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A Modified Technique for Trocar Placement in Robotic Partial Nephrectomy to Reduce Collision of the 3rd and 4th Robotic Arms
Kyle T. Finnegan, BS, Anoop M. Meraney, MD, Stuart S. Kesler, MD, Steven J. Shichman, MD.
Hartford Hospital, Hartford, CT, USA.

Background: The use of robotic nephron sparing surgery has significantly increased in recent years. Robotics provides many advantages such as 3D visualization and an endowrist with added degrees of freedom, which aids in the resection of tumors and repair of the defect. A single surgeon at our institution has performed >150 robotic partial nephrectomies and has modified the technique to achieve better results. One of the most important modifications was the change in the trocar placement to allow more movement in the arms and especially to prevent the collision of the 3rd and 4th robotic arms.

Methods: A single surgeon at our institution performed >150 RPN’s from October 2007 to April 2010. All patents were placed in the semi-lateral decubitus position with the operative table gently flexed to increase abdominal surface area. A total of 6 or 7 ports are used in robotic partial nephrectomies. There are 4 robot ports (3 robot arms and the camera, 30º down scope); 2 assistant ports; and for right sided cases an additional trocar for liver retraction.

Results: The initial robotic trocar inserted is the most cephalad robot working port, (right arm for right sided cases and left arm for left sided cases) this port is placed as cephalad as possible just off the midline and below the costal margin. On the right side, the port may need to be shifted caudally if a very large liver is encountered. The camera port is inserted in the midclavicular line, 5-6 cm from the most cephalad robot working port. The camera port is usually placed more laterally than the position typically used in a standard laparoscopic procedure; if the position of the tumor is very medial, the camera port will be shifted towards the midline. The contralateral robot port is inserted 5-6 cm caudal to the camera port slightly lateral to the midclavicular line. Finally, the 3rd robot working port is placed at least 6 cm caudal and most important medially to the adjacent robot working port. Medial and caudal positioning of this trocar prevents inadvertent collision of the adjacent robot arms. The assistant utilizes 2 accessory trocars allowing for suction, aid in retraction and positioning of the kidney, rapid insertion of sutures and application of Lapra-tys or Weck clips (fig. 1).

Conclusions: Several modifications have been made over the course of the >150 cases at our institution, however, the trocar placement has been a very important change. Not only does this allow for decreased collision of the 3rd and 4th robotic arms, but also the placement of the camera port in a more lateral position allows for increased visualization of the tumor and renal defect for repair, especially in posterior located tumors.

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