the da vinci surgical system was approved by the food and drud administration in 2000 . in urology , it has since been used clinically to perform radical prostatectomies , pyeloplasties , simple nephrectomies , donor nephrectomies , and recipient renal hilar anastomoses .
purported advantages include 3-dimensional stereoscopic optics , computer elimination of tremor , 6 degrees of motion at the distal end of the instruments , and improved surgeon ergonomics . as a pilot study , we set out to look at the feasibility of performing da vinci robotic laparoscopic partial nephrectomies .
prior to embarking on this study , the authors performed approximately 50 standard laparoscopic or hand - assisted laparoscopic ( hal ) partial nephrectomies , and several other urologic procedures using the da vinci system .
both surgeons participated in a 3-day animal training laboratory with the da vinci system prior to undertaking procedures in humans .
our first patient for partial nephrectomy was chosen based on the relatively small and exophytic nature of his renal tumor .
the patient was a 69-year - old male with a 2-cm , left , upper pole enhancing renal mass ( figure 1 ) .
he was american society of anesthesiologists ( asa ) class iii with mild obesity and stable coronary artery disease , as well as a remote past surgical history of open cholecystectomy .
he was typed and crossmatched for 4 units of packed red blood cells and received bowel preparation prior to surgery .
he was placed in the semilateral , flexed position , padded , and strapped to the table with 3-inch cloth tape .
a hassan technique was used to gain access . in an effort to expedite the robotic set up ,
allow flexibility for the surgeon , and ease placement of the robotic arms , we utilized four 12-mm ethicon endosurgical nondilating trocars ( figure 2 ) . during the robotic aspect of the operation
the 2 robotic arms were attached to their specialized trocars and then placed through the ethicon trocar ( figure 3 ) .
coronal t1 mri of left renal lesion ( a ) ; transverse t2 mri of same lesion ( b ) . schematic diagram of port placement .
the goals include isolating the renal hilum and exposing the renal capsule surrounding the tumor . during the standard laparoscopic dissection , a circulation nurse and an intuitive clinical specialist draped , set up , and calibrated the robot in an attempt to minimize operative setup time .
the second stage of the procedure was performed utilizing the da vinci surgical system . during this period
, it is imperative that an experienced table - side surgeon ( assistant ) be present . the console surgeon ( primary surgeon )
the table - side surgeon must know and understand all the steps , be able to aid in dissection with a suction irrigator , exchange robotic instruments , pass sutures , retrieve sutures , be capable of suturing laparoscopically and/or of converting if an emergent operative situation occurs .
the console surgeon utilized a flat cautery blade on the left robotic arm for retraction and dissection and a hook electrode on the right arm for electro - dissection .
the console surgeon scored the capsule and then retracted the kidney , placing the hilum on stretch while the table - side surgeon placed a laparoscopic bulldog on the left renal artery .
( for a right - sided lesion , we clamped both artery and vein . ) immediately after clamping , we switched out the hook electrode for scissors in the right robotic arm .
the tumor was excised with the robotic endoshears while the cautery / dissector ( flat blade ) in the left arm retracted the lesion and helped to elevate it during resection ( figure 4 ) .
the table - side surgeon utilized a suction / irrigator to help expose the bed and remove any blood from the field .
once excised , the deep margin of the specimen was visually inspected to assess completeness of excision .
we took biopsies of the deep renal bed with the robotic endoshears for pathologic confirmation .
these specimens were collected by the table - side surgeon and sent for frozen section immediately .
a 3 0 vicryl suture on a ct-1 needle was introduced by the side surgeon through the accessory port , and a large perforating vessel was suture ligated .
the argon beam coagulator was then introduced through the accessory port by the side surgeon , and the base of the renal defect was cauterized .
the side surgeon then introduced fibrin ( haemacure , montreal , canada ) soaked gelfoam ( pharmacia , peapack , nj ) , and the console surgeon laid it into the defect using the robotic needle drivers .
a percutaneously placed spinal needle was guided by both the table - side surgeon and console surgeon into the fibrin soaked gelfoam , and thrombin ( haemacure , montreal , canada ) was injected to create a gelfoam / fibrin - glue plug .
two mattress sutures were placed over the plug through the renal capsule by using 2.0 vicryl suture on a ct-1 needle .
the kidney was placed back on stretch , and the table - side surgeon released and retrieved the vascular bulldog .
hemostasis was confirmed while a mean arterial pressure above 90 mm hg was documented , an intraperitoneal pressure of 6 mm hg of co2 was documented and a valsalva maneuver was performed .
finally , gerota 's fascia overlying the excision site was reapproximated with a running 2.0 vicryl suture on a ct-1 needle .
the robot was then removed from the patient , the specimen was retrieved with a 10-mm endobag ( ethicon endosurgical , cincinnati , oh ) via the hassan trocar , and the abdomen was reinspected .
finally , a jackson - pratt drain was placed through a port site , and all trocars were removed and closed .
demographics , lesion size , location of tumor , depth of penetration , and indication for surgery were recorded .
intraoperative parameters included blood loss , complications , need for open conversion , and operative time .
operative time was defined as time of first incision to closure of all trocar sites and was subdivided into standard laparoscopic time , robotic docking time , and robotic surgery time .
the operative time , including da vinci setup ( 14 minutes ) , was 230 minutes .
warm ischemia time was 32 minutes , and robotic docking time performed prior to clamping was 4 minutes . estimated blood loss was 150 ml , and no intraoperative or postoperative complications occurred .
the patient was managed with intravenous patient - controlled analgesia for 24 hours after the procedure .
a regular diet and ambulation were successfully resumed by postoperative day 1 , and the patient was discharged home on postoperative day 2 with a hematocrit of 40.0% and a creatinine of 1.3 mg / dl . by postoperative day 10 , the patient had resumed normal activities .
we did not perform a collecting system reconstruction ; however , suturing was necessary to control hemorrhage from a terminal artery and close the renal capsule and gerota 's fascia .
two urologic surgeons with approximately 2 to 3 years of laparoscopic experience ( approximately 150 and 60 cases each ) participated in this procedure .
both surgeons had been previously trained on the da vinci in a 3-day animal laboratory .
we chose to perform this complex laparoscopic procedure using the da vinci because of its several purported advantages , mentioned earlier , over standard laparoscopy .
even so , those with extensive laparoscopic experience at a limited number of centers may feel more facile with a straight laparoscopic approach to partial nephrectomies .
regardless , the indications for partial nephrectomies and for minimally invasive surgery are both expanding , and the above described approach offers another tool in the armamentarium . in this case , we found the da vinci to aid us in wedge excision by allowing for perpendicular scoring and cutting through renal parenchyma .
this is not always feasible with standard laparoscopic instruments secondary to the limited ability to angle the instrumentation .
suturing was felt to be easier to perform secondary to 3-dimensional vision , improved angulation , dexterity , loss of tremor , and precise control of the robotic needle driver due to the endowrist technology .
potential disadvantages of the da vinci include cost , training , setup time , and lack of tactile sensation or haptics .
another potential disadvantage , should conversion be required , is having the surgeon unscrubed and away from the patient .
we also placed the robotic trocar ports through standard laparoscopic trocars to decrease docking time and , potentially , conversion time to standard or hand - assisted laparoscopy if it were necessary .
the time required for robotic preparation can be minimized by having an experienced nursing staff set up the device , while the surgeon enters the abdomen using standard laparoscopic trocars .
we report the first robot - assisted laparoscopic partial nephrectomy . potential benefits of the da vinci system may include a more accurate means of lesion resection and easier reconstruction of the renal defect .
it is yet to be proven whether this technology can decrease ischemia time , expand the indications for laparoscopic partial nephrectomy , and/or decrease complications like bleeding and collecting system leak . as we continue to utilize this technique , our hypothesis of
 the indications for nephron - sparing surgery and for minimally invasive surgery are continually expanding . nephron - sparing surgery , 
 also known as partial nephrectomy , presents a challenge to the minimally invasive surgeon . 
 herein , we describe our technique of robot - assisted laparoscopic partial nephrectomy . 
 this approach may have potential advantages of including easier excision and suturing . 
 moderate training is required . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION