Robotic partial nephrectomy in the setting of prior abdominal surgery

Abstract

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct‐vision trocar placement. PATIENTS AND METHODS From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally‐invasive scar. Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear‐tipped trocar. Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. RESULTS A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m2), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy‐2 patients (33%), open partial gastrectomy‐2 patients (33%) and exploratory laparotomy‐1 patient (17%). Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy‐10 patients (29%), umbilical/inguinal hernia repair‐9 patients (26%) and appendectomy‐7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement. CONCLUSIONS Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. Direct‐vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.

Multicentre outcomes of robot‐assisted partial nephrectomy after major open abdominal surgery

“…We have previously reported on the effect of PAS on RAPN in a single-institution setting [15]; of the 97 patients who underwent RAPN, 41 (43%) had history of PAS. We found no statistically significant differences between the two groups for BMI, tumour size, warm ischaemia time, EBL, clinical stage, transfusion rate, or complications [15].…”

“…Access techniques for patients with PAS were performed as previously described [15]. Peritoneal access was gained using a Veress needle or Hasson technique.…”

“…The impact of PAS on laparoscopic renal surgery and robotassisted prostatectomy has been studied by several groups [9][10][11][12][13][14]. Outcomes of RAPN after PAS have been previously reported in a few single-institution studies [3,15]. In the present study, we use a large multicentre database to evaluate perioperative outcomes of RAPN in patients who had had major PAS.…”

Challenging situations in partial nephrectomy

“…In the prior abdominal surgery group, there was a trend toward longer median warm ischaemia time (21 vs 16 min) and median estimated blood loss (150 vs 100 ml), without reaching statistical significance. There was no significant difference in intra or post operative complications [3]. Transperitoneal robotic partial nephrectomy therefore is feasible in the setting of prior abdominal surgery.…”

“…It has been shown to increase the risk of intra-abdominal adhesions making access difficult or even impossible [3]. Patients need to be consented appropriately and understand the increased risk of conversion to open surgery and injury to vascular or visceral structures in particularly to bowel.…”