RoboticAssisted Laparoscopic Radical Prostatectomy Thomas E Ahlering MD
Robotic-Assisted Laparoscopic Radical Prostatectomy Thomas E. Ahlering, MD Professor of Urology University of California, Irvine
Patient Selection · Indications ¨ Organ-confined prostate cancer ¨ Life-expectancy > 10 years · Contraindications ¨ Significant medical comorbidities ¨ Metastatic disease ¨ Multiple prior abdominal surgeries (relative)
Equipment Required · · · da Vinci Robot 18 F foley catheter (2) Knife with 15 blade Kelly clamp Trocars: 12 mm (2), 5 mm, 8 mm for robotic instruments (2) Robotic instruments · Laparoscopic instruments · ¨ Electrocautery scissors ¨ Bipolar forceps ¨ Needle driver (2) ¨ ¨ ¨ ¨ Suction-irrigator with long (25 cm) tip Atraumatic bowel forceps Scissors Grasping forceps with teeth (locking handle) Needle driver Endo. GIA stapler (45 mm vascular load, articulating handle) 10 mm specimen retrieval bag Bulldog clamps (straight & curved) with applicator Suture: 3 -0 monocryl, 4 -0 vicryl
Patient Positioning · Supine position, arms tucked at sides · Legs placed on spreader bars ¨ Abducted 30 ¨ Lowered 45 · Extreme (25 ) Trendelenburg position
Patient Positioning
Port Placement · Veress needle placed 6 cm lateral to umbilicus to insufflate to 20 mm Hg · Draw lines between umbilicus and femoral artery to estimate position of medial umbilical ligaments · 12 mm camera port cephalad to umbilicus (<22 cm from pubis) · 12 mm assistant port 2 cm cephalad to iliac crest · Robotic instrument ports (8 mm) 14. 5 -17 cm from pubic symphysis, >10 cm from camera port, and >8 cm lateral to midline · Suction port (5 mm) ¼ distance between robotic instrument port and camera port and 30 cephalad from camera port
Port Placement
Port Placement HEAD FEET
Steps of the procedure 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. (click to play video clip) Placing the ports Dropping the bladder Defatting the prostate Opening endopelvic fascia Stapling the dorsal vein complex Transecting the bladder neck Dissecting the vas and seminal vesicles Preserving the neurovascular bundles Transecting the urethra Suturing the vascular pedicles The vesicourethral anastomosis
Technical points: Tips · Cautery with the scissor jaws open is more effective than with them closed · Use the bipolar forceps like a mini-retractor to expose tissue planes · If there is some oozing from the stapled edge of the dorsal vein complex, apply a small (2 cm) sponge. A little pressure combined with the pneumoperitoneum will stop most bleeding · Frequent irrigation helps clear the field, especially during transection of the bladder neck and urethra and during nerve sparing
Technical points: Caveats · Ensure excellent hemostasis as a bloody field will absorb light and make visualization difficult · Beware of damaging the pelvic sidewall with the robotic arms outside of the field of vision · When transecting the bladder neck, avoid the temptation to start in the midline; rather, work from a lateral to medial direction on each side
Credits Surgeon: Thomas Ahlering, MD Professor of Urology Director of Urologic Oncology UC Irvine Medical Center Orange, CA 92868 714 -456 -6068 tahlerin@uci. edu Bedside assistant and video editor: James F. Borin, MD Clinical Instructor Laparoscopy/Endourology fellow UC Irvine Medical Center 714 -456 -3431 jborin@aya. yale. edu
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