ESTIMATED BLOOD LOSS:
TUBES AND DRAINS:
INDICATIONS FOR PROCEDURE: The patient is a year old who has a history of . discussed the options with the who agreed to have a Prior to the procedure today, the patient's history and physical was reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including were discussed, acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the operating room and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. SCDs were on and functioning IV antibiotics were administered. IV sedation and general anesthetic were administered. Patient had a endotracheal tube and orogastric tube placed by anesthesia. 16-French Foley placed sterilely with yellow urine return. The patient was placed in the supine position and prepped and draped in the normal sterile fashion with all pressure points padded, safely secured to the bed, arm board padded in proper position. Care was taken to double check the pressure points to confirm padding. The head and neck were well supported in a natural position and safety strap and silk tape used to secure patient to bed. Time out was performed confirming patient, procedure, side, all in the room agreed. To begin the case, we gained access in the midline supraumbilical region with a Veress needle. We aspirated and injected normal saline, confirming proper position prior to insufflating to mm CO2, which was maintained throughout the case. We placed a number mm camera port at this location at the midline supraumbilical region and visualized the entire abdomen and pelvis. There was no injury or complication during access. We carefully evaluated the intra-abdominal contents, the colon was unharmed, liver and spleen were visualized and were unharmed, the intestines, stomach and intra-abdominal contents and mesentery were all unharmed. We placed Da Vinci mm working port one handbreadth to the left laterally to the first port at the umbilical level and number mm port one handbreath to the right laterally to the midline port at the level of the umbilicus. A mm size was placed two handbreadths to the right of the midline port. Next, two handbreaths to the left of the midline port at the level of the umbilicus we placed an number mm airseal assistant port. A mm size was placed 2cm cephalad to the umbilical line in between the midline port and left medial port. All ports were placed under direct vision and placed without any complications. We then docked the robot. We placed the monopolar and bipolar cutting and coagulation on a setting of 3. We attached the robot scissors in the right, force bipolar in the left and had a prograsp in the far right port. We began the case by again carefully inspecting the intra-abdominal contents, there was no damage to any intra-abdominal contents during port placement and robot docking. We carefully examined the colon, small bowel, stomach, spleen, liver, vascular structures and pelvic contents, nothing was harmed. There were some adhesions holding the ascending colon near the liver and near the pelvis. Some sigmoid adhesions were taken down to the sigmoid by. We then performed a posterior dissection by incising over the vas deferens under the bladder and dissected through until we encountered the seminal vesicles. We used blunt and electrocautery to remove the tissue off of the seminal vesicles taking care to avoid cautery on the lateral portions of the vessels to avoid nerve injury. After the posterior dissection was performed, we dropped the bladder by dissecting the space of Retzius. We carried this incision along the medial umbilical ligament to the inguinal ring and then follow the vas deferens down 3 cm. After the bladder was dropped, we defatted the prostate and sent this tissue off as periprosthetic fat. We then sharply incised and the endopelvic fascia and swept the neurovascular bundle that was obviously not part of prostate away and continued this proximally and distally. We then manipulated the Foley catheter to observe the balloon and cutdown of the prostatic vesicle junction. We cut down while visualizing the bladder neck fibers to ensure a negative margin and entering the bladder. Foley catheter was deflated and placed on traction. We continued to dissect around the bladder neck taking care to stay far from the ureteral orifices and continue the dissection posteriorly until we opened into the posterior dissection and deliver the seminal vesicles and pulled them up for traction. We then exchanged the force bipolar for the synchroseal and carefully performed the neurovascular bundle. Care was taken to minimize any cautery adjacent to these valuable nerves. After the bilateral vascular bundle was ligated we continued the posterior dissection sweeping the tissue laterally and apically towards the apex. We then sync resealed the dorsal venous complex and cut through this using Bovie electrocautery. We cut down on the urethra until we saw the Foley catheter then sharply cut through the posterior plate of the urethra. Care was taken this area to avoid any cautery damage to the nerves that were obviously outside the prostate while we did not perform a nerve sparing, we did sweep off nerves that were clearly separate from the prostate. We circumferentially freed up all remaining tissue and the prostate was free. With informed bilateral pelvic lymph node dissection first on the right than on the left. When sized over the iliac vein and continued this dissection distally until he can you know okay which we removed and placed a left on the lymphatic vessels. We will continue to splinter all this lymph node packet and were able to visualize obturator nerve and avoided any damage to this. Weck clips were applied on large lymphatics and large veins. We will continue this approximately until the bifurcation of the iliacs. Ureter was undamaged during this. Lymph node dissection was the bifurcation of the iliacs, the bladder, the node of Cloquet, and the pelvic sidewall. We performed this on the left side identically to the right. The specimens were sent off as left and right pelvic lymph nodes We irrigated in the bed of the prostate multiple times with no evidence of bleeding. We then performed our anastomosis using a 3 OV lock 12 and sutured together and perform a circumferentially, can together excellently. Then leak tested with 100 mL and there is no leaking. At this point, specimen was placed in an EndoCatch bag. JP drain was placed. We closed the 12-mm camera port camera port using a Carter-Thomason. A periumbilical opening approximately 3cm was extended to take out the specimen. We then used 0 looped PDS to close the fascia in running format . At this point, we closed the remaining incisions using 4-0 Monocryl. We should note that prior to taking out the specimen and bagging it, we looked around the entire abdomen and pelvis. There was no evidence of bowel injury and no evidence of bleeding. There are no foreign bodies left in the abdomen and all the counts were correct x2. Dermabond was applied to the wound specimen sent to pathology. Patient was awakened, extubated, transferred to PACU in stable condition with all counts correct. The patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well. Please note that was present throughout the entire length of the procedure.
PLAN: The patient will be after meeting anesthesia criteria.