Robotic-Assisted Laparoscopic Partial Nephrectomy Technique

Updated: Sep 10, 2021
  • Author: E Jason Abel, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Technique

Approach Considerations

The robotic approach to renal surgery, particularly partial nephrectomy, has some inherent challenges, and some familiarity with the da Vinci robotic system is necessary. The surgeon must gain an understanding of the robotic arm movements and range of motion, especially in relation to the clutch and camera.

The advent of robotically assisted prostatectomy in 2001 [24] paved the way for widespread accessibility to the da Vinci robotic unit and its application to renal surgery. Since that time, at least one multi-institutional survey has demonstrated superiority of the robotic approach when compared to laparoscopic for outcomes of blood loss, hospital stay and a substantially shorter warm ischemia time, while maintaining equivalence in positive margin rate, operative time and complications. [12]

A transperitoneal approach is most commonly used. Prior abdominal operation is not necessarily a contraindication to this procedure, but access should be approached with regard for previous operation(s) by an experienced team.

See Positioning for a discussion of patient positioning and abdominal access.

Next:

Robotic Transperitoneal Approach

The patient is placed in a partial flank position with the table moderately flexed at the level of the contralateral kidney. The authors’ preference is not to use the kidney rest, and the upper arm is adducted along the side and hip, as described by Rashid et al. [60] In the authors’ experience, this position simplifies patient positioning and provides much better space for robotic arm movement in front of the patient (see image below).

Positioning in the Upside Arm Adducted (UAA) posit Positioning in the Upside Arm Adducted (UAA) position. This position maximizes access to the abdomen while avoiding robotic interference with the patient's arm.

After induction of general anesthesia, placement of urinary catheter, and gastric drainage, the patient is positioned and the camera port is placed roughly 8-10 cm below the costal margin on an axis 90° to the costal margin; one simple rule of thumb is that the camera port is placed one average male hand’s breadth away from the costal margin, perpendicular to it. Numerous different strategies can be used for camera and port position, but the authors find this approach to be easy and intuitive.

For the novice surgeon, it is useful to use an approach that minimizes the likelihood of disorientation, and the authors feel that positioning the operative arms on the long axis of the torso avoids this risk and allows unhampered vision in the caudal direction.

The abdomen may be insufflated via Veress needle placement before camera port insertion, or direct port placement may be used in the decompressed abdomen; the direct visual placement approach can be used without prior insufflation (see video below).

Direct insertion trocar placement. The trocar is placed directly into the decompressed abdomen and connected to CO2 insufflation. Once the peritoneal cavity develops the port may be pushed further in to the abdomen. (ENDOPATH® XCEL™ Bladeless Trocar, Ethicon Endosurgery)

The technique of peritoneal entry and insufflation should be determined by the surgeon; no single approach has been shown superior, although direct entry techniques are associated with a decrease in failed entry, omental injury, and extraperitoneal insufflation compared to Veress needle insertion in a meta-analysis. [61]

Depending on patient habitus, the camera may be placed above the lateral margin of the rectus muscles or in the midline superior to the umbilicus in the very thin patient. Correlation of the tumor location on imaging studies to the bony anatomy and planned approach may suggest modification of this scheme as appropriate to give the surgeon unfettered access to the renal hilum and tumor. In the authors’ practice, the right and left robotic ports are placed in roughly the anterior axillary line, again with attention to ensuring good triangulation for both hilar and tumor access.

Final site selection is best determined once abdominal insufflation is obtained and relative relationships between the ports can be optimized. In general, robotic and camera ports should be at least 8 cm apart to minimize clashing when using the "S" or Si" systems.

As noted in Positioning, surgeons using the "standard" Da Vinci system may wish to consider performing initial abdominal entry, as well as kidney preparation and dissection, laparoscopically before docking the robot for the partial nephrectomy owing to the decreased operative field with the earlier model of robot.

Two assistant ports are placed next—the first in the midline inferior to the umbilicus and the second is in the superior lower quadrant in a lateral location that is selected to minimize interference with the robotic arms and the other assist port. Alternatively, the midline superior to the camera may be used, although this can complicate simultaneous port utilization by a single assistant if the robotic camera is in between (see image below).

This illustrates port placement with the second as This illustrates port placement with the second assist port placed above the umbilicus and slightly lateral of midline. The lower assistant port is in the lower midline. Final positions are always determined after abdominal access, insufflation and camera port placement.

It is important to select a port size adequate to accept a CT-1 needle, clip, and bulldog clamp appliers and mini-laparotomy pad, if desired. The authors use a 15-mm port for one of the assist ports and a 12-mm or 15-mm port for the secondary assist port. It is important to tailor assist-port placement to the abdomen after camera and robotic arm placement. The robotic “fourth arm” may be placed through a lower-quadrant lateral port placement, although the authors rarely find this useful and reserve it for extremely complex masses or the absence of a skilled assistant.

The robot is docked from behind the patient with care taken to minimize the potential for arm clashing during the extensive lateral movement necessary for renal mobilization. A 30° down lens is used. When operating on the right side, an additional 5-mm port may be placed in the subxiphoid region, if necessary, to allow a laparoscopic blunt grasper to be placed beneath the liver edge and secured to the body wall in order to retract the liver superiorly for improved upper-pole access (see video below).

The 5-mm subxiphoid port is used to place a blunt grasper under the liver for this right-sided case and elevate it.

Renal access

With a monopolar scissor in the right robotic hand and a bipolar grasper in the left hand, the lateral attachments of the colon are carefully taken down with care to avoid exposure of the bowel to electrocautery. Some surgeons may prefer the Maryland bipolar grasper in the left hand.

The assistant should traction bowel in a downward direction with the tip of the suction irrigator while the surgeon provides upward countertraction to maximize exposure of the intervening structures. As the colon is reflected medially to enter the anterior pararenal space, care should be taken to identify and selectively transect the ligamentous attachments to the upper-quadrant structures and thus minimize risk of traction injury to the spleen or liver. Lateral body wall attachments of the kidney are left intact, and Gerota fascia is not entered (see videos below).

The colon is released from the lateral abdominal wall.
The anterior pararenal space is defined. Gerota fascia is not entered at this point.

Hilar access

Once the colon is safely released and reflected, careful identification and dissection of the renal vasculature is undertaken.

Preoperative planning and understanding of this anatomy should be obtained through appropriate imaging studies with care to note all arterial and venous variations and duplications.

Access to the vessels of the hilum is obtained by direct approach or, if difficult by identification of the ureter, gonadal vein and inferior great vessel on the appropriate side with careful progression superiorly to the hilum. Care must be taken to identify and preserve any accessory lower-pole vessels. The duodenum is kocherized on the right side. Using lateral traction on the kidney to stretch the hilar attachments, the vessels are dissected free from all surrounding tissue to allow easy and unhindered placement of temporary occlusive vascular "bulldog" clamps. Complete circumferential freedom of the vessels is critical to the effectiveness of the vascular control. Inclusion of any excess tissue in the clamp may prevent complete occlusion and worsen both bleeding and visualization during tumor resection (see video below).

The renal artery is freed from periarterial tissue.

Renal mobilization

Once the hilum is appropriately freed, attention is turned to acquiring access to the tumor before clamping. Generous access in the region of the tumor is of great importance, and the authors recommend that at least 2-3 cm surrounding the margins of the proposed resection be freed of perirenal fat and accessible to the surgeon. For posterior or upper-pole tumors, complete freedom of the kidney will likely be required to allow the kidney to be flipped or rotated into a favorable orientation. Gerota fascia is entered and the plane on the renal capsule developed with attention to dividing the perirenal fat in an orientation that will allow simple reconstruction of the fat over the tumor resection bed at the conclusion of the case.

As renal freedom is obtained, the kidney can be repositioned into the optimal orientation for resection. Often, a mini-laparotomy pad (sponge) can be passed in through a 15-mm port and used to prop the kidney up and stabilize it while providing an absorptive medium for any bleeding that occurs (see video below).

The tumor is free of Gerota fascia with a generous margin of clear capsule surrounding it. Overlying fat is left attached.

Identification of the tumor

For exophytic masses, the tumor can generally be identified visually during careful dissection of Gerota fascia. Care should be taken to avoid inadvertent tumor entry and, if possible, to isolate the perirenal fat over the tumor and leave it attached as an island. Endophytic or intrarenal tumors often benefit from intraoperative ultrasonography to identify the tumor margins and goals of resection; [62] the authors find that scoring the renal capsule with the monopolar scissors to mark the planned resection can be of great assistance, especially as the appearance of the kidney changes during resection.

Tumor resection

While preparations for resection are being made, 12.5 g of mannitol is administered intravenously 10 minutes before clamping is anticipated. When ready, bulldog clamps are applied to the renal artery(s) and, if desired, to the renal veins. The authors often place a second bulldog to ensure complete occlusion of the artery.

Reasonable attempts on the part of the anesthesiologist to lower the blood pressure should be undertaken to decrease bleeding. Some evidence suggests that the deleterious effects of warm ischemia are somewhat mitigated by clamping only the arterial inflow without vein clamping; [63] however, this can increase venous back-bleeding and, in some cases, interfere with visualization. The authors consider venous occlusion on a case-by-case basis: for smaller and more peripheral tumors, it is unnecessary; for larger tumors, for central tumors, or for novice surgeons, it may prove beneficial (see video below).

The assistant places two "Bulldog" vascular clamps on the renal artery.

Once vascular clamps are placed, the time is noted and attention is rapidly turned to tumor resection. Using the scissors in a “cold” fashion to allow optimal visualization of the parenchyma, the capsule is cut and the subjacent normal parenchyma is rapidly entered. Maintaining an appropriate orientation of resection angle is of critical importance to ensuring negative margins; it is often useful to direct the scissor tips away from the mass initially (see video below).

The initial phase of the resection is performed. Knowledge of the intrarenal anatomy of the tumor allows incision near the base; initial scissor orientation is straight down with tips away.

Excessive bleeding that interferes with visualization should be dealt with by first increasing the insufflation pressure to 20 mm Hg; suction is important but should be limited in order to maintain high insufflation pressure and not contribute to ongoing bleeding via abdominal decompression.

When an appropriate depth has been reached, the scissors can be turned “tips up” in order to prevent unnecessary diving into the kidney; knowledge that the Da Vinci monopolar scissors are 1 cm long can assist in assessing depth (see video below).

After reaching an appropriate depth, the scissors are turned and the base of the resection developed beneath the tumor.

Spot fulguration of areas of vigorous bleeding should be done with either monopolar or bipolar cautery as encountered, but resection should not be overly delayed. Entry into the collecting system should be noted; tumor resection is completed in less than 5 minutes, if possible. Reference to capsular scoring can be helpful during this resection, particularly with an indistinct mass. The authors start with roughly a 180° incision and complete the capsular incision on the "back" half as the tumor mass is becoming free. Margins are sent according to surgeon preference.

Renorrhaphy

When the renal mass is excised, it is set safely aside in a retrievable location and repair immediately commenced. Robotic instruments are exchanged for needle drivers on just the right hand or both, and the authors’ preference is to repair the tumor bed with a running 6-in, 3-0 V-Lok suture (Covidien, Dublin, Ireland) beginning outside the resection bed and with care taken to oversew vascular sinuses and repair collecting system violations as seen in the fashion originally reported by Shikanov et al. [64] The V-Lok suture may be simply cut once this running repair of the tumor bed is complete, taking advantage of its nonslipping qualities. This step may be unnecessary in smaller or uncomplicated resections (see video below).

A running suture, begun outside the resection bed, is placed to oversew collecting system and vascular structures. The authors prefer V-Lok suture, which is cut without tying.

Capsular renorrhaphy is undertaken with 0 polyglactin on a CT-1 needle. These are generally precut to a 4-in length with either a knot holding a Hem-o-lok clip (Teleflex, Research Triangle Park, NC, USA) in place at the distal end or a Lapra-Ty (Ethicon, Somerville, NJ, USA), securing the clip as described by Benway et al. [47] The authors do not use preformed bolsters.

A small section of precut Surgicel (Ethicon, Somerville, NJ, USA) is placed in the resection bed, and a hemostatic agent such as Floseal (Baxter Biosurgery, Deerfield, IL, USA) may be dispensed on top; the sutures are then placed with a 1- to 2-cm margin from the edge of the resection bed, passed into the bed, placed again into the opposing side of the defect, and pulled up from the opposing margin.

Moderate upward traction is used to pull the suture through so that the clip engages the capsule and pulls the defect closed with slight capsular dimpling; care is taken to avoid tearing the renal capsule. A Hem-o-lok clip is applied to the second side, slid down, and then locked in place with a Lapra-Ty after pulling an appropriate amount of hemostatic tension across the defect. This is repeated to result in resection bed closure with suture spacing every 5-7 mm along the wound. Placement of the Hem-o-lok clips so that the center of the clip engages the suture is important to allow controlled slipping and broad distribution of tension across the kidney capsule (see videos below).

Hemostatic agent and Surgicel are placed in the renal defect and 0 polyglactin on a CT-1 used to begin capsular closure.
Further capsular sutures are placed and tensioned with Hem-o-lok clips. Lapra-tys are then used to complete this "sliding-clip" renorrhaphy.

Vascular bulldog clamps should be removed as soon as possible to minimize ischemic time. In a more peripheral or limited resection, this can be done as soon as the first parenchymal suture is placed, if desired; in general, the authors release the clamps as soon as the first 3 capsular sutures are in place. The goal should be to have the clamps released before 20 minutes of warm ischemia has elapsed; however, oncologic success should never be compromised to shorten ischemia time. Optimal results are achieved with clamp times that are under 25 minutes; renal function is more likely to be compromised with longer times, especially in the setting of other microvascular comorbidity such as diabetes or hypertension. [65]

Once the clamps are released, attention is immediately returned to the resection bed. Further sutures are placed as necessary to achieve complete hemostasis, and the insufflation pressure is lowered to allow appropriate survey for bleeding. Final tightening of the capsular sutures is done. A second layer of Surgicel and hemostatic agent may be placed if the desired. Gerota fascia is closed over the repair with a running 2-0 or 3-0 polyglactin using intermittent Hem-o-lok clips to take up tension.

The specimen in placed in a bag and secured. The robot is undocked after a final survey with the pressure decreased, and a drain is placed if significant collecting system entry was suspected or bleeding feared. Ports of 10 mm or greater are closed with a Carter-Thomason device or under direct vision; 8 mm or smaller ports are generally not closed in the authors’ practice. [66]

Notes

The use of the intravenous contrast agent indocyanine green (ICN) may provide advantages in identification of appropriate vascular branches for clamp application, as well as for assessing tumor margins before and after resection. At the present time, utility is being assessed, and availability of this technology is limited and costly.

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