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INDICATIONS, PREOPERATIVE PREPARATION, ANESTHESIA, ANATOMY

POSITION

An adjustable vacuum beanbag should be placed on the operating table prior to bringing the patient into the room. The patient is positioned with the bag at the level of the flank with the break point of the table positioned below the ribs and above the iliac crest so as to allow a jackknife extension that may be useful in obese patients.

OPERATIVE PREPARATION

The patient is placed in a “slightly lazy” lateral position with the left arm crossing the chest and supported on a padded arm board (FIGURE 1A, B). The right arm is placed on a separate arm board, and an axillary roll is placed just inferior to the axilla. After the patient is positioned and the table flexed, the air is suctioned from the beanbag in order to secure the position. Liberal padding is used between and around both arms. In addition, the patient is secured across the chest and hips to the table with wide adhesive tape across towels because the operating room table will be tilted. The abdomen and flank area should be exposed and the right knee flexed, with a padding of blankets or pillows between the legs. The abdomen and flank are prepped, and sterile drapes applied. Then a time-out is performed.

INCISION AND EXPOSURE

During port placement, the bed is tilted in a more supine position (to allow the intestines to fall away from the abdominal wall). A 10-mm assistant port is placed in the left lower quadrant in the midclavicular line just below the level of the umbilicus using the open technique of Hasson, as described in Chapter 13. After carbon dioxide insufflation to 15 cm of water, a 30-degree laparoscope can be introduced. Alternatively, a Veress needle is placed in the subcostal midclavicular line for carbon dioxide insufflation, after which an Opti-View 10-mm assistant port with 0-degree laparoscope is placed. All four quadrants of the abdomen are examined for abnormalities, safety of other planned port sites, and evidence of any metastatic disease. Two 8-mm robotic ports are placed just to the left of the midline through the upper rectus muscle sheath, one just above the umbilicus for the robotic camera and the other about 5 cm above the first. A third 8-mm port is placed just lateral to the anterior axillary line midway between the costal margin and the iliac crest (FIGURE 1B).

DETAILS OF THE PROCEDURE

The bed is then tilted in a true lateral position (for lateral dissection of the spleen) and some reverse Trendelenburg (to allow the colon to fall inferiorly). The da Vinci Xi robot is docked at the patient’s left side, programmed for a left upper quadrant procedure. The ...

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