Optimizing robotic renal surgery: the lateral camera port placement technique and current results

PURPOSE: The successful completion of robot-assisted renal surgery requires optimal port placement in order to minimize arm collisions due to the bulky nature of the robotic system. We describe a novel technique of port placement to maximize range of motion during robotic renal surgery that has been used successfully in over 50 procedures and report on our results. METHODS: Five primary ports are placed utilizing a 30 degrees lens facing upward. The camera is in the most laterally placed port between the anterior axillary line and the midclavicular line, 3 to 4 cm below the costal margin. Two 8-mm robotic ports are placed 10 to 11 cm away from the camera port, triangulated towards the kidney. Assistant ports, if desired, are located medially and placed supra- (12 mm) and infraumbilically (5 mm). RESULTS: This technique resulted in the camera arm residing in an upward position, moving in a completely separate plane from the working robotic arms. We had no incidents of arm-camera collision in this position. We have used this port placement technique successfully in over 50 cases performed entirely robotically. We have had no need to change port location, redock the robotic system, or add additional ports during a procedure. CONCLUSION: We report on a port placement technique for robotic renal surgery that optimizes motion of the robotic arms, while eliminating external collisions. Placement of the camera port laterally and robotic ports anteromedially results in considerable flexibility of robotic arm movement.     

Primary common bile duct carcinoid

Endoscopic retrograde cholangiography was performed in a 32-year-old man with recurrent episodes of painless jaundice. There was demonstration of a large intraluminal mass causing partial obstruction of the common bile duct. The lesion proved to be a primary carcinoid tumor of the bile duct.     

Sonographic assessment of the bowel wall

The thickness and regularity of the bowel wall can often be assessed by sonographic imaging. In 26 normal patients, the bowel wall averaged 3 mm in thickness when distended and 5 mm when nondistended. In contrast, in 12 patients with an abnormally thickened bowel wall, bowel wall thickness averaged 23 mm and the affected bowel segment exhibited decreased or absent peristalsis on real-time scanning. The data derived from this study may enable the sonographic distinction of abnormally thickened bowel wall from normal bowel segments in the collapsed and distended state.     

Synchronous bilateral adrenalectomy for adrenocorticotropic-dependent Cushing's syndrome.

Select patients with ACTH-dependent Cushing's syndrome, such as patients with persistent Cushing's disease after failed hypophysectomy or patients with ectopic ACTH production, may require bilateral adrenalectomy. Laparoscopic bilateral adrenalectomy has been described, offering definitive treatment with reduced morbidity compared with open techniques. We report on the performance of synchronous bilateral adrenalectomy treated using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). To our knowledge, the usage of this minimally invasive approach for this operation has yet to be reported in literature. The details of the case and a brief review of the literature are described herein.     

Pathogenesis of giant colonic diverticula

The clinical, radiographic, and pathologic findings of 3 patients with giant colonic diverticula are presented. Although several theories have been proposed for the formation of these diverticula, they have not been fully documented. One of our cases illustrates the evolution of this disorder following typical colonic diverticulitis. The pathogenesis and differential diagnosis of this unusual entity are discussed.     

Interruption of gastroesophageal varices: steel coil technique

The Gianturco stainless steel coil occluding device was successfully used in the palliative obliteration of varices in three alcoholic cirrhotic patients via transhepatic catheterization of the portal vein and its tributaries. Complications of the procedure consisted of pulmonary embolization of a 1.3-cm-diam helical coil and contrast-medium-related acute renal failure in one patient with huge gastroesophageal varices. These complications resolved without significant sequelae. The coil has been found to be a simple, rapid, effective means of obliterating varices.