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Robotic Radical Nephrectomy

Dr. Stephen Lukasewycz

What is this procedure?Tap to read

A radical nephrectomy removes the whole kidney, usually for cancer, along with the fat around it.

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.

Removing the kidney: the kidney's artery and vein are sealed and cut, the kidney is placed in a bag, and it comes out through one slightly larger incision.

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.
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

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
Echelon stapler (45 or 60 mm) with white vascular reloads, usually used for the hilum. Have several reloads available.

Available in room, open only if asked

Weck Hem-o-lok XL applier ("gold") with XL clips
Lapra-Ty clips

Sutures and closure

0 looped PDS CTX ×1 for the extraction (mini-open) incision.
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
Large Endocatch specimen bag
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

Surgicel 4×8 and Surgicel powder with lap applicator

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.
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

Kidney to pathology in formalin.
Wound class: II (clean-contaminated).

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