Robot Left Radical Nephrectomy
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 right lateral recumbent position and prepped and draped in the normal sterile fashion with all pressure points padded, patient had a pillow between the knees and ankles, safely secured to the bed, arm board padded in proper position and axillary roll in place. 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 upper left quadrant 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 and visualized the entire abdomen and pelvis. There was no injury or complication during access. We carefully evaluated the intra-abdominal contents, the left descending 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 4 cm caudad and number mm port 4cm cephalad on either side in the upper quadrant in the medial clavicular line and a 4th port mm size located 4cm caudad and 2cm lateral to the inferior port. Next, superior to the umbilicus we placed an number mm airseal assistant port. All ports were placed under direct vision and replaced 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 (most caudad). 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 and pelvic contents, nothing was harmed. There were some adhesions holding the descending colon near the liver and near the pelvis. We then carefully dropped the descending colon starting at the splenic flexure and proceeding downward taking care to not place excessive traction on the colon and taking care not to use any cautery close to the colon. Bleeding was carefully coagulated using bipolar electrocautery. We continued to drop the colon and we could see a nice plane between Gerota's fascia and the colon and its mesentery. After we dropped the bowel sufficiently, we then dissected the tissue around the renal hilum We freed then up posteriorly, laterally, superiorly, releasing off the adrenal and isolated the renal vessels. We located the ureter and the gonadal vessel and follow this up to the renal hilum. The artery and vein were identified and we carefully dissected the tissue around this to get better visualization. We elected to take the artery and vein . We used the stapler with vascular loads and ligated and divided the vein and artery. There was no bleeding after removing the stapler. The remainder of superior aspect was freed off and the ureter was taken with Hem-o-Lok clips above and below and divided. The entire kidney was freed up, brought down the lower abdomen. We irrigated in the bed of the retroperitoneum, multiple times with no evidence of bleeding, no evidence of pneumothorax. At this point, specimen was placed in an EndoCatch bag. We closed the 12-mm camera port camera port using a Carter-Thomason. A periumbilical opening approximately 6cm 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.