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Laparoscopic robotic-assisted partial nephrectomy

Authors

Abstract

This video describes the procedure of partial nephrectomy performed with the DaVinci robot. The renal pedicle is first isolated and temporarily controlled with vascular clamps. The partial nephrectomy is then performed in a bloodless field.

Classification

robotic

Keywords

partial nephrectomy, robot, renal pedicle, vascular clamps, kidney

Media type

Duration

08'23''

Publication

2007-03

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Audio

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E-publication

WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2086.htm

Laparoscopic robotic-assisted partial nephrectomy

1. Trocar placement 00'14''

This patient presented with a 3.5cm tumor of the left kidney. He is installed in a dorsal position with the left side lifted up. Three ports are used for the robot and one for the assistant at the umbilicus. The 1st step consists in reclining the colon. Careful hemostasis is performed using the bipolar forceps. Dissection goes on with the electrocautery hook at the medial part of the kidney in order to get access to the renal pedicle.

2. Isolation of renal vessels 01'00''

The renal vein has already been dissected with a Hemolock clip on the genital vein. Beneath the vein, we can find the main renal artery. This is carefully dissected with the electrocautery hook. Using 2 forceps, the plastic loop is passed behind the renal vein. The extremities are secured with a Hemolock clip, which is placed by the bedside assistant. The same maneuver is performed around the renal artery. Thanks to the articulated instrument tips, this is much easier than in standard laparoscopy. Once the renal vessels have been prepared we can now go to the renal convexity and incise the Gerota’s fascia.

3. Renal parenchyma division 02'28''

The tumor can be identified and the fat left untouched on the top of it. Now we begin with the incision of the renal capsule around the tumor leaving a 1cm margin. A bulldog clamp can be applied by the assistant on the renal artery. The renal vein needs no clamping but the insufflation pressure is slightly increased. The position of the clamp is carefully checked before going back to the tumor. Incision of the renal capsule is resumed using the electrocautery hook. And we go on with the incision of the parenchyma. The incision is progressively performed with only few blood losses. Deeply we get access to the fat of the renal hilum. Blood vessels are also cut with the electrocautery hook. Thanks to the articulated instrument tips, it’s quite easy to perform a wedge-shaped incision around the tumor. The partial nephrectomy is now completed and the specimen is put on the side of the kidney.

4. Suture of kidney remnant 04'28''

Some stitches are placed on the main vessels in the renal hilum. You can appreciate how easy it is to transfer the needle from the needle holder to the other and to take advantage of the endowristed instruments. Combination of improved instrument movements and 3-dimensional vision explains why it is easy to tie knots with the robotic instruments. Once hemostasis has been obtained, the catheter is introduced through an additional 5mm port. Bioglue is then applied on the renal section. This requires a dry operative field. The artery clamp can then be removed. Checking for hemostasis shows no bleeding. Several 2/0 stitches are then applied on the renal fat. Again this is easily performed thanks to the articulated instrument tips and the 7 degrees of freedom which are equivalent to those of the human wrist. Additionally, thanks to 2 separate optic channels, the robotic system provides complementary vision for the left and right eyes of the surgeon. What you see on the screen is a classical 2-dimensional image but what the surgeon sees at the console is a real 3-D vision. Forehand or back-hand stitches are easy to perform so is the needle transfer from one needle holder to the other. Zooming in and out is also controlled by the surgeon. You can also appreciate the image stability. The peri-renal fat is carefully applied on the renal incision. Careful hemostasis and closure of the renal fossa allows to avoid any suction drainage. The vessel loops are cut by the assistant and removed from the artery and from the vein.

5. Specimen removal and closure of capsular fat 07'50''

An endobag is introduced through the 12mm port at the umbilicus. The specimen is put into it and extracted. The security margin is of 1cm around the tumor with an excellent aspect and a functional kidney on the postoperative CT-scan.

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