    • All ports are placed in a straight line at the lateral border of the ipsilateral rectus abdominus muscle.
      • Port placement medial to the rectus border risks injury to the epigastric vessels.
    1. Camera (12 mm): 2-3cm above the umbilicus
    2. Robotic Arm 1 (8 mm): 2 fingerbreadths below the costal margin
    3. Robotic Arm 2 (8 mm): 8 cm inferior to camera port
    4. Robotic Arm 3 (8 mm): above iliac crest
    5. Assistant 1 (12 mm): between camera trocar and Robotic Arm 1, medial to these ports
    • If right-sided, additional 5 mm trocaer placed just inferior to xiphoid process for liver traction. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field.
  • Step by step:
    • Patient positioning, antiseptic preparation, draping. Insert foley catheter. Position patient. Pressure points should be padded. Axillary roll should be placed to prevent neuropraxia. Arm boards for arms.
    • Veress needle access. Commonly where camera port will be. Palmer's point (3 cm below the left costal margin and in the midclavicular line) is another option. Confirm appropriate placement with saline test.
    • Achieve pneumoperitoneum. Have gas on low flow and determine opening pressure. If pressures are low (< 10 mmg Hg), increase to high flow. As the pressure slowly rises to 20, the port sites are prepared.
    • Insert ports. Once at 20mm Hg, the first port, the camera port is placed through a 12 mm transverse incision followed by the remaining five ports all under direct vision. Once all ports are positioned, AirSeal is installed and activated and the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
    • Dock robot
      • If Xi
        • Attach camera port to robot. Insert and attach camera. A 30° robotic camera looking upward facilitates placement of the other trocars. Target camera in pelvis. Hold camera port steady and allow robot to adjust. Attach remaining ports to robot.
      • Insert instruments into arms (Arm 1 - monopolar scissors, Arm 2 - bipolar Maryland graspers, Arm 3 - Prograsp fenestrated graspers). Connect cords. Advance arms under vision.
    • Medialize bowel to expose retroperitoneum. Incise peritoneum lateral to the white line of Toldt. 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.
      • On the right side there is no need for extensive mobilization of the bowel to expose the renal hilum.
      • During the mobilization of the duodenum medially, the use of cautery is minimized.
    • Identify ureter. The mid-ureter is identified along the anterior aspect of the psoas. Once identified, dissection a plane is created medial to the ureter, with careful identication of the gonadal vein. The plane is developed superiorly along the psoas muscle with anterior elevation of the ureter and/or gonadal vein to identify the renal hilum. The 3rd robotic arm with the Prograsp fenestrated graspers being is used for retraction.
      • 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 or to its insertion in the 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.
        • The gonadal vessels cross the left ureter after running parallel to it for a small distance
    • Dissect hilum. Dissect the renal hilum meticulously to clearly delineate the vascular structures prior to their ligation. After dissection complete, replace Arm 1 monopolar scissors with robotic EndoWrist clip applier, 10 mm Hem-o-Lok. Apply vessel clips (2 on the stay side, 1 on the go side)/vascular staples to ligate first the artery, and then the vein. The vessels are then transected.
    • Complete kidney dissection. The superior pole of the kidney is disected with a combination of cautery and blunt dissection. Adernal sparing surgery is recommended, when feasible. The plane is carried laterally to completely free the superior pole of the kidney.
    • Transect ureter. Apply clips to ureter and then transect the ureter.
    • Delver specimen. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and removed from an incision extended medially (to avoid injury to the inferior epigastric vessels) from the Arm 3 trocar site to form either a Gibson or Pfannensteil incision (more cosmetic).
      • Gibson: 3 cm above and parallel to the inguinal ligament.§
      • Pfannenstiel: transverse lower abdominal incision, superior to the pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior rectus sheath is divided transversely. The rectus muscle is open vertically in the midline sparing the muscle fibers from being divided. The peritoneum is then entered through a vertical incision. Be careful of branches from the inferior epigastric branches as well as the superficial epigastric.§
      • Care must be taken to make a large enough incision to prevent disruption of the specimen; this enables proper histopathological examination.
    • Undock robot.
    • Closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).

Complications

• Intra-operative
  • Bleeding
  • Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas)
• Early post-operative
  • Infection
  • Re-operation due to
    • Bleeding
    • Wound dehiscence
• Late post-operative
  • Incisional hernia

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.