Open on phone

Robotic Partial Nephrectomy

Dr. Stephen Lukasewycz

What is this procedure?Tap to read

A partial nephrectomy removes a tumor from the kidney while saving the rest of the kidney.

Robotic: the surgeon works through several small ports in the side and abdomen using the robot. The abdomen is inflated with gas to make working room.

Clamping: the kidney's artery (and sometimes vein) is clamped with small bulldog clamps so the tumor can be cut out without heavy bleeding. The kidney is then stitched closed and the clamps come off. Clamp time is kept as short as possible.

Ultrasound: a small robotic ultrasound probe finds the edges of the tumor before it is cut out.

Key points

Dr. Lukasewycz is present for all positioning. He marks the midline before positioning; have a skin marker ready.
Lateral, operative side up, flank over the bed's flex point. Have several rolls of tape ready.
Counted procedure.
Clamp time: start a timer when the artery/vein is clamped. No staff changes while clamped; put "Clamped – no breaks" signs on the doors.
Ultrasound: robotic drop-in probe (BK). Connect the probe before turning the machine on.
AirSeal for insufflation in all robotic surgery suites.

Ports

8 mm da Vinci ports ×4
12 mm AirSeal port ×1
Assistant port: 5 mm or 12 mm depending on the case. Ask the surgeon which.
Right kidney only: 5 mm port for the liver retractor. Not used on the left.
First (camera) port: blunt black reusable obturator from the robot set. Ports are placed using the da Vinci scope.
Obese patient: long 8 mm da Vinci ports and long 12 mm AirSeal trocar.
1% lidocaine plain for port sites.

Robotic instruments

Open

Monopolar curved scissors
Fenestrated bipolar
ProGrasp
Large needle drivers ×2
0° robotic scope
Robotic bulldog clamps and appliers
Robotic drop-in ultrasound transducer (BK)
Da Vinci Lapra-Ty applier

Available in room, open only if asked

30° robotic scope

Assistant (PA) instruments

Open

Suction irrigator (Surgiflex)
Laparoscopic scissors
10 mm laparoscopic spoon (Snowden Pencer)
Weck Hem-o-lok 10 mm applier ("purple") with large clips
Lapra-Ty clips

Available in room, open only if asked

Weck Hem-o-lok XL applier ("gold") with XL clips
Echelon stapler (45 or 60 mm) with white vascular reloads

Sutures and closure

Kidney repair (renorrhaphy): 3-0 V-Loc 90, CV-23 (violet) ×3.
Sliding-clip sutures: 2-0 Vicryl CT-1, undyed, cut to 6 inches. Number varies: at least 4; the surgeon will say how many. Tie a knot at the end, place a Lapra-Ty just in front of the knot, then a Hem-o-lok at 90° in front of the Lapra-Ty.
Bolster: Surgicel 4×8 wrapped around a small Gelfoam, sewn into place.
0 looped PDS CTX ×1 if the incision is extended (mini-open).
2-0 silk FS to secure the drain.
0 Vicryl UR-6 for port fascia.
4-0 Vicryl PS-2 for skin; Dermabond on port sites.

Other supplies

Open

General pan and robot pan
Specimen bag: Inzii 10 mm (the smaller bag)
19 Blake drain with reservoir: always opened for partials
Surgicel 4×8 (open one), small Gelfoam
Foley 16 Fr temperature-sensing tray
Skin marker; 3-inch tape ×5 rolls
Towels with skin stapler, lap chole drape, CHG Ioban strips
Warm saline for the irrigator

Available in room, open only if asked

More Surgicel 4×8; Surgicel powder with lap applicator
Surgiflo

Gloves: MD and PA

MD

Port placement: single 7.5 white.
Closing: double glove, 7.5 blue under 7.5 white.

PA

Aimee: 7 blue, 6.5 white
Carras: 7 blue, 6.5 white
Heather: 6.5 micro ×2
John: 7.5 blue, 7 white
Olivia: 7 blue, 6.5 white

Room setup

Robot bed in regular set-up (no diving board), with head piece.
Robot on the operative side, approaching over the patient's back.
Vision tower on the same side as the robot; AirSeal; boom suction at the patient's left shoulder, by anesthesia.
Ultrasound machine in the room. Urology ultrasound is in the equipment room; plug into the "TilePro input" (1st or 2nd slot on the back of the surgeon console). Connect the probe before turning the ultrasound on, or it won't register and must be restarted.
Erbe settings: coag 3, cut 5, bipolar 3.
To pair the bed to the robot: press Pair on the bed remote, then the button that appears on the robot tower monitor.

Anesthesia

General anesthesia.
Perioperative antibiotics: cefazolin (Ancef) 2 g IV, unless otherwise noted or allergy.
SCDs on and running before induction.
Foley after induction, secured to the thigh opposite the operative side.

Positioning

Midline marked by the surgeon before positioning.
Lateral, operative side up, flank over the flex point.
Rolled bath blankets (one single, one double roll) rolled into the draw sheet, front and back.
Foam axillary roll; arm across the chest on a CV armboard.
Pillows ×2–3 between the legs; bottom leg flexed, top leg straight; small foam donuts at the lateral knee and ankle.
Seat belt across the hips. After the table is flexed, blue towels over hips, shoulders and legs, taped.

Prep and drape

Clip hair if needed.
ChloraPrep: operative flank, nipples to pubis/hip bone, bedside to bedside.
The surgeon may want the abdomen lifted during the prep, with a sterile towel placed under it by the scrub.
Towels secured with skin staples, lap chole drape, CHG Ioban strips.

Specimens

Ask the surgeon how to send each specimen. He sometimes requests gross photos.
Dressing: Dermabond on port sites; drain sponge and Medipore on the drain.
Wound class: II (clean-contaminated).

← All briefings