**2. Introduction**

We use a standardised four robotic arm technique using the for renal surgery the Da Vinci Si Surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Suitable training must be achieved to acquire appropriate robotic skills before performing complex renal surgery. We recommend a modular training programme in keeping with European and British board standards [6, 7].

Ensuring that the early stages of the learning curve are supervised with a mentor is essential to reduce errors and aid development of confidence in robotic skills. Evidence on learning curves vary in robotic-assisted partial nephrectomy (RAPN), with a study reporting 44 case requirement by a laparoscopically trained surgeon, to achieve a warm ischaemia time (WIT) of less than 20 min and an operative time of less than 120 min [8]. An alternative report by another centre identified needing to perform 61–90 cases to reach a trifecta of no significant complications, negative surgical margins and WIT of less than 25 min [9]. Needless to say learning curves can be improved with better training techniques, volume and exposure [10]. WIT was found to decrease to 13 from 20 min, following performing 150 RAPN cases compared to the first 10 cases [11]. Robotic trainees under expert supervision were found to have longer operating and warm ischaemia time, but otherwise no worse outcomes than experts performing robotic partial nephrectomies [12]. In addition the patient-side assistant should be appropriately skilled in handling instruments safely and deploying ligature clips. All cases should be subjected to nephrometry scoring (PADUA and RENAL) and a thorough imaging review preoperatively to predict operative complexities and postoperative complications [13–16]. We incorporate the PADUA score due to its standardised use across the national nephrectomy register, collected by the British Association of Urological Surgeons.

is subsequently broken/flexed. This opens the flank, between the costal margin and the iliac crest. A reported variation may include a slight Trendelenburg position and a flat table [23]. The anterior abdomen lies on the edge of the operative table. The upper arm is flexed at the elbow and kept adjacent to the face [21]. We prefer adhesive tape to secure the patient to the bed, at the level of the iliac crest [23]. Additional adhesive tape used at the level of the mid thoracic cavity should be applied with caution to avoid reduced chest expansion, in the context of ventilation. The back can be stabilised using an additional back support attachment with gel pads. The bottom leg in the lateral position is flexed to 90° at the knee, and is separated from the extended top leg using pillows. All pressure points are padded [23]. A nasogastric tube (NGT) is placed in left sided tumours and a urinary catheter is inserted following anaesthetic induction for all cases, and prior to patient positioning [21]. The NGT is removed in recovery.

Robot-Assisted Partial Nephrectomy: Evolving Techniques

http://dx.doi.org/10.5772/intechopen.89712

237

**Figure 1.** Full flank patient positioning for left RAPN. Note port site marking made prior to knife to skin.

• A consistent surgical team who develop skills progressively with the surgeon, specifically for renal surgery is essential for optimal outcomes. Robotic renal surgery is approached

• It is vital that your anaesthetic staff is experienced with patient positioning and moving for

A uniform anaesthetic team will also lead to better pain control in the post-operative phase and consistently enhanced results particularly during the critical on-clamp (WIT) period of

differently from pelvic surgery and cannot instantly be translated.

**3.1. Tips and tricks**

robotic renal surgery.

partial nephrectomy.

## **3. Patient positioning**

The authors recommend this operative approach, based on the available disseminated techniques and preference in their experience and training [17–24]. In order to perform a robotic-assisted partial nephrectomy, the patient is positioned in a lateral decubitus/flank position (**Figure 1**) on the operative table to aid bowel mobilisation [24]. The operative table

**Figure 1.** Full flank patient positioning for left RAPN. Note port site marking made prior to knife to skin.

is subsequently broken/flexed. This opens the flank, between the costal margin and the iliac crest. A reported variation may include a slight Trendelenburg position and a flat table [23]. The anterior abdomen lies on the edge of the operative table. The upper arm is flexed at the elbow and kept adjacent to the face [21]. We prefer adhesive tape to secure the patient to the bed, at the level of the iliac crest [23]. Additional adhesive tape used at the level of the mid thoracic cavity should be applied with caution to avoid reduced chest expansion, in the context of ventilation. The back can be stabilised using an additional back support attachment with gel pads. The bottom leg in the lateral position is flexed to 90° at the knee, and is separated from the extended top leg using pillows. All pressure points are padded [23]. A nasogastric tube (NGT) is placed in left sided tumours and a urinary catheter is inserted following anaesthetic induction for all cases, and prior to patient positioning [21]. The NGT is removed in recovery.

#### **3.1. Tips and tricks**

collecting system [1]. The anatomical relations play an important role, particularly in hilar dissection, including the presence of the head of the pancreas and part of the duodenum overlying the right renal hilum. The left hilum is in close proximity to the body and tail of the pancreas, with the left colonic flexure bordering the left kidney anteriorly. In nearly 30% of cases more than one renal artery is identified supplying a kidney, often on the right side [2]. The renal arteries run posteriorly from the aorta to the kidneys, due to the orientation of the renal hilum. The arteries split into four anterior and one posterior segmental branches at the renal hilum [3]. The renal arteries sit in the middle at the hilum, with the renal veins anteriorly and the ureters/collecting systems posterior to the artery [4]. Multiple variants in renal artery anatomy have been reported in the literature, thereby highlighting the close attention war-

We use a standardised four robotic arm technique using the for renal surgery the Da Vinci Si Surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Suitable training must be achieved to acquire appropriate robotic skills before performing complex renal surgery. We recommend a modular training programme in keeping with European and British board standards [6, 7].

Ensuring that the early stages of the learning curve are supervised with a mentor is essential to reduce errors and aid development of confidence in robotic skills. Evidence on learning curves vary in robotic-assisted partial nephrectomy (RAPN), with a study reporting 44 case requirement by a laparoscopically trained surgeon, to achieve a warm ischaemia time (WIT) of less than 20 min and an operative time of less than 120 min [8]. An alternative report by another centre identified needing to perform 61–90 cases to reach a trifecta of no significant complications, negative surgical margins and WIT of less than 25 min [9]. Needless to say learning curves can be improved with better training techniques, volume and exposure [10]. WIT was found to decrease to 13 from 20 min, following performing 150 RAPN cases compared to the first 10 cases [11]. Robotic trainees under expert supervision were found to have longer operating and warm ischaemia time, but otherwise no worse outcomes than experts performing robotic partial nephrectomies [12]. In addition the patient-side assistant should be appropriately skilled in handling instruments safely and deploying ligature clips. All cases should be subjected to nephrometry scoring (PADUA and RENAL) and a thorough imaging review preoperatively to predict operative complexities and postoperative complications [13–16]. We incorporate the PADUA score due to its standardised use across the national nephrectomy register, collected by the British Association of Urological Surgeons.

The authors recommend this operative approach, based on the available disseminated techniques and preference in their experience and training [17–24]. In order to perform a robotic-assisted partial nephrectomy, the patient is positioned in a lateral decubitus/flank position (**Figure 1**) on the operative table to aid bowel mobilisation [24]. The operative table

ranted during the review of preoperative imaging [3, 5].

**2. Introduction**

236 Evolving Trends in Kidney Cancer

**3. Patient positioning**


A uniform anaesthetic team will also lead to better pain control in the post-operative phase and consistently enhanced results particularly during the critical on-clamp (WIT) period of partial nephrectomy.
