Table 3. Step by step description of robotic adrenalectomy.
| Step | Right robotic posterior retroperitoneoscopic adrenalectomy | Left robotic transabdominal adrenalectomy |
|---|---|---|
| Step 1: entry | (I) 12 mm transverse incision below the tip of the 12th rib; (II) Enter retroperitoneal space sharply with mayo scissors; (III) Develop space bluntly with surgeon finger |
Enter abdomen using Optiview technique with 12 mm trocar in the mid-clavicular line, 5 cm inferior to costal margin |
| Step 2: trocar placement | (I) Place 8 mm robotic trocar lateral to initial incision; (II) Place 8 mm robotic trocar medial approximately 3 cm below junction of 12th rib and paraspinous muscle; (III) Place 12 mm blunt balloon trocar in the access site; (IV) Additional (optional) 5 mm assistant port can be placed lateral and inferior to camera port |
(I) Place two 8 mm robotic trocars in triangulation with camera port; (II) Dock the robotic (cardiere forceps left arm, robotic hook cautery right arm) |
| Step 3: create operative space | (I) Obtain “triangulation view” of medial muscle and blue layer of the peritoneum with blunt dissection; (II) Dock the robot (cadiere forceps left arm, robotic hook cautery right arm) |
(I) Mobilize the splenic flexure of the colon; (II) Take down attachments between spleen and diaphragm and pancreas, kidney and adrenal allowing spleen and pancreas to be medialized |
| Step 4: Identification and mobilization of the gland | (I) Perform lateral to medial dissection detaching tissue above kidney; (II) Dissect adrenal gland and surrounding tissue from superior aspect of kidney |
(I) Identify adrenal tissue and separate from pancreas superiorly; (II) Continue dissection medially and inferiorly |
| Step 5: identification and ligation of the adrenal vein | (I) Identify adrenal vein medially extending to vena cava; (II) Clip adrenal vein with 5 mm Hem-o-lock clips |
(I) Identify adrenal vein medial and inferior draining in to renal vein; (II) Clip adrenal vein with 5 mm Hem-o-lock clips |
| Step 6: mobilization from the retroperitoneal fat | Remove adrenal gland from retroperitoneal attachments with hook cautery | Dissect adrenal gland with a rim of surrounding fat off of the retroperitoneum |
| Step 7: removal of gland | Place adrenal gland in bag and remove through 12 mm port | Place adrenal gland in bag and remove through 12 mm port |