Adnexectomy, laparoscopic, robot-assisted laparoscopy (DaVinci)

DaVinci:

• Positioned in lithotomy (or more securely on spreadable straight leg supports) ideally on a large vacuum cushion or non-slip mat
• It is recommended to position both arms alongside the body (caution: cotton wrapping when positioning with a cloth sling), or to position one arm on the side of the robot
• For leg positioning, padded "boots" are recommended so that the legs can be moved separately and covered sterilely as needed. Alternatively, the legs can be positioned in leg cradles with fixation in these (Caution: compartment syndrome).
• The legs should be adjustable in angle via the operating table control during the procedure
• Shoulder supports bilaterally to prevent the patient from slipping off the operating table
• For longer procedures, application of pneumatic compression cuffs for the legs for thrombosis prophylaxis
• Attachment of a cervical adapter

Note: It is important to be aware of the risk of injury to the patient from the instruments if the patient slips. With coupled tables in the Xi system, intraoperative position changes are possible without uncoupling. In the absence of "Table-Motion" technology, the surgical robot must always be undocked and removed from the operating table before any position change.

Davinci:

Creation of a pneumoperitoneum by inserting a Veress needle approximately 20 cm away from the target anatomy (usually periumbilical). The three to four 8 mm robotic trocars are positioned in a straight, horizontal line (Xi) or a slightly curved line towards the operative site (X, SI). Ideally, there is a distance of 8 cm between each trocar (minimum 7 cm to maximum 10 cm). The 10 or 12 mm assistant trocar can be placed in the lower abdomen, cranial to the trocars, or as an additional trocar along the straight line, depending on the assistant's positioning at the operating table and the surgeon's preference (see illustration). The patient is positioned at the end of the operating table and then placed in a steep Trendelenburg position (approximately 30°). The table tilt is adjusted as necessary for anesthetic or surgical requirements. The laser marking is aligned so that the crosshair points directly at the camera trocar (Xi). The DaVinci system is then aligned. The arms are connected (docked) with the three to four 8 mm robotic trocars. Subsequently, the instruments are introduced under visual control and parked under the anterior abdominal wall.

Caution: The trocars must be positioned with the wide black ring at the level of the muscular abdominal wall (so-called remote center) to avoid injury during movement.

Note: Depending on the operating room and the surgeon's preference, the positioning of the DaVinci "patient cart" and the trocars can be varied.

During laparoscopy, inspection of the abdomen is performed, including the upper abdominal area, the diaphragmatic domes, the liver, the gallbladder, the stomach, and the omentum. Additionally, an inspection of the intestines and peritoneum is conducted, and the pelvis is inspected, taking into account the uterus, both adnexa, the Douglas pouch, as well as the transperitoneal representation of both ureters.