Robotic kidney surgery - Revision history

wikademia>Eme at 07:13, 9 May 2011

2011-05-09T07:13:54Z

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	'''Step 10: Specimen Retrieval and Closure'''<br />		'''Step 10: Specimen Retrieval and Closure'''<br />
	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.		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 ==		== See Also ==
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	== References ==		== References ==
	<references/>		<references/>

			[[Category:Surgery]]

wikademia>Wikademia: moved Robotic Kidney Surgery to Robotic kidney surgery

2009-10-27T12:34:53Z

moved Robotic Kidney Surgery to Robotic kidney surgery

← Older revision	Revision as of 12:34, 27 October 2009
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wikademia>Wikademia at 22:43, 19 August 2009

2009-08-19T22:43:09Z

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	~~{{AfDM\|page=Robotic Kidney Surgery\|logdate=2009 August 7\|substed=yes\|help=off}}~~
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	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.		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 ==		== Background ==

wikademia>Wikademia: 13 revisions

2009-08-08T05:43:29Z

13 revisions

← Older revision	Revision as of 05:43, 8 August 2009
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wikademia>Crogers1 at 21:04, 7 August 2009

2009-08-07T21:04:16Z

← Older revision		Revision as of 21:04, 7 August 2009
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	== ~~Introduction~~ ==		== 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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L., Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>		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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L., Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>
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	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.		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.<ref>Rogers CG, Menon M, Weise ES, et al. Robotic partial nephrectomy: a multi-institutional analysis J Robotic Surg 2008; 2:141-3.</ref>		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.<ref>Rogers CG, Menon M, Weise ES, et al. Robotic partial nephrectomy: a multi-institutional analysis J Robotic Surg 2008; 2:141-3.</ref>


	== Surgical Steps ==		== Surgical Steps ==

wikademia>Crogers1 at 21:03, 7 August 2009

2009-08-07T21:03:13Z

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	~~Introduction~~		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.
	~~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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open ~~partial nephrectomies for single renal tumors. J Urol~~, ~~178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips~~, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic ~~partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted~~ robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the ~~NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L~~.~~, Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>~~


	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.		== Introduction ==

			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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L., Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>

	== How Robotic Kidney Surgery Works <ref>http://www.kidneyrobotics.com/Kidney_Robotics/About_Robotic_Kidney_Surgery.html</ref>==		== How Robotic Kidney Surgery Works <ref>http://www.kidneyrobotics.com/Kidney_Robotics/About_Robotic_Kidney_Surgery.html</ref>==

wikademia>Crogers1 at 21:01, 7 August 2009

2009-08-07T21:01:24Z

← Older revision		Revision as of 21:01, 7 August 2009
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	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.<ref>Rogers CG, Menon M, Weise ES, et al. Robotic partial nephrectomy: a multi-institutional analysis J Robotic Surg 2008; 2:141-3.</ref>		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.<ref>Rogers CG, Menon M, Weise ES, et al. Robotic partial nephrectomy: a multi-institutional analysis J Robotic Surg 2008; 2:141-3.</ref>

	Surgical Steps
	Step 1: Trocar Placement		== Surgical Steps ==

			'''Step 1: Trocar Placement'''<br />
	A 12 mm port for the da Vinci camera can be placed laterally using a 0o or 30o angle up scope<ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref> <ref>Badani, K. K., Muhletaler, F., Fumo, M. et al.: Optimizing robotic renal surgery: the lateral camera port placement technique and current results. J Endourol, 22: 507, 2008</ref>or medialy using a 0o or 30o down scope.<ref>Rogers, C. G., Singh, A., Blatt, A. M. et al.: Robotic partial nephrectomy for complex renal tumors: surgical technique. Eur Urol, 53: 514, 2008</ref> 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.		A 12 mm port for the da Vinci camera can be placed laterally using a 0o or 30o angle up scope<ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref> <ref>Badani, K. K., Muhletaler, F., Fumo, M. et al.: Optimizing robotic renal surgery: the lateral camera port placement technique and current results. J Endourol, 22: 507, 2008</ref>or medialy using a 0o or 30o down scope.<ref>Rogers, C. G., Singh, A., Blatt, A. M. et al.: Robotic partial nephrectomy for complex renal tumors: surgical technique. Eur Urol, 53: 514, 2008</ref> 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		'''Step 2: Medial Mobilization of the Bowel'''<br />
	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.		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		'''Step 3: Identify Anatomical Landmarks'''<br />
	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.		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		'''Step 4: Hilar Dissection'''<br />
	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.		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.

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	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.		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		'''Step 6: Hilar Clamping'''<br />
	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.		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.		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.		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		'''Step 7: Tumor Excision'''<br />
	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.		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
			'''Step 8: Renal Reconstruction'''<br />
	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.		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) Inner Layer Closure
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	b) Capsule Reconstruction		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.<ref>Bhayani, S. B., Figenshau, R. S.: The Washington University Renorrhaphy for robotic partial nephrectomy: a detailed description of the technique displayed at the 2008 World Robotic Urologic Symposium. J Robotic Surg, 2: 139, 2008</ref> 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.		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.<ref>Bhayani, S. B., Figenshau, R. S.: The Washington University Renorrhaphy for robotic partial nephrectomy: a detailed description of the technique displayed at the 2008 World Robotic Urologic Symposium. J Robotic Surg, 2: 139, 2008</ref> 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
			'''Step 9: Removal of Hilar Clamps'''<br />
	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.		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		'''Step 10: Specimen Retrieval and Closure'''<br />
	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.		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.

wikademia>JohnCD: RM hangon tag, article no longer under speedy

2009-08-07T17:20:19Z

RM hangon tag, article no longer under speedy

← Older revision		Revision as of 17:20, 7 August 2009
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	<!-- For administrator use only: {{oldafdfull\|page=Robotic Kidney Surgery\|date=7 August 2009\|result='''keep'''}} -->		<!-- For administrator use only: {{oldafdfull\|page=Robotic Kidney Surgery\|date=7 August 2009\|result='''keep'''}} -->
	<!-- End of AfD message, feel free to edit beyond this point -->		<!-- End of AfD message, feel free to edit beyond this point -->
	~~{{hangon}}~~

	Introduction		Introduction
	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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L., Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>		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.<ref>Ljungberg, B., Hanbury, D. C., Kuczyk, M. A. et al.: Renal cell carcinoma guideline. Eur Urol, 51: 1502, 2007</ref> 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.<ref>Allaf, M. E., Bhayani, S. B., Rogers, C. et al.: Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol, 172: 871, 2004</ref><ref>Lane, B. R., Gill, I. S.: 5-Year outcomes of laparoscopic partial nephrectomy. J Urol, 177: 70, 2007</ref><ref>Gill, I. S., Kavoussi, L. R., Lane, B. R. et al.: Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 178: 41, 2007</ref> 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.<ref>Caruso, R. P., Phillips, C. K., Kau, E. et al.: Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol, 176: 36, 2006</ref><ref>Stifelman, M. D., Caruso, R. P., Nieder, A. M. et al.: Robot-assisted laparoscopic partial nephrectomy. Jsls, 9: 83, 2005</ref><ref>Rogers, C. G., Menon, M., Weise, E. S., Gettman, M. T., Frank, I., Shephard, D. L., Abrahams, H. M., Green, J. M., Savatta, D. J., Bhayani, S. B.: Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg, 2: 141, 2008</ref><ref>Kaul, S., Laungani, R., Sarle, R. et al.: Da vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol, 51: 186, 2007</ref><ref>Phillips, C. K., Taneja, S. S., Stifelman, M. D.: Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 19: 441, 2005</ref><ref>Gettman, M. T., Blute, M. L., Chow, G. K. et al.: Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology, 64: 914, 2004</ref>

wikademia>Crogers1 at 16:44, 7 August 2009

2009-08-07T16:44:56Z

Show changes

wikademia>Crogers1 at 15:30, 7 August 2009

2009-08-07T15:30:32Z

← Older revision		Revision as of 15:30, 7 August 2009
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	== Post-Operative Complications ==		== Post-Operative Complications ==
	'''Post-operative Pain'''<br />		'''Post-operative Pain'''<br />
	Pain medication can be given in the hospital via an intravenous catheter or by medication taken by mouth or by an injection (pain shot) administered by the nursing staff. ~~You may experience some~~ minor transient shoulder pain (1-2 days) related to gas used in inflate your abdomen during the laparoscopic surgery. You will take oral pain medications as needed after discharge.<br />		Pain medication can be given in the hospital via an intravenous catheter or by medication taken by mouth or by an injection (pain shot) administered by the nursing staff. Some minor transient shoulder pain (1-2 days) may be present and related to gas used in inflate your abdomen during the laparoscopic surgery. You will take oral pain medications as needed after discharge.<br />
	<br />		<br />
	'''Bruising and Blisters around the incision sites'''<br />		'''Bruising and Blisters around the incision sites'''<br />
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	<br />		<br />
	'''Abdominal Distention, Constipation or Nausea'''<br />		'''Abdominal Distention, Constipation or Nausea'''<br />
	~~You~~ may ~~experience~~ sluggish bowels for several days. Make sure you are taking your stool softener as directed. If you don’t have a bowel movement or pass gas or are feeling uncomfortable 24 hours after surgery, you may try taking Milk of Magnesia (2-4 tbsp) as directed on the bottle. If this is ineffective you may use a Dulcolax suppository as directed. You may experience some nausea immediately after surgery related to the anesthesia. Medication is available to treat persistent nausea.<br />		There may be sluggish bowels for several days. Make sure you are taking your stool softener as directed. If you don’t have a bowel movement or pass gas or are feeling uncomfortable 24 hours after surgery, you may try taking Milk of Magnesia (2-4 tbsp) as directed on the bottle. If this is ineffective you may use a Dulcolax suppository as directed. You may experience some nausea immediately after surgery related to the anesthesia. Medication is available to treat persistent nausea.<br />
	<br />		<br />
	'''Weight Gain'''<br />		'''Weight Gain'''<br />
	~~Do not be alarmed.~~ This is temporary due to the gas and fluid shifts. ~~Your weight~~ will return to normal 2-3 weeks after surgery.<br />		This is temporary due to the gas and fluid shifts. Weight will return to normal 2-3 weeks after surgery.<br />
	<br />		<br />
	'''Fatigue'''<br />		'''Fatigue'''<br />
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	This is not abnormal if it occurs in both legs. Elevating your legs should help. Call us if the swelling occurs in one leg or you experience calf pain.		This is not abnormal if it occurs in both legs. Elevating your legs should help. Call us if the swelling occurs in one leg or you experience calf pain.

	== Symptoms ~~to Report~~ ==		== Possible Post-Operative Symptoms ==
	• Fever greater than 101º F<br />		• Fever greater than 101º F<br />
	• Chills<br />		• Chills<br />