1. Robotic Assisted Laparoscopic Pyeloplasty Dr J. Hagerty Pediatric Urology 1-2010

2. ComponentsSteps 1. Prepare pt 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg 2. Access (Hassan technique) 1.Umbilical incision 2.Viccryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera 3. Evaluation for kidney location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically 4. Dock Robot 1.Direct robot into position 2.Attach arms to ports 3.Insert camera and then instruments of choice 5. Surgery 1.Set up 2.Dismember the UPJ - 3.Anastomosis 4.Finishing up components &steps feedback & remediation OR set up Sutures Instruments

3. Component 1 “Prepare Patient” Prepare Patient 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg STEPS

4. Component 1: Drain Bladder With Foley Prepare Patient 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg STEPS

5. Component 1: Bump Under Flank Prepare Patient 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg STEPS

6. Component 1: Stomach Drained By Anesthesia Prepare Patient 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg STEPS

7. Component 1: Trendeleberg Prepare Patient 1. Drain bladder with Foley 2. Bump under flank 3. Stomach drained by anesthesia 4. Trendeleberg STEPS

8. Component 2 “Access” (Hassan Technique) Access (Hassan Technique) 1.Umbilical incision 2.Viccryl on fascia 3.Open fascia 4.Insert trocar and insufflate 5.Insert camera STEPS

9. Component 2: Umbilical Incision Access (Hassan Technique) 1.Umbilical incision 2.Viccryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera STEPS Umbilical incision – 8.5 mm

10. Component 2: Vicryl On Fascia Access (Hassan Technique) 1.Umbilical incision 2.Vicryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera STEPS 2-0 vicryl on fascia b/l

11. Component 2: Open Fascia Access (Hassan Technique) 1.Umbilical incision 2.Vicryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera STEPS

12. Component 2: Insert Trocar And Insufflate Access (Hassan Technique) 1.Umbilical incision 2.Vicryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera STEPS Insert trocar, insufflate – confirm low pressure, switch to high flow, pressure to 12mm hg

13. Component 2: Insert Camera Access (Hassan Technique) 1.Umbilical incision 2.Vicryl on fascia 3.Open Fascia 4.Insert trocar and insufflate 5.Insert camera STEPS Insert camera and survey for injury from port placement

14. Component 3 “Evaluation For Kidney Location” Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS

15. Component 3: Look For Kidney Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS Look for kidney, reposition bed to drop bowel away to better visualize by airplaning and increasing trendelenberg.

16. Component 3: Placement Of Trocars Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS Placement of trocars – ipsilateral – lower quadrant and midway between xiphoid and umbilicus, 5 or 8mm.

17. Component 3: Decrease CO2 To 8 mmhg Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS

18. Component 3: Determine If Transmesenteric Approach Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS  Determine if transmesenteric approach (Left only) or need to take down colon If transmesenteric – continue with robot docking

19. Component 3: Determine If Taking Down Colon Approach Evaluation For Kidney Location 1. Look for kidney 2. Placement of trocars 3. Decrease CO2 to 8 mmhg 4. Determine if transmesenteric approach Continue with robot docking 5. Determine If taking down colon approach Continue laparoscopically STEPS  If taking down colon – continue laparoscopically (difficult to do with robot as it requires to much excursion of the robot) Use harmonic to take down colon along white line

20. Component 4 “Dock Robot” Dock Robot 1.Direct robot into position 2.Attach arms to ports 3.Insert camera and instrument of choice STEPS

21. Component 4: Direct Robot Into Position Dock Robot 1.Direct robot into position 2.Attach arms to ports 3.Insert camera and instrument of choice STEPS

22. Component 4: Attach Arms To Ports Dock Robot 1.Direct robot into position 2.Attach arms to ports 3.Insert camera and instrument of choice STEPS

23. Component 4: Insert Camera And Instrument Of Choice Insert camera and then instruments of choice – typically hook and Maryland to start Dock Robot 1.Direct robot into position 2.Attach arms to ports 3.Insert camera and instrument of choice STEPS

24. Component 5 “Surgery” Surgery 1.Set up 2.Dismember the UPJ 3.Anastomosis 4.Finishing up STEPS

25. Component 5: Set up Surgery 1.Set up 2.Dismember the UPJ 3.Anastomosis 4.Finishing up STEPS  If transmesenteric: Open windows in mesentery overlying the UPJ  Identify ureter and renal pelvis and dissect free  Place stay suture with 4-0 vicryl on pelvis  Place stay suture on anterior-medial ureter with 5-0 vicryl

26. Component 5: Dismember The UPJ Surgery 1.Set up 2.Dismember the UPJ 3.Anastomosis 4.Finishing up STEPS  Cut through from medial to lateral proximal to the UPJ using scissors  Bring ureter around crossing vessel if present to lie anterior to  Spatulate ureter through stricture and long enough for anastomosis to be dependent

27. Component 5: Anastomosis Surgery 1.Set up 2.Dismember the UPJ 3.Anastomosis 4.Finishing up STEPS  Place 5-0 monocryl through apex of ureter outside in, then inside out on the most dependent portion of the pelvic opening  Run the back wall closed  If to place stent, pass wire down 14g angiocath and pass down ureter. Have nurse fill bladder with methylene blue. Place stent over wire and pass down the ureter until get to the end of the stent as identified by the black line. Pull wire and check for blue efflux. Then place prox end in the pelvis.  Place second 5-0 monocryl at the apex on the front wall and run the front wall closed. Remove any excess ureter as needed prior to completion.

28. Component 5: Finishing Up Surgery 1.Set up 2.Dismember the UPJ 3.Anastomosis 4.Finishing up STEPS  Remove holding sutures from pelvis  Have assist pass drain (7f JP) through Lower quadrant port with a Maryland grasper. Undock the robot  Remove all ports, close sites with 2-0 vicryl for fascia and 5-0 monocryl for skin.  Mastisol, steri strips, and tegaderms over incisions. Dermabond in umbilical incision and to close angiocath site.

29. feedback & remediation

30. OR set up

31. Instruments

32. sutures