Miko24
Guru
The robot is brought in and docked to the ports. The instruments are inserted under direct visualization with the camera. The left colon is identified. Sharp dissection is used to mobilize the left colon from the splenic reflection to the pelvis. The ureter is visualized at the level of the psoas. The ureter is mobilized from the psoas to the pelvis using sharp dissection. Eventually the ureter is mobilized to the level of the ureteral hiatus. Gentle traction is used on the ureter until I can visualize bladder mucosa. The mucosa is incised using cautery circumferentially around the ureter with an adequate margin. The ureter is freed. The stent is immediately removed from the ureter via the assistant port. The distal ureter is then clipped with a Wek clip. The bladder opening was quite small and is very retracted at this point such that it is no longer visible. Therefore, I decided not to formally close the cystotomy. The pelvis is closely inspected and there appears to be excellent hemostasis.
The robotic instruments are removed at this point. The ports are undocked from the robot, and the robot is removed. The ports are removed from the abdomen and the skin incisions are closed with staples. A left lower quadrant incision is made with the scalpel after injecting local anesthetic. The incision is carried down to the level of the peritoneum using the bovie. The peritoneum is opened sharply using a metzenbaum scissors. The Lap disc is inserted and the abdomen is insufflated with a 10mm port through the Lap disc. The camera is inserted and used to visualize the kidney. My hand is inserted into the abdomen. Staples are removed from the two most superior port incisions. A 12mm Airseal port is then placed through one of the ports and a 10mm port is placed through the most cephalad port. My hand was in the abdomen and used to guide these ports such that no injury occurred to the underlying abdominal contents.
The camera is inserted along with the Harmonic scalpel. The left colon is visualized. The lateral attachments are mobilized sharply and the colon is mobilized medially and inferiorly. The posterior peritoneum is incised over the superior and medial pole of the kidney. Attachments to the spleen are taken down sharply.
Inferior to the kidney, sharp dissection is used to identify the ureter. The ureter is freed sharply from surrounding structures. Traction is applied to the inferior pole of the kidney. Medial attachments to the kidney are then taken down sharply until the hilum can be visualized. Blunt dissection is used with my finger to free up circumferentially around the hilar vessels. The endoscopic GIA stapler with 45mm vascular load is used to divide the hilar vessels en bloc. The stapler is then used to divide supero-medial attachments to the kidney. The Harmonic scalpel is then used to divide the remaining superior and lateral attachments to the kidney. The kidney and ureter are now completely freed. The hilum is inspected and excellent hemostasis is assured. There is minor bleeding from a small capsular tear of the spleen. I held pressure and applied surgicel, and excellent hemostasis was achieved.
The nephroureterectomy specimen is then removed via the hand port and processed for pathology. The abdomen is insufflated once again. The abdomen is inspected and hemostasis is ensured. The lap count is correct at this point and the abdomen is desufflated and the ports are removed.
The hand port incision is then closed in two layers. The inner layer is closed with interrupted #1 vicryl pop-offs. The outer layer is closed with a running 0 PDS suture. The incision is irrigated with normal saline. The skin incisions are then closed with staples. Sponge and needle counts are correct at this time. This is the end of the procedure.
50548 52234 ?????
The robotic instruments are removed at this point. The ports are undocked from the robot, and the robot is removed. The ports are removed from the abdomen and the skin incisions are closed with staples. A left lower quadrant incision is made with the scalpel after injecting local anesthetic. The incision is carried down to the level of the peritoneum using the bovie. The peritoneum is opened sharply using a metzenbaum scissors. The Lap disc is inserted and the abdomen is insufflated with a 10mm port through the Lap disc. The camera is inserted and used to visualize the kidney. My hand is inserted into the abdomen. Staples are removed from the two most superior port incisions. A 12mm Airseal port is then placed through one of the ports and a 10mm port is placed through the most cephalad port. My hand was in the abdomen and used to guide these ports such that no injury occurred to the underlying abdominal contents.
The camera is inserted along with the Harmonic scalpel. The left colon is visualized. The lateral attachments are mobilized sharply and the colon is mobilized medially and inferiorly. The posterior peritoneum is incised over the superior and medial pole of the kidney. Attachments to the spleen are taken down sharply.
Inferior to the kidney, sharp dissection is used to identify the ureter. The ureter is freed sharply from surrounding structures. Traction is applied to the inferior pole of the kidney. Medial attachments to the kidney are then taken down sharply until the hilum can be visualized. Blunt dissection is used with my finger to free up circumferentially around the hilar vessels. The endoscopic GIA stapler with 45mm vascular load is used to divide the hilar vessels en bloc. The stapler is then used to divide supero-medial attachments to the kidney. The Harmonic scalpel is then used to divide the remaining superior and lateral attachments to the kidney. The kidney and ureter are now completely freed. The hilum is inspected and excellent hemostasis is assured. There is minor bleeding from a small capsular tear of the spleen. I held pressure and applied surgicel, and excellent hemostasis was achieved.
The nephroureterectomy specimen is then removed via the hand port and processed for pathology. The abdomen is insufflated once again. The abdomen is inspected and hemostasis is ensured. The lap count is correct at this point and the abdomen is desufflated and the ports are removed.
The hand port incision is then closed in two layers. The inner layer is closed with interrupted #1 vicryl pop-offs. The outer layer is closed with a running 0 PDS suture. The incision is irrigated with normal saline. The skin incisions are then closed with staples. Sponge and needle counts are correct at this time. This is the end of the procedure.
50548 52234 ?????