Benjamin T. Ristau, MD, MHA, Randall A. Lee, MD, and Alexander Kutikov, MD, FACS, present a retroperitoneoscopic robot-assisted partial nephrectomy on a morbidly obese patient.
retro peritoneum aske opic, robot assisted partial gastrectomy. In a morbidly obese patient with a tumor in the upper pole. The patient is a 57 year old male with Crohn's disease and A. B. M. I. Of 45.6 who presents for a consultation regarding a three centimeter left upper pole renal mass that was incidentally discovered on abdominal imaging performed for Crohn's disease. Exacerbation patient is on Vettel is a mob for Crohn's disease. Active surveillance was discussed with the patient given young age, he elected to proceed with resection more. Full metric considerations for retro peritoneum topic approach include assessment of tumor location, body habits and retro peritoneal adipose tissue content, ideal tumors for the retro peritoneal approach are located posterior lee and in the mid to lower pole. Patients with low B. M. I. And minimal retro peritoneal fat are ideal candidates when the surgeon is new to this technique. In this video, we present a real world example where the feasibility of the retro peritoneal approach and a morbidly obese patient with an upper pole tumor is showcased. The operating room is arranged as seen here. The robot will be docked over the patient's head. As such. The bed should be rotated and the robot positioned accordingly. Anesthesia may need extension tubing for safe patient ventilation for a left sided tumor. The patient is placed in the right lateral de cuba. This position with optional use of a kidney bar. With experience. We have stopped using the kidney bar without deleterious consequences on the procedure. Simple table, flexion appears to be adequate. The operating table is placed inflection to increase the distance between the iliac crest and the sub costal margin. All pressure points are carefully padded, utilizing gel pads and foam, and the patient is secured to the table with straps. The report cites and anatomical landmarks are marked prior to incision. The 12 millimeter camera ports. Site is marked in the posterior axillary line between the tip of the 12th rib and the iliac crest, cheating slightly towards the left rib and patients with upper pole tumors. A lateral eight millimeter ports site is March 6 to 8 centimeters from the 12 millimeter camera ports. Site, two medial eight millimeter ports. Sites are marked 6 to 8 centimeters from the 12 millimeter camera ports site, a 12 millimeter assist sports site is marked just off the iliac crest and triangulated between the 12 millimeter camera ports and the first medial eight millimeter robotic ports site, mm hmm. Absolutely. A transverse incision for the 12 millimeter cam report is made. An Army Navy retractors are used to identify the lumbar dorsal fashion. A kelly clamp is used to enter the retro peritoneal space mm hmm mm hmm mm hmm. A finger is used to bluntly dissect and develop the retro peritoneal space. A 12 millimeter trow car with balloon dilator is placed in the retro peritoneal space. 40 pumps are applied to inflate the balloon and develop the retro peritoneal space mm hmm. An eight millimeter bariatric robotic Stroker is placed in the previously marked lateral ports. Site into the developed retro peritoneal space under tactile finger guidance. Thank you. A balloon tracker is placed in the 12 millimeter camera ports. Site A 30° up camera is used using a laproscopic Kittner. The peritoneum is swept immediately by finding the plane between it and the abdominal wall. In our practice we routinely use the fourth robotic arm necessitating thorough mobilization of the peritoneum. Immediately a small tear in the peritoneum can occur and should not discourage the surgeon procedure can proceed as planned. The remaining two robotic ports and assistant ports are placed under direct vision, mm hmm mm hmm mm hmm. The robot is parked over the patient's head as far away from the table to make the camera arm on the robot in the distal sweet spot. This maneuver minimizes the camera arm from losing its orientation when looking caught early on the S. I. Da Vinci robotic system. If the camera is docked in place, it can be very difficult to guide robotic arms into the appropriate location as such. We have the assistant hold the camera within the camera ports without docking it. We then doc. Each working arms separately, mono, polar scissors, bipolar Maryland and a progress in the most medial arm are used. Each instrument is guided to the space behind the lower pole of the kidney under direct vision. The camera, which has now been switched from a 30° up to 0° lens is docked last. Thanks. The pro grasp is used to provide Antero medial retraction. This step is key to achieve proper tension on the road as fashion. Mm hmm. Gerard's fascist entered using the mono polar scissors and the incision is carried cranial coddle the plane of the soas muscle should be used as the horizon. Mm hmm. For left sided tumors, the soas muscle can be followed to the para aortic nodes. Dissection then needs to jump over the nodes in order to find the renal artery and avoid dissecting behind the aorta. Okay, for right sided tumors, the soas muscle should be followed carefully to the site of pulsation. Or the renal artery can be found behind the Vienna Kaveh during these initial maneuvers and when locating the renal artery, establishing the dimensions of each patient's retro peritoneal space is one of the key aspects of learning curve for the retro peritoneal approach. Yeah, mm hmm. That's right. As one can see this extremely obese patient with an abundance of retro peritoneal fat with toxic nature markedly increases the difficulty of the dissection. Mm hmm. The renal artery is localized by deliberate and careful dissection through the perry renal adipose tissue pulsations can be detected and the renal vein and renal artery can be visualized. The importance of adequate retraction with the third arm Progress cannot be underemphasized yet too many readjustments of the third arm can ruffle retro peritoneal fat so that the visualization can be difficult as such calibrate third arm movements and sweeps carefully the renal artery is dissected such that a bulldog clamp can be applied. That's true. Perry reno adipose tissue is removed to expose the kidney. Parang comma. The kidney parang comma is followed removing overlying fat until the tumor is exposed and isolated. Thank you. Mono polar electro coterie is used to delineate borders for tumor excision. Mm hmm. Yeah, mm hmm mm hmm. The isolated renal artery is clamped with a bulldog clamp, mm hmm mm hmm. The upper pole location of this tumor creates somewhat challenging angles for both reception and run or fight. The angles for tumors in the inter polar and lower pole region are usually more favorable. The tumors excised using a combination of mono polar and round tip scissors with a visually appreciated negative margin and placed aside for later extraction. Yeah, that's right. Yeah. Yeah. Using the surface intermediate base resection score. This tumor was removed via a one plus one plus one equals three and nuclear resection approach. Okay, mm hmm mm hmm mm hmm. Despite arterial clamping some bleeding is common due to an unclaimed venus system. Should this inhibit adequate visualization. The renal vein maybe clamped as well. Yeah, that's true. The resection bed is closed using a 30. B locks. Future pledge jetted with nu knit and secured with him Allah clips, all visible bleeding at the tumor base is over soon. Yeah. Thank you horizontal mattress Reinsdorf is completed with a two OV locks. Future clips are used to achieve appropriate tension on the parang comma. Yeah. Mhm. Search sell bolsters are placed prior to tightening the future to facilitate homeostasis when a dead space is created. If parang comma to parang comma, approximation is possible. Holsters are not used. Yes. Once the rain or fee is completed, the bulldog clamp is carefully removed from the renal artery. Right? That's correct. Following unclad ping the resection bed is inspected for residual bleeding. The tumor is removed using an endo catch bag. Mm hmm. The robot is then undocked and the ports are removed. We generally extract the tumor through the camera ports site. The incisions are closed care must be taken to only suture fashion and avoid big bites of the oblique musculature when closing the extraction site. Since this can cause neuropathic pain in a derma tonal distribution that can be quite bothersome on the rare occasion that this occurs in our experience, it resolves within several months. Final surgical pathology revealed a three centimeter P. T. One a grade two renal cell carcinoma. Surgical margins were negative for carcinoma. Post operative imaging at 2.5 months demonstrates complete excision of the renal mass. Excellent healing of the renal unit is evident at the two week postoperative follow up appointment. The incisions are intact and well heeled. It's completely different