Toupet Fundoplicatio for GERD, Robot-Assisted

Patient Positioning:

• Supine position on a large vacuum cushion. The use of the cushion eliminates the need for additional supports
• Padding for extremities and pressure-prone areas
• A protective bar is recommended to shield the patient from robotic arms
• After trocar placement, tilt the operating table to:
  • 15° Anti-Trendelenburg
  • 5° Right tilt (tilt right)
• The robotic arms are docked to the patient

Cautions:

• Ensure secure positioning due to the risk of abdominal wall injuries if the patient slips while docked to the robot
• Verify the vacuum cushion for leaks before sterile draping

Setup Details:

• Surgeon: Operates from the robotic console with visibility of both the patient and the table assistant
• Table Assistant: Positioned on the patient’s right
• Anesthesiologist: At the patient’s head
• Patient Cart: Approaches the patient from the left side
• Scrub Nurse: Positioned to the right of the table assistant

Pneumoperitoneum Creation:

• Use a Veress needle at Palmer’s Point (left upper abdomen)
• Establish insufflation and determine optimal trocar positions at the inflated abdomen

Trocar Placement:

• Robot Trocar Alignment:
  • All robotic trocars (8 mm) are positioned in a straight line approximately 20 cm below the anticipated target anatomy (using the xiphoid process as a landmark)
  • Maintain an 8 cm distance between trocars to avoid robotic arm collisions
• Assistant Trocars:
  • One 12 mm trocar on the far-right side, aligned with robotic trocars
  • One 5 mm trocar in the epigastrium for liver retraction

Docking and Targeting:

• Place the patient in 15° Anti-Trendelenburg and 5° right tilt positions
• Approach the Patient Cart from the right cranial side
• Attach the robotic arms to the trocars
• Perform targeting and insert instruments under direct vision
• Park instruments under the anterior abdominal wall

 Instrument Configuration (Patient’s Right to Left):

• Trocar 1: Fenestrated bipolar forceps
• Trocar 2: 30° Camera
• Trocar 3: Monopolar curved scissors, later replaced by vessel sealer extend
• Trocar 4: Cardiere grasping forceps
• Assistant Trocar 1 (12 mm, right): Atraumatic grasping forceps, optionally suction
• Assistant Trocar 2 (5 mm, epigastric): Liver retractor

Cautions and Recommendations:

• Remote Control Setup:
  • Position the wide black ring of each trocar at the level of the muscular abdominal wall to minimize shear forces during movement
• Trocar Inspection:
  • Before starting the operation, inspect the robotic trocars with the camera inserted via the assistant trocar to ensure proper placement