453 - Robot-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy

| The Surgical Technologist | SEPTEMBER 2021 402 P A T I E N T P O S I T I O N I N G Left lateral (right-side up), arm board under left arm, right arm supported by arm positioner. The bed will be flexed to elevate the patient’s mid-section and rotated to the patient’s right (slightly supinating the patient). The patient will need to be amply padded to prevent pressure ulcers. Once the ports are placed, the robot will be positioned on the patient’s right (behind the patient now) and the robot arms come across the patient so that robotic instrument tips will be aimed dorsally. S P E C I A L C O N S I D E R A T I O N S Coordination with vascular surgery is strongly recom- mended, and it is advisable to have a vascular surgeon present during IVC dissection and cavotomy, if possible, in the event that conversion to open becomes emergently necessary. The patient will ideally have a central line, two intravenous lines, and an arterial line placed before drap- ing to enable real-time vital sign monitoring and rapid fluid volume replacement, if necessary. P R O C E D U R A L S T E P S 5 The patient will be prepped with a chlorhexidine gluconate solution and draped. Local anesthetic will be injected, and a small incision will be made using an electrosurgical pen- cil. Two penetrating towel clamps will be used to elevate the skin and abdominal wall and a Veress needle will be inserted. Once access has been confirmed with a drop test, the insuf- flation tubing will be attached, and the peritoneum will be insufflated with CO2. The Veress needle will be removed and replaced with a long 12mm laparoscopic port to allow the camera to be inserted. The robotic camera will be brought to the field and once in place, remaining ports will be placed under direct super- vision (see image). Once access has been established and the ports have been placed, the robot will be docked to the patient from behind, and instruments will be placed as follows, from the surgical technologist’s right to left: Arm 1 – Mono- polar curved scissors Arm 2 – Fenes- t r a t e d b i p o l a r forceps Arm 3 – Pro- grasp forceps The surgeon will break scrub and take their place in the console. First, any adhesions will be removed and the surgi- cal field will be exposed. The upper pole of the kidney will be carefully dissected first, elevating the lower lobe of the liver off of the anterior surface of Gerota’s fascia. A laparoscopic grasper will be placed through the sub-xyphoid 5mm assis- tant port to retract the liver superiorly. Dissection will con- tinue along the Line of Toldt, freeing the hepatic flexure of the colon, which allows for better access to the lower pole of the kidney, which will be dissected free. The hilum of the kidney will be dissected to visualize the ureter, renal vein, and renal