**8.2 Patient positioning and robot docking**

Following general anaesthesia the patient is placed in the supine position and strapped into position on the operating table. Depending upon the type of liver

resection the patient may be kept in reverse-Trendelenburg position whilst supine or placed in this position with legs parted. With the patient in the desired position the optimal position for the ports is marked with a surgical pen. The general recommendation is the robotic ports should be placed 15–20 cm from the target liver segment/lobe. Importantly in laparoscopic surgery ports can be placed at various points within the abdomen however in robotic surgery the ports generally need to be placed in a horizontal line (**Figure 7**). Each port should be placed 7–10 cm apart depending upon the patient's abdominal girth. Additional assistant ports should be placed 7–10 cm caudal to this horizontal plane of robotic ports. Due to the limited degree of freedom of the Harmonic scalpel correct positioning of the instrument through the assistant port is critical in order to follow the transection line particularly for major liver resections. However with availability of the robotic Harmonic scalpel does make this less of an issue. The patient positioning and trocar placement vary depending upon the area of the liver to be resected. Trocars will be positioned very high subcostal and lateral for the posterior superior segments or closer to the transverse umbilical line for the anterior segments shifting towards the left or the right depending on the lesion location. The same basic principle that applies to laparoscopic surgery applies to robotic surgery that is to create adequate triangulation with enough space in between the ports to avoid instrument clashing and aid efficient movement of instruments. Sometimes this might require a switch of the instrument in between the left and right operative arm.

We recommend an open/Hassan technique to inserted the optical robotic port to establish pneumoperitoneum. Robotic ports are specialised metallatic ports. Once pneumoperitoneum is satisfactory a diagnostic laparoscopy is performed in order to

#### **Figure 7.**

*The placement of robotic ports for liver resection. Demonstrates the robotic post placement for liver resection of segment 2, 3, 4, 5, 6 and cholecystectomy. R1–4 represent the robotic arms. Each of these robots ports can be used an optical port. Note the assistant port (A) is placed in the caudal position to provide optimal port placement.*

**227**

the robotic arms.

**8.3 Surgical procedure**

anatomical liver resections is discussed.

*8.3.1 Anatomical/major robotic liver resection*

*Robotic Liver Surgery*

**Figure 8.**

*known as docking.*

*DOI: http://dx.doi.org/10.5772/intechopen.87995*

exclude the presence of metastases or occult disease. An IOUS is also performed in order to have a better understanding of the size, number and location of the lesions and their relationship to major vascular and biliary structures. Once confirmed that the resection is to proceed the patient cart is brought into the surgical field. A tracker laser is positioned over the optical robotic port to ensure that the robot is in the optimal position. Further robotic ports are then inserted under direct vision in the previously marked position. The metallatic extension on the robotic optical port (present on all robotic ports) is then engaged onto the robot arm using the port clutch—this procedure is known as 'docking' the robot (**Figure 8**). The endoscope is then placed through the robotic port and engaged onto the top of the robotic arm. By pressing the instrument clutch the endoscope is manovered into the peritoneal cavity and is then used to visualise the target anatomy (e.g. liver lesion). The targeting button is then pressed on to endoscope that then automatically places the remaining robotic arms into optimal positions. The remaining robot ports are then docked and the appropriate instruments inserted through the ports and engaged in

*Docking of the robotic ports. All robotic ports require to be docked to the robot arms on the patient cart prior to their use. The metallatic extension on the ports is engaged with the robot port using the port clutch in a process* 

The precise liver procedure to be performed will be dependent upon the type of liver resection to be performed. Below a description of anatomical and non-

Prior to any form of liver resection the central venous pressure is lowered to less than 5 mmHg in order to reduce blood loss that is used in conjunction with reverse Trendelenburg position for the same reason [26]. For anatomical or major robotic liver resection there are three surgical steps that have been recommended for safe

For major robotic liver resections the falciform ligament is usually divided with a vascular stapler or robotic stapler followed by a retrograde cholecystectomy using the same principles of laparoscopic cholecystectomy. In the case of left hepatectomy the left triangular ligaments can now be divided in order to mobilise

resection outlined in **Table 2** and are similar to open liver surgery.

#### **Figure 8.**

*Liver Disease and Surgery*

resection the patient may be kept in reverse-Trendelenburg position whilst supine or placed in this position with legs parted. With the patient in the desired position the optimal position for the ports is marked with a surgical pen. The general recommendation is the robotic ports should be placed 15–20 cm from the target liver segment/lobe. Importantly in laparoscopic surgery ports can be placed at various points within the abdomen however in robotic surgery the ports generally need to be placed in a horizontal line (**Figure 7**). Each port should be placed 7–10 cm apart depending upon the patient's abdominal girth. Additional assistant ports should be placed 7–10 cm caudal to this horizontal plane of robotic ports. Due to the limited degree of freedom of the Harmonic scalpel correct positioning of the instrument through the assistant port is critical in order to follow the transection line particularly for major liver resections. However with availability of the robotic Harmonic scalpel does make this less of an issue. The patient positioning and trocar placement vary depending upon the area of the liver to be resected. Trocars will be positioned very high subcostal and lateral for the posterior superior segments or closer to the transverse umbilical line for the anterior segments shifting towards the left or the right depending on the lesion location. The same basic principle that applies to laparoscopic surgery applies to robotic surgery that is to create adequate triangulation with enough space in between the ports to avoid instrument clashing and aid efficient movement of instruments. Sometimes this might require a switch of the

We recommend an open/Hassan technique to inserted the optical robotic port to establish pneumoperitoneum. Robotic ports are specialised metallatic ports. Once pneumoperitoneum is satisfactory a diagnostic laparoscopy is performed in order to

*The placement of robotic ports for liver resection. Demonstrates the robotic post placement for liver resection of segment 2, 3, 4, 5, 6 and cholecystectomy. R1–4 represent the robotic arms. Each of these robots ports can be used an optical port. Note the assistant port (A) is placed in the caudal position to provide optimal port placement.*

instrument in between the left and right operative arm.

**226**

**Figure 7.**

*Docking of the robotic ports. All robotic ports require to be docked to the robot arms on the patient cart prior to their use. The metallatic extension on the ports is engaged with the robot port using the port clutch in a process known as docking.*

exclude the presence of metastases or occult disease. An IOUS is also performed in order to have a better understanding of the size, number and location of the lesions and their relationship to major vascular and biliary structures. Once confirmed that the resection is to proceed the patient cart is brought into the surgical field. A tracker laser is positioned over the optical robotic port to ensure that the robot is in the optimal position. Further robotic ports are then inserted under direct vision in the previously marked position. The metallatic extension on the robotic optical port (present on all robotic ports) is then engaged onto the robot arm using the port clutch—this procedure is known as 'docking' the robot (**Figure 8**). The endoscope is then placed through the robotic port and engaged onto the top of the robotic arm. By pressing the instrument clutch the endoscope is manovered into the peritoneal cavity and is then used to visualise the target anatomy (e.g. liver lesion). The targeting button is then pressed on to endoscope that then automatically places the remaining robotic arms into optimal positions. The remaining robot ports are then docked and the appropriate instruments inserted through the ports and engaged in the robotic arms.
