在達文西Si手術系統藉操作手及器械轉換達成單次對接機器人輔助腎輸尿管切除及膀胱袖口切除術
吳芃諺、楊晨洸
台中榮民總醫院 外科部 泌尿科
Ingle-docking robotic-assisted nephroureterectomy with bladder cuff excision on Da Vinci Si system with arm and instrument switching
Peng-Yen Wu, Cheng-Kuang Yang
Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
Purpose: To describe a simplified approach of robotic nephroureterectomy with bladder cuff excision which allows access to both upper urinary tract and lower urinary tract without intraoperative repositioning and redocking.
Surgical setting: The da Vinci Si robotic surgical system with 30 degree camera was used in this operation. The patient with upper tract urothelial carcinoma was positioned in a modified flank position with affected side up. The 12mm camera port was placed at the level of the umbilicus and lateral to it. The three 8 mm robotic ports were placed under direct endoscopic vision. The first robotic port (A) was inserted lateral to the rectus sheath and 8cm cranial to the umbilicus. The second robotic port (B) was introduced medial to the anterior axillary line, slightly caudal to the umbilicus where the camera port, robotic ports A and B could form a 120 degree angle. The third robotic port (C) was placed in the midline and 8cm caudal to the umbilicus, forming a straight line with camera port and robotic port A. The assistant port was placed at the level of umbilicus and the opposite side of the camera port.
Surgical procedure: The whole procedure was separated into the two portions: nephrectomy and bladder cuff excision. During the nephrectomy portion, the camera was directed toward the right kidney. The robotic port A was set as right arm (monopolar scissors) and ports B and C were set as left arm (bipolar forceps and prograsp forceps, respectively). After completing the nephrectomy, the camera was directed to the bladder. The robotic port A remain set as right arm with the instrument switched to prograsp forceps. The port B was switched to right arm and the instruments were switched to the scissors. The port C remain set as left arm and the instrument was changed to bipolar forceps. In this configuration the ureter was dissected and the bladder cuff excision was performed.
Conclusions: The present technique with arm and instrument switching made the transition from upper urinary tract to lower urinary tract available with the instruments angling ideally with minimal possibility of clashes. Intraoperative repositioning of the patient and redocking of the robot was not recquired. The technique could be safely reproduced with the da Vinci SI system.