Myotomy and Dor fundoplication, robotically assisted

The patient is positioned in supine position on the large vacuum cushion. The left arm can be positioned separately. The use of the cushion eliminates the need for any additional supports. The extremities and all pressure-sensitive areas are padded. A bar is recommended to protect the patient from the robotic arms. After inserting the trocars, the operating table is tilted approximately 15° in the anti-Trendelenburg position and approximately 5° to the right side (tilt right).

Caution: Positioning is of particular importance due to the docking of the patient to the robot's manipulator. There is a risk of injury to the abdominal wall if the patient slips.

Note: Vacuum cushions may have leaks. Check again before sterile draping.

The following setup is chosen: The surgeon sits at the console, ideally with the ability to view both the patient and the table assistant, who sits to the left of the patient. Anesthesia is located at the patient's head. The patient cart is brought to the patient from the right cranial side, and the instrumenting surgical nurse is located to the right of the table assistant.

Creation of a pneumoperitoneum using a Veress needle at Palmer's Point in the left upper abdomen. Due to the varying compliance of the abdominal wall, it is advisable to determine the optimal position of the trocars on the inflated abdomen with pneumoperitoneum. The robotic trocars are positioned in a line approximately 20 cm below the anticipated target anatomy (Xyphoid as a landmark).

The trocars are inserted symmetrically with a distance of 8 cm between each other. All robotic trocars are 8 mm trocars. Additionally, two assistant trocars are used.

Tip: Strict attention should be paid to maintaining the 8 cm (hand width) distance between the Da Vinci trocars to avoid collisions of the robotic arms.

The patient is positioned in 15 degrees anti-Trendelenburg and 5 degrees right lateral tilt. The patient cart approaches from the right cranial side. The arms are connected (docked) with the robotic trocars. Initially, the targeting maneuver is performed. Subsequently, the instruments are introduced under visual control and parked under the ventral abdominal wall. Instrument placement from right to left (from the patient's perspective) Trocar 1: fenestrated bipolar forceps, Trocar 2: camera, Trocar 3: monopolar curved scissors and later vessel sealer extend, Trocar 4: Cardiere forceps, Assistant trocar 1: probe, Assistant trocar 2: atraumatic grasping forceps, if necessary, suction device.

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

Remark: Ideally, the robotic trocars are inspected with the camera via the assistant trocar when introducing the robotic instruments. This allows for easy verification of the position of all robotic trocars before the start of the operation.

o  Incision in the left upper abdomen, insertion of the Veress needle

o  Pneumoperitoneum

o  Marking the line and points for trocars (each 8 cm apart)

o  Insertion of the first 8 mm robotic trocar

o  Insertion of the camera by hand

o  Insertion of 3 additional Xi trocars

o  Insertion of the assistant trocar (11mm) far right

o  Positioning: 15° anti-Trendelenburg, 5° tilt right

o  Dock camera arm + insert camera (Port 2)

o  Targeting

o  Dock 3 additional arms

o  Arms always one fist width apart

o  Insertion of instruments and introduction into target anatomy (1: Cardiere, 2: Camera, 3: bipolar forceps, 4: monopolar scissors/vessel sealer)

o  Control of the remote center via assistant trocar

o  Burping

o   Switch to the console