Case presentation and Patient Preparation
- Patient is placed in left or right steep lateral decubitus position with all pressure points padded
- Table is placed in simple flexion
- Achieving maximum distance between 12th rib and ASIS is a must
Trocar Placement and Docking of the Robot
- Trocar Insertion
- The 12 mm Airsealâ trocar is placed by open access on the paramedian line at the level of the umbilicus. In obese patients this trocar can be placed more laterally.
- A stable pneumoperitoneum of 12 mmHg is introduced for the continuation of the port placement.
- Under direct vision, four 8 mm Da Vinci Xiâ trocars are introduced in a straight line towards the surgical field while respecting a minimum distance of 5 mm between the ports. The first robotic port is placed in the epigastric area, paramedian from the falciform ligament. The second and third 8 mm robotic port are placed at supra- and infra-umbilical level respectively with triangulation of the 12 mm Airsealâ trocar. The fourth 8 mm robotic port is placed in the left or right iliac fossa in a straight line towards the surgical field eg. Right or left flank region.
- A 5 mm assist trocar is not routinely used. If needed, eg in cases with excessive bleeding, it can be placed during surgery between the first and second 8 mm robotic port by the tableside assistant.
- After port placement, the pneumoperitoneum is lowered to 5 mmHg to minimize the peri-operative morbidity as a part of “low-impact surgery”.
- Bariatric ports are only used in specific indications in very obese patients.
Docking the Robot
- Side-docking of the Da Vinc Xi iâ surgical system is adopted. The position of the patient cart is determined by using the green lasercross that is oriented on the cameraport. With a 30 degree down camera we target the surgical field intra-abdominally and the docking procedure can be continued.
- While the camera is manipulated manually, each working working instrument is guided into the abdominal space under direct vision -- monopolar scissors, large needle driver, and Prograsp are usually used. The 12 mm Airsealâ trocar is used by the tableside assistant to introduce surgical clips. An additional 5 mm port can be used for aspiration.
- The Da Vinci Xi â surgical system offers the advantage of ‘port hopping’ in order to optimize the vision while introducing the ports and robotic instruments.