Retroperitoneal approach for robot-assisted partial nephrectomy: a step-by-step description of surgical technique

Abstract

In the last decades, minimally invasive partial nephrectomy (PN) has gained traction and, as of today, robot-assisted laparoscopic PN (RAPN) is increasingly being performed; this procedure might be performed with a transperitoneal or retroperitoneal (rRAPN) approach. However, rRAPN is less standardized in the literature. Therefore, we describe our rRAPN technique using a da Vinci Xi Surgical System and four robotic arms. First, with the patient placed in full flank position, the camera port is placed at the level of the Petit’s triangle apex. Retroperitoneal space is created by turning the index finger in a 180° movement through this port. After, the two first 8 mm robotic ports are blindly placed with the surgeon’s index finger guide, 8 cm far from the first port, respectively along the anterior and posterior axillary line; 3-5 cm caudally to the last one, a 12 mm AirSeal® assistant port is placed in the same manner. To create space for the last 8 mm robotic port, the peritoneum is reflected medially and downward off of the transversus abdominis muscle laparoscopically. Only then, the last port is placed under direct vision 8 cm ventral and about 2 cm cephalad from the port on the anterior axillary line. The robotic ports placement will result in a caudally convex arc. This technique, due to the extensive use of the surgeon index, implies fast access to the retroperitoneum, protects the underlying anatomical structures from damage, and, due to the trocar positioning along an arc, lowers the arm conflict risk.