Right Hemihepatectomy, Robotically Assisted

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  1. Patient Positioning and Operating Room Setup

    • Positioning: Supine position with legs spread on a vacuum cushion. The cushion ensures stability, reducing the need for additional supports
    • After trocar placement, the table is tilted to a 15° – 30° Anti-Trendelenburg position to optimize access
    • Robot Docking:
      • The Xi system offers flexibility in the docking position, typically from the left
      • For X or Si systems, the cart is docked cranially from the right
    • Team Positioning:
      • Surgeon: At the console, ideally with a view of the patient and assistant
      • Assistant: Positioned between the legs, sitting or standing
      • Scrub Nurse: On the right side of the patient
      • Anesthesiologist: At the patient’s head, on the right side
  2. Pneumoperitoneum, Trocar Placement, and Docking

    Video
    Pneumoperitoneum, Trocar Placement, and Docking 1
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    Pneumoperitoneum, Trocar Placement, and Docking 3
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    Pneumoperitoneum Creation:

    • Use a Veress needle at the Palmer point in the left upper abdomen.
    • Establish an insufflation pressure of 12–15 mmHg
    • Alternatively, employ Optiview technique

    Trocar Placement:

    • Total Ports:
      • Four 8 mm robotic ports in a linear arrangement, 15–20 cm from the target anatomy (infraumbilical)
    • Two 12 mm laparoscopic ports:
      • Assistant trocar (caudal between robotic ports 2 and 3)
      • Pringle maneuver trocar (caudal between robotic ports 1 and 2)
      • Spacing: Approximately 8 cm between each port
      • Position robotic trocars at the level of the muscular abdominal wall (aligning the broad black ring, the “Remote Center”)

    Initial Instrument Configuration:

    • Robotic ports (from right to left):
      • Port 1: Monopolar curved scissors
      • Port 2: Camera
      • Port 3: Bipolar forceps
      • Port 4: Prograsp forceps

      Docking the Robot:

    • Dock the camera arm first (port 2)
    • Execute Targeting (Xi system) to align robot arms with the surgical target
    • Dock the remaining arms, ensuring 1 fist-width spacing between them
    • Insert instruments under direct visualization via the assistant trocar

    Key Precautions and Tips

    Trocar Stability:

    • Ensure the “Remote Center” aligns with the muscular abdominal wall to minimize shear forces during instrument movement

    Instrument Placement:

    • Use the assistant trocar and camera to inspect trocar alignment and verify instrument positioning before proceeding

    Preventing Patient Movement:

    • Double-check the vacuum cushion for leaks before sterile draping
    • Secure arms during docking to avoid injury if the patient shifts

    Control Checks:

    • Before docking:
      • Mark trocar points and ensure proper spacing
      • Introduce the camera manually for inspection
    • After docking:
      • Verify arm alignment and positioning of instruments
Pre-Docking Checklist

Perform a small incision in the left upper abdomen for Veress needle placementEstablish pneumoperit

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