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Bianchi et al. Mini-invasive Surg 2021;5:37 https://dx.doi.org/10.20517/2574-1225.2021.64 Page 5 of 11

Thereafter, blunt laparoscopic instruments, placed into the AirSeal® assistant port and the 8 mm robotic
port in the posterior axillary line, are used to gently reflect the peritoneum medially and downward from the
transversus abdominis muscle and allow the creation of space anteriorly for the fourth 8 mm robotic port
[Figure 4].

This is placed under direct vision along the other robotic ports arc, 8 cm ventral and about 2 cm cephalad
from the one placed on the anterior axillary line [Figures 2F]. A needle can be inserted to confirm the site
before the port is inserted under vision.

Particular care should be taken during this critical step to avoid breaching the peritoneum. If this does
happen, surgery may still proceed aided by using a 4th robotic arm by retracting anteriorly the kidney and
plugging the opening; alternatively, the breaching can be widely opened and surgery converted to a
posteriorly-approached transperitoneal procedure.

The final aspect of the robotic ports placement will result in a caudally convex arc, which creates generous
movement space for the four robotic arms (the camera port and the three robotic arms), as well as for the
bedside assistant surgeon [Figures 5-7].

Robot docking
Using the da Vinci Xi Surgical System with a rotating boom, the robot can be brought in at several different
locations and the tower rotated to align with the trocars. In our practice, the patient cart is brought in from
the patient ventral side, the boom is extended, the camera is docked, the target surgical site is confirmed, the
Xi system automatically calibrates the arms, and then we dock them. Once docked, the robotic instruments
are inserted under direct vision starting from the fourth arm to facilitate the vision: Maryland bipolar
forceps in the left hand, monopolar curved scissors in the right hand, and large needle driver in the fourth
arm. The assistant access to the kidney is through the 12 mm Airseal® assistant port [Figure 8].

Surgical technique
The first step consists in dissecting the pararenal fat to expose the psoas muscle and the posterior layer of
renal fascia [Figure 9A]. The next step is to make an incision in the posterior layer of renal fascia just above
and parallel to the psoas muscle, exposing the perirenal fat [Figure 9B and C]. At this point, perirenal fat is
dissected from the kidney following the plane along the psoas muscle, which is exposed by retracting
anteriorly the kidney using the 4th arm [Figure 9D]. When a perirenal fat pulsation is found, the renal
vascular hilum can be easily identified [Figure 9E and F], thus the rest of the operation follows the standard
tRAPN steps. At the end, the specimen is retrieved through the camera port.

DISCUSSION
[13]
Since the first laparoscopic nephrectomy by Clayman et al. in 1991 and a few years after the
retroperitoneal approach by Gaur et al. were described, a debate about the different minimally invasive
[14]
PN approaches was started, and it is still going on as of today.

Selection of the optimal approach plays a critical role in renal surgery. This must be guided by several
aspects including the surgeon’s experience, the characteristic and location of the kidney mass, and the
patient’s characteristics and clinical history. Due to larger intra-abdominal space and familiar anatomical
landmarks, the transperitoneal access may especially be attractive at the start of the surgeon’s experience in
this field. On the other hand, a smaller working space and the absence of anatomic landmarks, which limit
retroperitoneal approaches, may disorient the beginner surgeon . In addition, limited working space
[15]