Total extra-peritoneal (TEP) access for robotic-assisted laparoscopic radical prostatectomy (RARP) in patients with prior major abdominal surgeries: A step-by-step approach

Abstract

IntroductionPrior major open abdominal surgery is relative-contraindicated for conventional RARP as intra-abdominal adhesions substantially increases risks of visceral injuries and post-operative ileus. These risks can be minimized by total extra-peritoneal (TEP) approach. This presentation aims to present a novel RARP surgical-access technique by TEP approach in a series of 5 consecutive patients with prior major laparotomies. MaterialsA step-by-step TEP surgical access technique is as follows: (1) initial 15-degree Trendelenburg-position to gravitate visceral cranially, lengthening the sub-umbilical space, (2) extra-peritoneal space was created digitally anterior to preperitoneal fat-plane, (3) extra-peritoneal space was further expanded with a kidney-shaped balloon-dissector, (4) robotic and a 5-mm ports were inserted under digital-guidance, (5) full Trendelenburg-tilt and docking of robotic arms and insertion of the 12-mm and 4th robotic ports were done under laparoscopic-guidance, (6) RARP was performed by antegrade-dissection technique with SPARTAN (Sandwiched Posterior-anterior Reconstructed Tissue-glued Anastomosis) vesicourethral anastomosis. Patient demographics, peri‑ and postoperative short-term outcomes were analysed. ResultsThe patients had major laparotomies for the following indications: gastric carcinoma, colon carcinoma and complicated appendicitis. One patient had concurrent bilateral open inguinal herniorrhaphy. The median age was 64 (56- 66) years, mean BMI: 28.6 (21.5 – 36) kg/m2, mean setup time: 53 (35 – 80) mins, mean operative time: 198 (165 – 235) minutes, mean hospital stay: 2.2 (1–3) days. All patients had successful trial removal of catheter at post-operative day 7. Final histology confirmed 40% (2 of 5 patients) had pT3, the remaining 60% of patients with pT2 and mixed intermediate to high-grade disease (Gleason grade group ≥2, or Gleason grade ≥ 3 + 4). There was only one patient who had focal positive margin with adverse histology of Gleason 3 + 4, pT3a (extra-capsular extension). There were no significant Clavien-Dindo complications post-operatively. ConclusionsIn patients with prior major abdominal surgery and scarred abdomen, RARP by TEP access and initial port-entry guided digitally into the extra-peritoneal space enable performance of otherwise risky trans-peritoneal surgery safely.