INDICATIONS, PREOPERATIVE PREPARATION, ANESTHESIA, ANATOMY
A vacuum-assisted 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 position.
The patient is placed in a “slightly lazy” right lateral position with the right arm crossing the chest and supported on an arm board (FIGURE 1A). The left arm is placed on an arm board, and an axillary roll is used just inferior to the axilla (FIGURE 1A). After the patient is positioned and the table flexed, the air is suctioned from the beanbag in order to secure the position. 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 left knee flexed, with a padding of blankets or pillows between the legs. The abdomen and flank are prepped, and sterile drapes are applied. Then a time-out is performed.
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 right lower quadrant just lateral to 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 is 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 inserted. All four quadrants of the abdomen are examined for abnormalities, safety of other planned port sites, and evidence of any metastatic disease.
An 8-mm robotic port is placed just lateral to the anterior axillary line between the costal margin and iliac crest. Three 8-mm robotic ports are placed just to the right of midline, starting just below the umbilicus for the camera port, followed by a port about 5 cm above this for the right hand, and another above this for the liver retractor (FIGURE 1B). Placement of the ports may need to be varied depending on the patient and tumor size. The liver retractor port may need to be lowered for a large liver.
The bed is then tilted in a true lateral position and reverse Trendelenburg (head-up, to allow the colon and intestines to fall inferiorly). The da Vinci ...