Right Robotic Nephrectomy

RESPONSIBLE SURGEON: Garth Sherman, MD ASSISTANT SURGEON: Dr. Emily Carter PREOPERATIVE DIAGNOSIS: Right renal mass. POSTOPERATIVE DIAGNOSIS: Right renal mass. OPERATION PERFORMED: Robotic-assisted laparoscopic right radical nephrectomy. DVT PROPHYLAXIS: SCDs to bilateral lower extremities prior to induction, 5000u heparin. ANTIBIOTIC: Ancef 2g given within an hour of incision time. SPECIMENS: Right Kidney. INDICATION FOR PROCEDURE: John Doe, 58, male, with a right renal mass. I explained the risks, benefits, indications, and alternatives to the above procedure and agreed to proceed. Notably, we discussed CKD secondary to solitary kidney, injury to bowel, injury to the spleen, injury to the pancreas, injury to the stomach, leaving behind residual cancer, benign pathology, potential for bleeding requiring transfusion, hernia, requiring additional surgery. FINDINGS: THERE WERE NO COMPLICATIONS. THE SKIN WAS CLOSED WITH running subcuticular stitches. MY ASSISTANT Dr. Emily Carter WAS NECESSARY GIVEN THE COMPLEXITY OF THE CASE AND WAS PRESENT THE ENTIRE CASE. DESCRIPTION OF OPERATION: After the induction of excellent general anesthesia, a surgical time-out was performed. The patient identification, surgical site, and procedure were verified and visually confirmed with skin marking. We also verified the patient received perioperative antibiotic within an hour prior to beginning the surgery. Available imaging was pulled up in the room, confirming the correct patient, DOB to help confirm sidedness of the procedure. They were then carefully placed in a modified right flank position. A Foley catheter was placed and the abdomen was prepared with chloropep and allowed to dry for 3 minutes. They were draped in a sterile fashion. We placed the varees in Palmer's point. They were insufflated to 12 mmHg. We made an incision for the camera port superior and lateral to the umbilicus. The fascia and rectus were pierced with an 8mm port and then inspected the abdomen with the robotic camera and did not observe any injury to internal structure. We placed 4 additional trocars in the abdomen, three 8 mm trocars, and a 12mm airseal assistant trocar in the routine positions for the robotic technique. The DaVinci robot was docked. I turned my attention to the console while my assistant stayed at the bedside. The right colon was kocherized in the standard fashion, taking care to avoid injury to the bowel. The liver was mobilized away from the kidney and a liver retracter was placed by grasping the lateral abd wall. We incised the peritoneum lateral to the colon and exposed the right retroperitoneum. Using a combination of bipolar and monopolar energy, a plane was developed between Gerota's fascia and surrounding structures. Care was taken to avoid injury to the liver, IVC, and duodenum. The gonadal vein was identified medialized, then used to follow up to the IVC. We then identified the right renal vein. Then we identified the right ureter, separated this from the psoas, and lifted the kidney with the 4th arm. We then continued to dissect the hilum until we identified the right renal artery and right renal vein. Once the artery and vein were appropriately isolated, we used a 45mm vascular stapler to divide the vein and artery separately. We then proceeded to completely mobilize the kidney from its surrounding structures. We continued to mobilize the kidney, including using weck clips proximally and distally to ligate the ureter. We then carefully inspected all areas, and there did not appear to be any problems with hemostasis. A piece of Surgicel was placed in the renal fossa. An incision was made to extract the kidney superior to the umbilicus. The robotic camera port was closed with 0 vicryl. We closed the fascia with two #1 PDS sutures superiorly and inferiorly. No drain was placed. Deep layers were approximated with 3-0 Vicryl. All skin wounds were then closed with running subcuticular stitches, infiltrated with 0.25% Marcaine plain, and covered with Dermabond. The patient was then extubated without event, transferred to cart, and transported to the Recovery Room in good condition. ESTIMATED BLOOD LOSS: 150 mL