Table 2.
Step-wise details of adaptations made for two children (14 and 33 kg) undergoing robotic partial nephrectomy for suspicious small renal masses.
| Adult (>70 kg) | Pediatric (≤33 kg) | |
|---|---|---|
| Preoperative | Clears, enema day prior | Clears, glycerin PR day prior |
| Positioning | Modified flank position | Modified flank position |
| Arm hugging a pillow | Arm at left side | |
| No axillary roll | No axillary roll | |
| Tape secured over arm, chest, hips, and legs | Tape secured over arm, chest, hips, and legs | |
| Ports | 12-mm camera port | 12-mm camera port |
| 8-mm left robotic port | 8-mm left robotic port | |
| 8-mm right robotic port | 8-mm right robotic port | |
| 12-mm assistant port | 12-mm assistant porta | |
| 5-mm assistant port | 5-mm assistant port | |
| (5-mm port for subxiphoid liver retractor) | (5-mm port for subxiphoid liver retractor) | |
| Insufflation | 15 mmHg for port placement | 12 mmHg for port placement |
| 15 mmHg for procedure | 8 mmHg for procedure | |
| 20 mmHg for tumor resection | 15 mmHg for tumor resection | |
| Instruments | Fenestrated bipolar (settings 30) | Microbipolar forceps (settings 15) |
| Monopolar scissors (settings 30, 30) | Monopolar scissors (settings 15,15) | |
| Laparoscopic suction/irrigator | Laparoscopic suction/irrigator | |
| Locking graspers (Hunter) | Locking graspers (Hunter) | |
| Clamping | 12.5 mg mannitol (optional) | Weight based mannitol (0.4 mg/kg; optional) |
| Artery only on left, artery and vein on right | Artery only on left, artery and vein on right | |
| Early unclamping after tumor bed closed | Early unclamping after tumor bed closed | |
| Tumor resection | Demarcate w ultrasound guidance | Demarcate w ultrasound guidance |
| 4 × 4 radio-tagged sponge pre-placedb | 2 × 2 radio-tagged sponge pre-placedb | |
| Cold scissors | Cold scissors | |
| Closure of tumor bed | 12 inch running 3–0 V-LOC stitch | 6 inch running 3–0 V-LOC stitch |
| Sliding clip renorrhaphy | 5 inch 0-VICRYL w Weck clip and knot at end | 4 inch 0-VICRYL w Weck clip and knot at end |
| Interrupted capsule to capsule stitches | Interrupted capsule to capsule stitches | |
| Weck clips to suture exiting capsule | Weck clips to suture exiting capsule |
a
12-mm port required for passage of ultrasound probe.
b
Preplaced if needed for hemostasis, may also be used to position kidney optimally for resection and suturing.