Robotic Partial Nephrectomy Operative Note

Urologist's Robotic Partial Nephrectomy Operative Note **Procedure:** Robotic-assisted laparoscopic left partial nephrectomy with excision of renal mass **Date:** 1 November 2024 **Surgeon:** "Dr. Thomas Kelly", Consultant Urological Surgeon **DVT Prophylaxis:** Mechanical sequential compression devices applied to bilateral lower extremities prior to induction of anaesthesia. Pharmacological prophylaxis with 40mg enoxaparin administered subcutaneously 12 hours pre-operatively and planned for continuation post-operatively. **Antibiotics:** 2g Cefazolin administered intravenously 30 minutes prior to incision. **Operative Time:** 3 hours 45 minutes, commencing at 08:15 and concluding at 12:00. **Estimated Blood Loss:** 150 ml. **Warm Ischemia Time:** 22 minutes using renal artery clamping. Additional intraoperative medications included 10mg IV Ketorolac for post-operative pain management. A 16 Fr Foley catheter was inserted prior to incision to monitor urine output. **Findings:** Intraoperatively, a well-circumscribed, exophytic renal mass measuring approximately 3.5 cm was identified on the anterior aspect of the left kidney, consistent with imaging findings. No significant adhesions were noted. The renal capsule appeared intact over the mass. Adjacent renal parenchyma appeared healthy. No regional lymphadenopathy was observed. **Ports:** Four ports were utilised: one 12 mm umbilical port, two 8 mm robotic ports in the left iliac fossa and suprapubic region, and one 5 mm assistant port in the left flank. **Position:** Patient was placed in a modified right lateral decubitus position with the left side elevated at approximately 45 degrees. Arms were secured to the side, and all pressure points were well-padded. A gel pad was used beneath the patient to maintain position. **Description:** The patient was prepped and draped in the standard sterile fashion for a left laparoscopic renal procedure. A Veress needle was used at the umbilicus to establish pneumoperitoneum to 15 mmHg. The 12 mm umbilical trocar was inserted, and a 0-degree laparoscope was introduced. Subsequent robotic and assistant ports were placed under direct vision. The colon was mobilised medially to expose the left kidney. The renal hilum was identified, and the renal artery was dissected. The tumour was localised using intraoperative ultrasound. After careful dissection, the renal artery was clamped, initiating warm ischemia. The tumour was then sharply excised with a clear margin of healthy renal parenchyma. The renal defect was closed using 2-0 absorbable barbed sutures in a running fashion, and haemostasis was confirmed. The renal artery clamp was then removed. Haemostasis was meticulous, with no active bleeding observed. The resected specimen was placed into an endo-bag and extracted through the umbilical port incision, which was extended slightly. A 10 Fr Jackson-Pratt drain was placed in the left renal fossa. Port sites were closed in layers, and skin was approximated with absorbable sutures. Final sponge and needle counts were correct. Enhanced recovery protocol instructions include early mobilisation within 4 hours post-operatively, regular paracetamol and ibuprofen for pain, and a light diet progressing as tolerated. Thromboprophylaxis with enoxaparin will continue for 10 days post-discharge. The Foley catheter will be removed on post-operative day one. Physiotherapy will encourage deep breathing exercises and ambulation. Postoperative laboratory orders include a full blood count and basic metabolic panel 6 hours post-operatively and again on post-operative day one. Daily fluid balance monitoring and vital signs every 4 hours for the first 24 hours. Monitor for signs of bleeding or infection. Discharge planning aims for a length of stay of 3-4 days, with discharge criteria including adequate pain control on oral analgesia, tolerating oral intake, and independent ambulation. Patient education provided regarding wound care, activity restrictions (no heavy lifting for 6 weeks), and signs of complications. For concerns, contact the ward on 020 7946 0000. Red flag symptoms requiring immediate attention include severe abdominal pain, high fever, uncontrolled bleeding from port sites, or difficulty passing urine. **Follow-up:** Follow-up appointment scheduled for 6 weeks post-operatively in the Urology Outpatient Clinic with "Dr. Thomas Kelly". No specific investigations are required prior to this review.