Robotic Kidney Surgery

Kidney surgery is traditionally performed as an open surgery, which requires a large incision and possibly removal of a rib, which causes greater pain. Robotic kidney surgery requires is minimally invasive because it uses robotic arms to perform the surgery.
Background
Surgical resection is the gold standard for treatment of renal cell carcinoma, and partial nephrectomy (PN) is the treatment of choice for tumors smaller than 4 cm in size. Laparoscopic PN is a viable alternative to traditional open PN as it has been shown to achieve good long-term cancer cure and renal function results. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., SunnyVale, CA) with wristed instruments and magnified, 3-dimensional vision may facilitate some of the technical challenges during laparoscopy including intracoporial suturing and renal reconstruction. Robotic partial nephrectomy (RPN) is still in its infancy compared to laparoscopy. The technique of RPN is still evolving and a number of institutions have recently reported their results.
How Robotic Kidney Surgery Works
Conventional laparoscopy, robotic kidney surgery less invasive but limits the surgeon’s dexterity, visualization and control compared to open surgery. When performing a robotic kidney surgery, the surgeon sits at a console and controls the movements of miniature instruments and a tiny camera on the end of robotic arms inserted through several small incisions in the body. The robot cannot be programmed nor can it make decisions on its own; it is under the complete control of the surgeon at all times.
Precision
The precision and dexterity of the miniature robotic instruments allow the surgeon to perform complex steps of tumor resection and kidney reconstruction with greater accuracy.
3-Dimensional Optics
Standard laparoscopic surgery uses one single camera and limits a surgeon’s vision to a 2-D view similar to watching your television. Some robotic cameras consist of two high resolution fiber optic cameras which produce a 3-dimensional color picture for the surgeon. Magnification of up to twelve times can be achieved with these cameras, whose position is precisely controlled using a robotic arm.
Different Types of Robotic Kidney Surgery
Robotic Partial Nephrectomy
Partial nephrectomy removes the kidney tumor while preserving the normal and unaffected portion of the kidney, thus preventing the loss of the entire kidney. The kidney tumor must be cut out precisely to ensure complete removal. The area of the kidney that has been cut out must be closed with complex surgical techniques. Robotic assistance can allow the surgeon to perform these complex steps with greater ease and precision. Robotic partial nephrectomy can provide a minimally invasive, kidney spariwng option for kidney tumors, avoiding the potential need for a total nephrectomy or open surgery An advantage of removing only the tumor from the kidney instead of removing the entire kidney is that the patient will have more normal kidney remaining, with a lower chance of long term kidney failure, dialysis, or other medical problems.
Robotic Radical Nephrectomy
Robotic surgery to remove the entire kidney for large tumors or disease involving the entire kidney.
Possible Advantages to Robotic Kidney Surgery
• Less pain
• Fewer complications
• Shorter hospital stay
• Faster recovery
• Less scarring
• Less blood loss
Robotic assistance offers the surgeon a number of tools to aid with the technical challenges of LPN. Articulating instruments and magnified 3-dimensional vision facilitate precise tumor excision and renal reconstruction during robotic partial nephrectomy (RPN) while minimizing warm ischemia times. Radiographic images can also be integrated onto the console screen with the TilePro feature to guide tumor localization and resection.
The literature for RPN is showing promising results. Multiple small, single-institution studies have demonstrated the safety and feasibility of RPN. A larger multi-institutional study of 148 RPN procedures performed by 9 surgeons beginning their initial experience in RPN confirmed safety and feasibility of RPN, with early oncologic results and perioperative outcomes comparable to more mature reports for OPN and LPN.
Surgical Steps
Step 1: Trocar Placement
A 12 mm port for the da Vinci camera can be placed laterally using a 0o or 30o angle up scope or medialy using a 0o or 30o down scope. With a medial camera position, two 8 mm da Vinci ports are placed under vision approximately 5-6 cm away from the camera. These three ports are triangulated towards the renal hilum. With a lateral camera position, the ports are more in a line that is perpendicular to the line drawn from the camera port to the hilum. A port for the fourth robotic arm may be placed approximately 4-5 fingerbreadths medially to the most caudal robotic instrument port. A 12mm assistant port is placed near the umbilicus or lateral to the rectus in obese patients. An optional 5 mm assistant port can be placed below 12 mm port if necessary. For right sided cases, a 5mm subxiphoid port can be placed for retraction. The robot is docked posteriorly at approximately a 20o angle towards the head of the patient.
Step 2: Medial Mobilization of the Bowel
The colon must be mobilized medially to expose the kidney. The Line of Toldt is incised lateral to the colon by cutting the superficial layer of peritoneum. The colon is retracted medially by the assistant while the relatively avascular plane between the posterior mesocolon and anterior Gerota’s fascia is developed. This dissection is continued to the upper pole of the kideny. The perinephric fat under Gerota’s can be distinguished from mesenteric fat by its paler yellow color. This difference in color may help orient the surgeon if the dissection leaves the desired plane. Care is taken not to use cautery near the colon to avoid a thermal injury.
Step 3: Identify Anatomical Landmarks
A plane is developed between the packet containing the ureter and gonadal vein, and the psoas muscle. Gerota’s fascia is grasped and the kidney is lifted anteriorly to help expose the ureter and gonadal vein. The fourth robotic arm can be used to help lift the kidney and ureter to facilitate dissection. The ureter and gonadal vein are identified, and traced to the renal hilum.
Step 4: Hilar Dissection
The hilum is identified by tracing the gonadal vein superiorly. On the left, the gonadal is traced to its insertion in the renal vein. On the right, the gonadal is traced to the vena cava, then followed to the renal vein. Once the renal vein is identified, the renal artery is dissected. The artery usually sits behind the vein, and visualization of arterial pulsations may aid in identifying its exact location. The hilar vessels are dissected and small venous branches and lymphatics are divided. Dissection may be facilitated by using the fourth robotic arm to retract the kidney laterally placing the renal hilum on stretch.
Step 5: Tumor Identification
A flexible laparoscopic ultrasound is introduced through the 12 mm assistant port. Intraoperative ultrasound images and preoperative radiographic imaging can be displayed on the console screen as a picture on picture display using the TilePro feature of the da Vinci S system. The tumor is identified and Gerota’s fascia is opened over the tumor. The perinephric fat over the tumor is removed and sent to pathology as a frozen section. Adequate fat is removed to expose normal parenchyma on all sides of the tumor to facilitate future capsular reconstruction. The ultrasound probe is again used to demarcate the tumor margins and depth. Cautery is used to score the renal capsule demarking the planes of resection.
Step 6: Hilar Clamping
Prior to clamping, ensure that all stitches and instruments are available for resection and renal reconstruction in order to minimize warm ischemia time. Ensure there is adequate CO2 for insufflation and that the patient has received 12.5g of manitol for osmotic diuresis.
There are two commonly used methods for hilar clamping, laparoscopic bulldog clamps, and a Statinsky clamp. Laparoscopic bulldog clamps are placed by the assistant through the 12 mm port. The artery is test clamped to ensure the entire vessel can be occluded. The renal artery is clamped first, followed by the renal vein. If the tumor is small or exophytic, the renal artery alone may be clamped.
If individual dissection of the renal vessels is difficult, en bloc clamping of the hilum can be performed with a Statinsky clamp. This clamp should be placed parallel to the aorta and inferior vena cava. Use of the Statinsky requires a dedicated port, therefore the assistant must be able to perform all tasks through a single port, or an additional port must be placed. Care must be taken to avoid movement of the clamp or collision with any of the robotic arms as this may cause injury to the renal vessels.

Step 7: Tumor Excision
Cold excision with monopolar scissors is used along the demarcated margins to remove the tumor. As cancer cure is the primary concern, a small margin of normal parenchyma is also exicsed. If the tumor is entered, the scissors are backed up and the plane of excision is corrected. A ureteral catheter is not can be placed prior to surgery, however we do not routinely place them as the collecting system can be visualized sufficiently with the improved magnification of the robotic camera. During excision, the assistant uses a suction tip to clear any blood in the surgical field as well as apply counter traction on the renal parenchyma to help delineate the plane of resection. Once the tumor is removed, it is placed out of the way for later retrieval.
Step 8: Renal Reconstruction
The robotic instruments are replaced with a needle drivers. We currently prefer a needle driver in the right hand, and Prograsp Forceps in the left. Prograsp Forceps allow for effective grasping of needles and sutures, and can throw stitches if the right arm is occupied.
a) Inner Layer Closure
A 3-0 or 4-0 vicryl on a RB-1 or SH needle is used to repair any entry into the collecting system and achieve hemostasis. A running baseball stitch starting at the far end of the defect and working towards the camera is performed. The end of the suture is prepared with a preplaced Lapra-Ty to avoid knot tying, and another Lapra-Ty is placed by the assistant to secure the stitch when the suturing is completed. If bleeding continues, additional stitches are placed as needed.
b) Capsule Reconstruction
0-vicryl sutures on a CT-1 needle, cut to a length of 5 inches are prepared with a weck clip on the outer end secured with a Lapra-Ty and knot. Interrupted stitches are placed to help reapproximate the capsular edges starting at the far side of the defect and working toward the camera. The stitches are secured with weck clips which are slid down the suture by the console surgeon to apply appropriate tension. The interrupted stitches with a weck clip spreads the force of the suture over a larger surface area allowing stitches to be cinched tighter for a closer reapproximation of the edges and better hemostasis. Large bites of capsule are taken to ensure the suture does not rip through. If the defect is large, Surgicel bolsters can be positioned under the sutures with a hemostatic agent such as Floseal. After clamp removal, Lapra-Ty clips are placed by the assistant on the capsular stitches next to the weck clips to secure them. The sutures are cut and the needles are removed.
Step 9: Removal of Hilar Clamps
Following reconstruction of the renal defect, the hilar clamps are removed. The venous clamp is removed first followed by flashing of the arterial clamp to confirm hemostasis. Hemostasis can also be tested by reducing the pneumoperitoneum to 5 mmHg. If oozing continues, pressure can be applied by a laparoscopic sponge. Another 12.5g of manitol is given once the clamps are removed.
Step 10: Specimen Retrieval and Closure
The specimen is retrieved from the pelvis and placed into an extraction bag inserted through the 12 mm assistant port. A Jackson-Pratt drain may be placed through the fourth robotic arm port and is secured with a nylon suture. The 12mm assistant port incision is extended to removed to tumor specimen. The fascia of the incision is closed with interrupted 0- braided polyester sutures. The skin is closed with 4-0 braided polyglactin, subcuticular sutures and sterile strips.
See Also
Nephrectomy
da Vinci Surgical System

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