**4. Port placement**

Precise port placement and patient cart position are important for successful outcomes in robotic renal surgery. Unlike in pelvic surgery, the operative field is wider increasing the potential for robot arms to clash. With some basic principles, success can be replicated case after case. As with radical prostatectomy, the ports must be placed with a minimum 8 cm distance apart. However, with different laterality of renal surgery, an additional consideration is placing arm 3 of the patient cart. In the case of right sided renal tumours, arm 3 should be positioned on the left of the cart stem. The reverse is true for left renal surgery.

This should give adequate room for the 4th robotic arm port, which will then complete the kite or cross shape, placed laterally roughly in the anterior axillary line. It is possible that arm 1 (when operating on the right kidney) can hold the ProGrasp™ forceps, rather than arm 3. The robot is then manipulated to dock over the patient's upper shoulder at an angle of 45 degrees

Robot-Assisted Partial Nephrectomy: Evolving Techniques

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• Use of the bariatric ports can be beneficial to achieve greater distance between the robot arms, particularly in smaller patients. This will reduce the potential for robot arm clashing.

• Should the arms clash, then 'burping' the ports away from each other can create additional room and potentially avoid restricted movement of the instruments, which can severely limit surgical progress. The ports placed under traction, tents the abdominal wall exter-

Evidence from a meta-analysis reveals similar surgical outcomes and complications between transperitoneal and retroperitoneal robot-assisted partial nephrectomies. The retroperitoneal approach may have a specific role in selected cases including posterior tumours and in patients with pervious significant transperitoneal surgery. Absence of the need to mobilise bowel and easy access to the hilar vessels, leads to a shorter operative time [26]. However, the choice between retroperitoneal or transperitoneal approach lies based on surgeon's expertise

We recommend a trans-peritoneal approach, particularly in the early phase of the learning curve. This will ensure that adjacent structures can be adequately mobilised away from the kidney. In addition, operative space is optimised when within the peritoneum. This will avoid injury to sensitive structures such as the duodenum on the right and the spleen; tail of the pancreas and duodeno-jejunal junction on the left. The authors recommend using a 0° camera lens in the early learning curve period, unless experienced in 30° downward scope lens from laparoscopic surgery [23]. Use of 30° downward lens has a role in the later stages of dissecting posterior tumours [24]. A pneumoperitoneum of 10–12 mmHg is established. In almost all cases the kidney can be adequately mobilised to expose renal masses to perform a partial nephrectomy successfully in the trans-peritoneal approach. However, some surgeons transferring from retroperitoneal laparoscopic surgery may feel suitably experienced in translating skills to perform retroperitoneal robotic surgery. Guides are available on performing

A wide array of instruments and preferences exist in performing a RAPN. The authors perform the procedure with the surgeon holding the EndoWrist® Fenestrated Bipolar Forceps and the EndoWrist® Hot Shears™ monopolar curved scissors in the non-dominant and dominant hand robotic ports respectively. Sharp dissection is performed along the white line of Toldt.

nally, increasing intra-abdominal space to work in [25].

to the kidney.

**4.1. Tips and tricks**

**5. Surgical technique**

and patient factors [17].

retroperitoneal RAPN [27, 28].

We recommend marking the skin to plan port positioning. Formation of a skewed cross or upside-down kite shape should be made with the camera port forming the apex. However the reference point should be the subcostal port, as it offers least flexibility in positioning. The camera port, target organ and patient cart should form a straight line, thereby creating adequate triangulation for safe operating. The contralateral operating port will form a horizontal line to the subcostal port, with the camera port bisecting this line in the middle (**Figure 2**).

**Figure 2.** Port site marking for a right RAPN.

This should give adequate room for the 4th robotic arm port, which will then complete the kite or cross shape, placed laterally roughly in the anterior axillary line. It is possible that arm 1 (when operating on the right kidney) can hold the ProGrasp™ forceps, rather than arm 3. The robot is then manipulated to dock over the patient's upper shoulder at an angle of 45 degrees to the kidney.

#### **4.1. Tips and tricks**

**4. Port placement**

238 Evolving Trends in Kidney Cancer

**Figure 2.** Port site marking for a right RAPN.

Precise port placement and patient cart position are important for successful outcomes in robotic renal surgery. Unlike in pelvic surgery, the operative field is wider increasing the potential for robot arms to clash. With some basic principles, success can be replicated case after case. As with radical prostatectomy, the ports must be placed with a minimum 8 cm distance apart. However, with different laterality of renal surgery, an additional consideration is placing arm 3 of the patient cart. In the case of right sided renal tumours, arm 3 should be

We recommend marking the skin to plan port positioning. Formation of a skewed cross or upside-down kite shape should be made with the camera port forming the apex. However the reference point should be the subcostal port, as it offers least flexibility in positioning. The camera port, target organ and patient cart should form a straight line, thereby creating adequate triangulation for safe operating. The contralateral operating port will form a horizontal line to the subcostal port, with the camera port bisecting this line in the middle (**Figure 2**).

positioned on the left of the cart stem. The reverse is true for left renal surgery.

