Assistant Trocar Research Articles

Simple Trocar Placement for Robotic Liver and Pancreatic Surgery: Multiple Access Devices at 5-cm Single Umbilicus Incision with 2 Robotic Ports.

Robotic trocars are recommended to be placed 6-8 cm apart, and assistant trocars are placed 7 cm away from the horizontal line of the robotic trocar placement. However, adhering to these rules may be difficult, particularly in lean patients. This study aims to demonstrate our standardized simple trocar placement, 5-cm single umbilicus incision + 2 ports for robotic liver resection (RLR) and robotic pancreaticoduodenectomy (RPD). During 2022-2024, patients undergoing RLR and RPD at The University of Tokyo were identified from a prospectively maintained database. Our standardized trocar placement consisted of multiple access devices at the 5-cm umbilicus incision, including two robotic trocars and one assistant trocar, and two other robotic trocars inserted to shape a hemi-circle around the surgical object. A total of 29 and 31 consecutive patients underwent RLR and RPD, respectively. The 5-cm single umbilicus incision + 2 ports method was used in 82.8% of patients undergoing RLR and 100% of patients undergoing RPD. No patients undergoing RLR developed hepatic insufficiency and bile leakage with the median postoperative hospital stay of 5 days. No patients undergoing RPD developed clinically relevant pancreatic fistula, delayed gastric emptying, and bile leakage with the median postoperative hospital stay of 8 days. Our standardized trocar placement technique is simple and widely feasible for lean-to-obese patients, allowing for RLR and RPD while minimizing incisions for patients.

510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY

Abstract Background Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges. Methods A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler. Results The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery. Conclusion The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery. https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link

Reduced-port robotic pancreaticoduodenectomy with optimized surgical field deployment: early results of single-site plus-two ports method

BackgroundThe adoption of Robotic Pancreaticoduodenectomy (RPD) is increasing globally. Meanwhile, reduced-port RPD (RPRPD) remains uncommon, requiring robot-specific techniques not possible with laparoscopy. We introduce a unique RPRPD technique optimizing surgical field exposure.MethodsOur RPRPD utilizes a single-site plus-two ports technique, facilitated by a single-port platform through a 5-cm incision. The configuration of robotic arms (arm1, arm2, arm3, and arm4) were strategically designed for optimal procedural efficiency, with the arms2 and arm3, alongside the assistant trocar, mounted on the single-port platform, while the arms1 and arm4 were positioned laterally across the abdomen. Drainage was established via channels created at the arm1 and arm4 insertion sites. A “gooseneck traction” was principally employed with the robotic instrument to prop up the specimen rather than grasp, improving the surgical field’s visibility and access. Clinical outcomes of patients who underwent RPRPD performed between August 2020 and September 2023 by a single surgeon across two centers in Taiwan and Japan were reviewed.ResultsFifty patients underwent RPRPD using the single-site plus-two ports technique. The gooseneck traction technique enabled goodsurgical field deployment and allowed for unrestricted movement of robotic arms with no collisions with the assistant instruments. The median operative time was 351 min (250–488 min), including 271 min (219–422 min) of console time and three minutes (2–10 min) of docking time. The median estimated blood loss was 80 mL (1–872 mL). All RPRPD procedures were successfully performed without the need for conversion to open surgery. Postoperative major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) was observed in 6 (12%) patients and median postoperative hospital stay was 13 days.ConclusionsThe single-site plus-two ports RPRPD with the gooseneck traction proves to be a safe, feasible option, facilitating surgical field visibility and robotic arm maneuverability.Graphical

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study.

To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model. Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated. In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation. Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT Luca Antonelli, Adrian Duss, Leutrim Zahiti, Agostino Mattei, and Christian D. Fankhauser Luca AntonelliLuca Antonelli More articles by this author , Adrian DussAdrian Duss More articles by this author , Leutrim ZahitiLeutrim Zahiti More articles by this author , Agostino MatteiAgostino Mattei More articles by this author , and Christian D. FankhauserChristian D. Fankhauser More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal segmental glomerulosclerosis (FSGS) is a histologic pattern that is associated with nephrotic syndrome in children and adults and represents an important cause of end-stage renal disease worldwide. The underlying podocytopathy is a consequence of multiple pathways either individually or collectively. The associated heavy proteinuria represents a perioperative risk factor for complications after transplantation. Therefore, a bilateral nephrectomy before transplantation is recommended to stop protein loss by the kidneys. METHODS: A 19 years-old woman with therapy resistant FSGS had a persistently low serum albumin level requiring 70g human albumin supplementation each week. A bilateral kidney embolization or surgical removal before listing for a kidney transplantation was required. To improve perioperative outcomes and cosmesis in a young female patient, she was scheduled for a robotic subumbilical access to avoid scar tissue in the upper abdomen.The patient was positioned in a supine position with 30° head down. Four robotic 8mm trocars were placed in a subumbilical line and a 5mm and 12mm assistant trocar were positioned laterally of the medial umbilical ligaments. No repositioning of the patient during the whole case was required. The peritoneum was incised at the level of the ileocecal valve up to the ligament of Treitz. A hammock-like barrier is created by suturing both lateral edges of the parietal peritoneum to the anterior abdominal wall. Subsequently the renal hilus was dissected and the kidney mobilized. The renal vessels were clipped. A 18mm laparoscopic morcellator was introduced after extending the 12mm assistant trocar incision and the kidneys were removed through the morcellator. RESULTS: Blood loss was <50 mL and theatre time 325 minutes. After the surgery the patient had mild bruises on both shoulders because of the long-time period in the Trendelenburg position but resolved without further treatment. Postoperative length of stay was 4 days. After successful removal of both kidneys, the patient was listed for a kidney transplant with priority given her age < 20 years. CONCLUSIONS: Bilateral robotic nephrectomy using a subumbilical access and removal of the kidney using a morcellator is technically demanding but feasible. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luca Antonelli More articles by this author Adrian Duss More articles by this author Leutrim Zahiti More articles by this author Agostino Mattei More articles by this author Christian D. Fankhauser More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-07 WIRE-GUIDED EXTRAVESICAL ROBOT-ASSISTED BLADDER DIVERTICULECTOMY AND Y-V PLASTY FOR RECURRENT BLADDER NECK STRICTURE

You have accessJournal of UrologyCME1 Apr 2023V07-07 WIRE-GUIDED EXTRAVESICAL ROBOT-ASSISTED BLADDER DIVERTICULECTOMY AND Y-V PLASTY FOR RECURRENT BLADDER NECK STRICTURE Francesco Ditonno, Alessandro Veccia, Giovanni Novella, Lorenzo De Bon, Paola Irene Ornaghi, and Alessandro Antonelli Francesco DitonnoFrancesco Ditonno More articles by this author , Alessandro VecciaAlessandro Veccia More articles by this author , Giovanni NovellaGiovanni Novella More articles by this author , Lorenzo De BonLorenzo De Bon More articles by this author , Paola Irene OrnaghiPaola Irene Ornaghi More articles by this author , and Alessandro AntonelliAlessandro Antonelli More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003288.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To present the surgical technique for robot-assisted wire-guided extravesical bladder diverticulectomy and simultaneous Y-V plasty for recurrent bladder neck stricture. METHODS: A 58-year-old man referred to our center for recurrent LUTS after TURP. Thereafter, the patient underwent TUIP and 2 endoscopic bladder neck incisions, unsuccesfully. A CT scan showed two bladder diverticula of 4 and 8 cm located on the right and left postero-lateral wall, respectively. The patient was scheduled for robot-assisted bladder diverticulectomy and Y-V plasty for recurrent bladder neck stricture. As first step, a double J stent was placed bilaterally and a guidewire was inserted in the lumen of each diverticulum to facilitate their identification and handling. The robotic stage was performed with Da Vinci Xi platform, with the patient in supine position, with a 25 degrees Trendelemburg. Six ports were placed across the lower abdomen, transperitoneally: four 8 mm robotic trocars and 2 assistant trocars (12 and 5 mm). The peritoneum was incised to expose posterolateral bladder wall. Perivesical fat was dissected and protruding mucosa of the diverticula isolated. A blunt dissection was mostly used, detaching the mucosa from the bladder wall. Once completely isolated, bladder mucosa was entirely excised and the neck of the diverticulum closed with a triple-layer continuous 3-0 monofilament absorbable suture. Retzius space was then opened and prostatic defatting was performed. The bladder neck was incised obtaining a Y-shaped flap. Two stay 3-0 monofilament sutures were placed at the end of the two branches of the Y. The flap was advanced and the margins closed with a double-layer emicontinuous 3-0 barbed absorbable suture. RESULTS: Operative time was 318 min. Estimated blood loss was 200 mL. There were no perioperative or postoperative complications. A voiding cystourethrogram before catheter removal, after 12 days, showing almost complete resolution of diverticular protrusion. Ureteral stents were removed 30 days post-operatively. CONCLUSIONS: Robot-assisted extravesical diverticulectomy and simultaneous Y-V plasty of the bladder neck is a safe and feasible procedure. Endoscopic guide-wire insertion into the diverticulum allowed for easier traction and dissection of the tissues. Advantages of the procedure consist of avoidance of cystotomy, easy individuation and excision of diverticular mucosa and concomitant resolution of relapsing cervico-urethral obstruction. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e597 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Ditonno More articles by this author Alessandro Veccia More articles by this author Giovanni Novella More articles by this author Lorenzo De Bon More articles by this author Paola Irene Ornaghi More articles by this author Alessandro Antonelli More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION

You have accessJournal of UrologyCME1 Apr 2023V10-06 INTRAOPERATIVE USE OF PET/CT SPECIMEN IMAGER TO GUIDE ROBOTIC RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION Marco Oderda, Serena Grimaldi, Giorgio Calleris, Daniele D'Agate, Federico Lavagno, Alessandro Marquis, Giancarlo Marra, Desireé Deandreis, and Paolo Gontero Marco OderdaMarco Oderda More articles by this author , Serena GrimaldiSerena Grimaldi More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Daniele D'AgateDaniele D'Agate More articles by this author , Federico LavagnoFederico Lavagno More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Desireé DeandreisDesireé Deandreis More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Today, PSMA is the most accurate radiopharmaceutical in PCa and it can be used as a tracer to identify PCa foci in resected specimens. To do so, a small, high-resolution PET/CT-imaging device (XEOS AURA®) was developed, with near five-fold optimization in spatial resolution as opposed to the standard clinical PET/CT devices. Aim of this feasibility study was to test the intraoperative use of this brand-new PET/CT specimen imager to guide robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND). METHODS: To date, we performed three cases of RARP and PLND with intraoperative use of XEOS AURA® specimen imager. All patients underwent preoperative staging with MRI and PSMA PET/CT. Surgeries were performed with Da Vinci Xi robot. During trocar placement, an intravenous injection of 68-Ga PSMA, 2 mBq/kg, was performed. Lymph nodes were immediately removed through the 12-mm assistant trocar and inserted into the specimen imager for analysis. After complete excision, the prostate was removed through a short Pfannestiel incision while maintaining CO2 insufflation, and analysed with the specimen imager to check for positive margins (PSM) before doing the urethra-vesical anastomosis. RESULTS: On average, the time required by XEOS AURA® to analyse each specimen was 12 minutes (SD 3). Total and positive nodal yield were 17.3 (5.8) and 0.3 (0.5 SD), respectively. PET/CT specimen imager showed a marked uptake for the only positive node retrieved, and a diffuse, weak uptake in several negative nodes. There was a good correspondence between marked uptake and node positivity, reflecting also preoperative PET/CT findings (Table 1). XEOS AURA® was useful to predict negative surgical margins, although in one locally advanced case this evaluation was uncertain. CONCLUSIONS: The use of PET/CT specimen imager is safe and feasible. The intraoperative knowledge of prostate cancer (PCa) location within lymph nodes or inside the prostate is essential to improve the oncological radicality of the procedure while safely pushing the boundaries of a hyper-conservative surgery. Source of Funding: University of Turin © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Oderda More articles by this author Serena Grimaldi More articles by this author Giorgio Calleris More articles by this author Daniele D'Agate More articles by this author Federico Lavagno More articles by this author Alessandro Marquis More articles by this author Giancarlo Marra More articles by this author Desireé Deandreis More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-02 ROBOTIC PARTIAL NEPHRECTOMY WITH REVERSIBLE SELECTIVE ARTERY ENDOLUMINAL BALLOON OCCLUSION ON A KIDNEY GRAFT

You have accessJournal of UrologyCME1 May 2022V10-02 ROBOTIC PARTIAL NEPHRECTOMY WITH REVERSIBLE SELECTIVE ARTERY ENDOLUMINAL BALLOON OCCLUSION ON A KIDNEY GRAFT Patrick-Julien Treacy, Severine Lagarde, Al Emadi Ibrahim, Thomas Prudhomme, Marine Lesourd, Rayan Atme, Matthieu Durand, Imad Bentellis, Michel Soulié, and Nicolas Doumerc Patrick-Julien TreacyPatrick-Julien Treacy More articles by this author , Severine LagardeSeverine Lagarde More articles by this author , Al Emadi IbrahimAl Emadi Ibrahim More articles by this author , Thomas PrudhommeThomas Prudhomme More articles by this author , Marine LesourdMarine Lesourd More articles by this author , Rayan AtmeRayan Atme More articles by this author , Matthieu DurandMatthieu Durand More articles by this author , Imad BentellisImad Bentellis More articles by this author , Michel SouliéMichel Soulié More articles by this author , and Nicolas DoumercNicolas Doumerc More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Small kidney tumors on renal grafts are accessible to partial nephrectomy surgery, but expose to clamping difficulties due to challenging access to graft vessels. Endoluminal balloons provide a reversible alternative to clamping of the graft artery. The objective of this video was to show the safety and efficiency of this technique for robot-assisted partial nephrectomy on kidney graft. METHODS: 69-year-old patient, transplanted in 2012, with extensive cardiovascular history. Discovery on follow-up ultrasound of a 2.5x2.3 cm tumor, confirmed by CT scan. Decision of robot-assisted partial nephrectomy after the multidisciplinary consultation meeting. An endoluminal balloon was placed in the segmental artery vascularizing the tumor after ponction of the femoral artery in interventional radiology. The patient was then installed in a supine position in the operating room for robotic-assisted partial nephrectomy, with trocar positioning similar to pelvic robotic surgery (assistant on the left side of the patient, two assistant trocars in the left iliac fossa and between the optical trocar and arm #1). RESULTS: The operative time in interventional radiology was 25 minutes, performed under local anesthesia. The operative time of the partial nephrectomy was 45 min, with a 10 min occlusion of the segmental artery. Blood loss was 200 cc. The postoperative period was uneventful, with the patient being discharged on day 2 after surgery. The serum creatinine level at discharge was 80 micromol/L, and the 3-month level was similar. Histopathologic analysis confirmed the malignant nature of the tumor, with clear cell renal cell carcinoma classified as pT1a Nx MO, nucleolar grade 3 (WHO 2018), with negative margins. 2 additional patients were performed using this technique, with similar results. CONCLUSIONS: Selective and reversible endoluminal balloon occlusion of segmental arteries appears to be a safe and effective alternative in arterial clamping for robotic-assisted partial nephrectomies on kidney grafts. A larger cohort will allow us to confirm our hypothesis. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e848 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick-Julien Treacy More articles by this author Severine Lagarde More articles by this author Al Emadi Ibrahim More articles by this author Thomas Prudhomme More articles by this author Marine Lesourd More articles by this author Rayan Atme More articles by this author Matthieu Durand More articles by this author Imad Bentellis More articles by this author Michel Soulié More articles by this author Nicolas Doumerc More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP50-13 FEASIBILITY AND OPTIMAL SETTING OF ROBOT-ASSISTED PARTIAL NEPHRECTOMY USING A NOVEL MULTI-ARM, MODULAR ROBOTIC PLATFORM

You have accessJournal of UrologyCME1 May 2022MP50-13 FEASIBILITY AND OPTIMAL SETTING OF ROBOT-ASSISTED PARTIAL NEPHRECTOMY USING A NOVEL MULTI-ARM, MODULAR ROBOTIC PLATFORM Carlo Andrea Bravi, Luca Sarchi, Angelo Mottaran, Pietro Piazza, Fernando Gonzalez Meza, Marco Corsetti, Sophie Knipper, Marco Paciotti, Marco Amato, Rui Farinha, Stefano Puliatti, Simone Scarcella, Geert De Naeyer, Ruben De Groote, and Alexandre Mottrie Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Angelo MottaranAngelo Mottaran More articles by this author , Pietro PiazzaPietro Piazza More articles by this author , Fernando Gonzalez MezaFernando Gonzalez Meza More articles by this author , Marco CorsettiMarco Corsetti More articles by this author , Sophie KnipperSophie Knipper More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Marco AmatoMarco Amato More articles by this author , Rui FarinhaRui Farinha More articles by this author , Stefano PuliattiStefano Puliatti More articles by this author , Simone ScarcellaSimone Scarcella More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002625.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephron-sparing surgery is a challenging procedure that requires surgical dexterity and speed of execution. Due to its technical complexity, the benefits provided by the robotic approach have led to an increasing interest in robot-assisted partial nephrectomy (RAPN). Our aim was to assess procedural feasibility and to describe our technical setting for RAPN using the novel HUGO RAS system (MedTronic ©) on a pre-clinical model. METHODS: HUGO RAS System was used to perform 3 RAPNs on human cadavers. This novel robotic system has independent robotic arms that allow for a modular configuration, an open high-definition console, 3-dimension vision goggles, and easy-grip “pistol-like” controllers. We sought to describe the optimal setup configuration for this new robotic platform, and to assess technical feasibility of all the procedural steps. All components of surgical team (console surgeon, bed-side assistant and scrub nurse) received an official technical training. Patient positioning, arm cart disposition, and trocar placement were described. Docking time, operative time, and technical errors of the system were recorded, as well as intra-operative complications such as clashing of the instruments and/or injury to abdominal organs. RESULTS: Instruments consisted of monopolar scissors, forceps bipolar, and needle driver; a 0-degree camera was used. With patients on flank position, four robotic trocars (one 11-mm optic port, and three 8-mm robotic ports) were positioned in a ‘diamond’ configuration, with three arm carts behind the back of the patient, and one arm cart positioned in front of the abdomen (Figure 1). One 12-mm assistant trocar was placed on the para-rectal line. All procedures were performed trans-peritoneally, and all cases were completed following all traditional steps. Docking time ranged between 3 and 7 minutes. Mean (standard deviation) operative time was 55 (±15) minutes. No operative complications, nor technical failure by the system occurred with our setup. CONCLUSIONS: RAPN with HUGO RAS system is feasible and safe in a pre-clinical setting. Future investigations should focus on technical standardization and optimal setting of this novel robotic platform in a clinical setting. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e870 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Carlo Andrea Bravi More articles by this author Luca Sarchi More articles by this author Angelo Mottaran More articles by this author Pietro Piazza More articles by this author Fernando Gonzalez Meza More articles by this author Marco Corsetti More articles by this author Sophie Knipper More articles by this author Marco Paciotti More articles by this author Marco Amato More articles by this author Rui Farinha More articles by this author Stefano Puliatti More articles by this author Simone Scarcella More articles by this author Geert De Naeyer More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF DownloadLoading ...

A Novel Suction-Irrigation Cannula-Guided Hydrophilic Tip Guidewire Technique of Intraoperative Ureteral Stent Placement During Robot-Assisted Radical Prostatectomy

Background: Patients with large median lobe, history of pelvic radiotherapy, or transurethral resection of the prostate are on the verge of ureteral orifice (UO) injury during robot-assisted radical prostatectomy (RARP). Not all aforementioned patients require ureteral stent placement. Intraoperative findings justify whether to proceed with ureteral stent placement or not. Previously described techniques of intraoperative stent placement involve use of transurethral cystoscopy or suprapubic skin incision, which makes procedure further difficult especially with robotic arms in place.1 Herein, we describe a simple and efficacious method Suction-Irrigation cannula-Guided Hydrophilic Tip guidewire (SIGHT) technique for intraoperative ureteral stent placement. Technique: The case shown here is a 64-year-old gentleman with Gleason 8 prostate cancer and opted for RARP. After division of bladder neck, the interior of the bladder was routinely inspected and the UOs were found too close to the bladder margins. The decision was made to proceed with bilateral ureteral stents placement. To facilitate stent placement, bladder margin is held up using 4th arm of the robot. The bedside assistant inserted laparoscopic suction irrigation cannula from 5 mm assistant trocar. Cannula tip was held a couple of centimeters away from respective UO. A 0.038 Inch diameter, 150 cm long hydrophilic straight tip guidewire is fed into the abdomen through shaft of the cannula. The surgeon on console (A.T.) places the wire into UO and feeds it proximally until the resistance is met. The bedside assistant (R.B.) then feeds the stent over the wire into the abdomen, and the surgeon threads the stent over the wire. The assistance held back-tension on the wire. A pusher is then guided over the wire in similar manner and stent is advanced until distal end of the stent is seen. The wire is pulled out by the bedside assistant, and the distal end of the stent is confirmed with use of robot and secure inside the bladder. Surgery proceeded as usual. Stent placement was verified postoperatively by plain kidney, ureter and bladder radiograph. Patient was discharged next day. Catheter removal was done at postoperative day 7. Ureteral stents were removed under local anesthesia in the office at 4 weeks postoperative visit without complication. Conclusions: Our SIGHT technique is safe, effective, and easily adaptable method for intraoperative ureteral stent placement during robotic procedures. It avoids intraoperative cystoscopy or suprapubic skin incision or use of additional guidewires thereby saving time during which patient is under anesthesia during surgery. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music Source:www.epidemicsound.com Copyright: Author owns copyright/license for the music used in the video. A.T. has served as a site-PI on pharma/industry-sponsored clinical trials from Kite Pharma, Lumicell Inc., Dendreon, and Oncovir Inc. He has received research funding (grants) to his institution from Department of Defence, National Institute of Health, Axogen, Intuitive Surgical, Arthur M. Blank Family Foundation, and other philanthropy. A.T. has served as an unpaid consultant to Roivant Biosciences and advisor to Promaxo. He owns equity in Promaxo. Rest of the authors do not have conflict of interests. Runtime of video: 3 mins 21 secs

Robotic Management of Diaphragmatic Endometriosis in 10 Steps

To present 10 standardized steps of the surgical management of diaphragmatic endometriosis using Da Vinci robotic assistance. Surgical education video. The local institutional review board confirmed that the video met ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The film presents a standardized way of performing excision of diaphragmatic endometriosis using the following 10 steps: (1) The patient is placed in left lateral decubitus and 10° proclivity [1,2]. (2). Three 8-mm wide incisions are made, including on the right medio-clavicular line for the endoscope, on the medio-axillar line for the bipolar forceps, and 2 cm below the xiphoid appendix for the scissors. A 10-mm incision is made 3 cm above the umbilicus for the assistant trocar. (3) The procedure starts by an inspection of the right diaphragmatic surface; the falciform ligament is sectioned to allow exploration of the left diaphragm and supplementary mobilization of the liver. (4) Adhesions are completely sectioned, down to the hepato-phrenic cul de sac, tangentially to the liver surface. (5) Small lesions, which do not require full thickness excision, are first removed, before creating a pneumothorax, using a low monopolar setting at 20 watts [3]. (6) Full thickness excision of transfixing lesions or holes is carried out using monopolar scissors and results in an immediate complete right pneumothorax [2,4]. (7) The pleural cavity is inspected to identify disseminated lesions in the chest, located far from the diaphragm. (8) Repairing of the diaphragm is carried out by performing a unidirectional barbed suture. (9) Before performing the final knot, the laparoscopic suction irrigation canula is introduced into the chest cavity, and the CO2 used for inflation is fully aspirated, leading to the creation of the diaphragm concavity; the use of a chest drain is therefore not necessary. (10) Despite the lack of high-level of evidence data, we routinely use an antiadhesion agent, with an aim to reduce postoperative adhesions. Operative time varies from 30 min to 1 hour. Chest X-ray is routinely performed at postoperative day 1. To date, in 76 patients, X-ray did not reveal postoperative relevant pleurisy requiring chest drainage. The robotic-assisted laparoscopic excision of deep endometriosis involving the diaphragm is a standardized 10-step procedure that allows a complete removal of diaphragmatic lesions with good clinical outcomes.

Laparoscopic ovarian cystectomy in the gravid patient

To demonstrate safety and efficacy of laparoscopic surgery in pregnancy while describing specific surgical techniques employed in this particular population. The surgery was performed at an academic affiliated community hospital. The patient was a 24 year old G2P1001 at 17 weeks gestation undergoing laparoscopic surgical management of ovarian torsion with a 12 cm ovarian dermoid cyst. We performed a laparoscopic ovarian cystectomy and detorsion of an ovary in a gravid patient in the second trimester. Laparoscopic surgery is safe and feasible during pregnancy. Entry using an open approach with a multiport device may enhance safety and minimize the need for placement of multiple assistant trocars. Given adnexal hypervascularity, delicate tissue handling and aggressive hemostasis is of utmost importance. It is beneficial for even experienced surgeons to refamiliarize themselves with laparoscopy in pregnancy prior to performing these operations.

Robotic revision surgery for type IV choledochal cyst

Complete excision of the cyst with Roux-en-Y hepaticojejunostomy (RYHJ) is the standard treatment for a choledochal cyst (CDC). Incomplete cyst excision and anastomotic stricture are the common causes of recurrent symptoms. The use of the robotic platform for re-operation after open surgical treatment of the CDC has not been previously reported. The technique of robotic revision surgery using the daVinci®XiTM robotic surgical system is described in this report. A 24-year-old female with a history of open CDC excision and choledochoduodenostomy at three months of age, presented with intermittent fever and abdominal pain for ten years duration. Preoperative evaluation with upper gastrointestinal endoscopy and magnetic resonance imaging revealed choledochoduodenostomy stricture with cystic dilatation of biliary radicals predominantly in the left lobe liver suggestive of type IVa choledochal cyst. The patient underwent robotic dismantling of strictured choledochoduodenostomy, left hepatectomy and Roux-en-Y right hepaticojejunostomy. The procedure was performed with four 8 mm robotic trocars placed at the umbilicus level and one infraumbilical assistant trocar. Key steps are intra-abdominal adhesiolysis, dismantling of the choledochoduodenostomy, inflow control to the left hemiliver, parenchymal transection to the left of the middle hepatic vein, division of left hepatic duct, intraparenchymal transection of the left hepatic vein and Roux-en-Y right hepaticojejunostomy. The operative time, blood loss, and postoperative hospital stay were 410 minutes, 200 mL, and four days, respectively. At seven months follow-up, the patient is asymptomatic with normal liver function test. Robotic revision surgery for CDC is safe and the feasibility reported in the present patient needs to be documented in a large case series.

Combination of Robotic Pyeloplasty and Percutaneous Renal Surgery for Simultaneous Treatment of Ureteropelvic Junction Obstruction and Calyx Stones

Introduction: Ureteropelvic junction obstruction (UPJO) and the simultaneous presence of kidney calyx stones represent a challenge for renal surgery. We present a novel technique for the simultaneous treatment of UPJO by robotic pyeloplasty in combination with the percutaneous endoscopic treatment of kidney calyx stones by flexible nephroscopy. Patients and Methods: Between January 2018 and February 2020, 4 patients were diagnosed with UPJO and simultaneous pelvic or calyceal stones. UPJO was treated by conventional robotic pyeloplasty. After opening the renal pelvis, a flexible 16-French cystoscope was introduced via the 12-mm assistant trocar into the renal pelvis. The kidney calyx stones (n = 1–15) were removed endoscopically through a flexible nephroscope using a Dormia helical basket. Before suturing the anastomosis of the renal pelvis, a ureter stent was inserted. Results: After the procedure, all patients were stone free. Using the Clavien-Dindo classification, no complications were noted. The mean size of the calculi was 6.69 mm (range: 1–25). Up to 15 calyx stones (mean 3.46) were removed per patient. A complete stone clearance confirmed by postoperative X-ray imaging was achieved in all patients. The mean operative time was 149 min (range: 130–178). Mean hospital stay was 7 days (7–8). The urethral stent was removed after 4–6 weeks. Conclusions: Robotic management of UPJO and simultaneous flexible nephroscopy for removal of calyceal stones is an effective treatment in 1 session. Combining robotic surgery with flexible percutaneous renal surgery is a feasible, safe, and effective method of the treatment of UPJO and concomitant calyceal stones.

Robotic left lateral sectionectomy for hepatocellular carcinoma (HCC) on cirrhotic liver

Purpose: We present the case of a 82 years-old patient affected by HCV liver fibrosis with a diagnosis of a single resectable 2cm HCC of the superior border of segment II. The patient underwent a robotic left lateral sectionectomy. Method: Pre-operative work-up included liver MRI, thoracic CT-scan and blood exams. Child-Pugh score A5, MELD score 8, Platelet count normal, AFP within normal values. Gastroscopy was normal. After multidisciplinary discussion a liver resection was indicated using a robotic minimally invasive approach. Results: During intraoperative ultrasound, after excluding other missed lesions, careful evaluation of the tumor is done in order to precise the relationship with the terminal part of the left hepatic vein. Kelly clamp crushing technique is performed with assistant driven irrigation of the instrument. When dissection needs to be more precise an original use of cavitron ultrasonic surgical aspirator (CUSA), introduced in the assistant trocar and guided by the robotic arm. Final section of the hepatic vein is made with scissors after vascular clamping. A double 5/0 polypropilene running suture is performed to close the venous stump. The specimen is then extracted by a Pfannenstiel incision. There were no intraoperative complications, the post-operative course was uneventful with patient discharged at POD 4.Pathological findings: pT1 well-differentiated hepatocellular carcinoma (Edmonson-Steiner grade 1), with no vascular invasion, R0 (complete resection). Conclusion: Robotic liver resection allows a precise dissection, vascular suturing is more ergonomic because of the articulating instruments tip.

V10-02 ROBOTIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-02 ROBOTIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA Jeremy Archer*, Jonathan Pavlinec, Shavano Stedman, Tejal Patel, Sara Falzarano, and Li-Ming Su Jeremy Archer*Jeremy Archer* More articles by this author , Jonathan PavlinecJonathan Pavlinec More articles by this author , Shavano StedmanShavano Stedman More articles by this author , Tejal PatelTejal Patel More articles by this author , Sara FalzaranoSara Falzarano More articles by this author , and Li-Ming SuLi-Ming Su More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau disease (VHL) are risk of bilateral adrenal pheochromocytomas. Total adrenalectomy was historically the standard of care for patients with hereditary syndromes, but this leads to lifelong steroid supplementation. Adrenal-sparing surgery has been described in the treatment of adrenal incidentaloma, aldosteronoma, isolated metastasis, and the hereditary pheochromocytomas of MEN2 and VHL. Synchronous bilateral laparoscopic partial adrenalectomy with intraoperative ultrasonography has been described for pheochromocytomas as safe and technically feasible, but the majority of bilateral lesions have been treated by staged operations. We report our experience of synchronous bilateral robotic partial adrenalectomy for multifocal bilateral adrenal pheochromocytomas. METHODS: A 36-year-old female with marfanoid habitus and biopsy-proven medullary thyroid cancer was found to have bilateral adrenal masses on staging workup. Laboratory results showed elevated serum metanephrines, and she was started on alpha blockade with phenoxybenzamine. Imaging revealed a 3 cm right adrenal mass with a separate area of 1 cm irregularity and a 2 cm left adrenal lesion. Bilateral robotic partial adrenalectomies were successfully performed using a 4-arm technique with the daVinci Xi robotic platform (Intuitive, Sunnyvale CA) and a 12mm assistant trocar at the umbilicus. The patient was positioned in full-flank positioning for each side with docking from the same side of the room. The midline subxiphoid robotic 8mm and the 12mm assistant trocars were used for both portions of the operation. RESULTS: Enucleation of the tumors was performed with a total operative time of 330 minutes and estimated blood loss of 50mL. Pathology revealed three pheochromocytomas, and the patient was started post-operatively on a steroid taper. She was referred for genetic counseling given suspicion for MEN2B syndrome. CONCLUSIONS: Bilateral adrenal-sparing surgery for pheochromocytoma is safe and feasible and may be achieved using a robotic 4-arm technique with linear trocar configuration with repositioning. This approach in patients with genetic predisposition to synchronous adrenal lesions may preclude or delay the need for lifelong steroid supplementation. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e931-e931 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremy Archer* More articles by this author Jonathan Pavlinec More articles by this author Shavano Stedman More articles by this author Tejal Patel More articles by this author Sara Falzarano More articles by this author Li-Ming Su More articles by this author Expand All Advertisement PDF downloadLoading ...

Single-docking transperitoneal robotic-assisted nephroureterectomy: surgical techniques and outcomes

Objective To introduce and discuss the efficacy of a new technique to perform transperitoneal single-docking robot-assisted laparoscopic nephroureterectomy (RNU). Methods A total of 44 patients diagnosed with urothelial neoplasm of the renal pelvis or were investigated from January 2016 to November 2019. RNU was performed by a single surgeon. Among the 44 patients, 31 were male, and 13 were female. The median age was 63 (IQR: 58-71). The median body mass index (BMI) was 23.08 (IQR: 21.55-24.60) kg/m2. All operations were performed with general anesthesia. The patients were positioned 80 degrees flank with the diseased side up, and the head was tilted 10 degrees downwards. The camera port was placed one finger lateral to the umbilicus. For the right-sided tumors, robotic arm 1 was inserted through the trocar on the right pararectus line, 8 cm above the umbilicus, and robotic arm 2 was inserted through the trocar on the same line, 8 cm below the umbilicus. Assistant trocar 1 was placed where the anterior midline joins the perpendicular bisector of the camera port and robotic 2, and assistant trocar 2 was placed below the xiphoid process. For the left-sided tumors, all trocars were centrosymmetric to that of the right-sided tumors, except that assistant port 2 was placed 3 finger width above the pubic symphysis. The peritoneum was incised along the Toldt line, and the inferior vena cava was isolated (for left sided tumor, the abdominal aorta was isolated instead). The renal artery and vein were clipped with Hem-o-lok and ligated, and the kidney were isolated. The ureter was identified and isolated downwards across the common iliac artery and then clipped distal to the tumor site. The bladder cuff was resected and sutured under the laparoscopy. Results The median operation time was 145 (IQR: 130-175) min, with the median console time of 119 (IQR: 108.5-136.0) min, the anastomosis of bladder cuff of 12 min, and the median estimated blood loss of 50(20-100)ml. After the surgery, 6 Clavien-Dindo grade 2 complications occurred, including 2 chylous leakage, 1 hemostasis, 1 blood transfusion, 1 deep vein thrombus, and 1 acute coronary syndrome. The median length of stay (LOS) was 8 (IQR: 6.5-10.0) d. The median length of follow-up was 12 months. In total, 5 patients were dead, including 3 cancer-specific death. Four recurrence occurred and caused 3 death. The 2-year overall survival and progression-free survival were 68.2% and 77.9%, respectively. Conclusions The technique of RNU with simultaneous bladder cuff excision (BCE). Our technique improved the surgical outcome. The perioperative complication rate was low, and the short-term survival outcomes were satisfactory. Key words: Ureteral neoplasms; Upper tract urothelial carcinoma(UTUC); Nephroureterecto-my; Robotic surgery; Laparoscopic surgery

Robotic Revision Of A Post-Whipple Hepaticojejunostomy Stricture After Previous Open Pancreatoduodenectomy

Presenter: Zayne Belal | Texas Tech University Health Sciences Center Background: Hepaticojejunostomy (HJ) is one of the three anastomoses made during a pancreatoduodenectomy (Whipple) procedure. A rare complication of a HJ anastomosis is a stricture, which is often symptomatic with pain, jaundice, cholangitis and potential biliary cirrhosis. The recommended initial treatment for this complication is to first attempt percutaneous dilations of the stricture and then perform surgical stricture revision if the percutaneous dilations fail. In this video, we describe a robotic approach to a post-Whipple resection hepaticojejunostomy stricture revision. Methods: A robotic camera with 3 robotic arms and an assistant trocar were used for the procedure. The omental attachments to the free edge of the right liver were released until the hepatic hilum was exposed. The jejunal loop anastomosed to the bile duct was encountered and released from the surrounding attachments until the hepaticojejunostomy was fully identified and circumferentially dissected. The presumed bile duct portion of the HJ was grasped with robotic graspers to confirm the indwelling PTC tube and HJ. The HJ anastomosis was then opened over the PTC tube with electrosurgery until the tube was exposed. The tube was then retracted and the associated debris, stones and stricture were removed. The entire HJ was then taken down after the PTC tube was removed. The bile duct orifice was examined; it was thick-walled and measured roughly 7-8 mm in diameter. The HJ stricture scar was excised completely. The same jejunotomy was used for re-anastomosis. A new HJ was created with running posterior and anterior layers of 4-0 Vicryl sutures on RB-1 needles. The patency of the anastomosis was confirmed using a robotic grasper. The anterior and posterior sutures were then tightened and tied, completing the new HJ anastomosis. Surgical drain was placed around the HJ. Results: The procedure time was 195 minutes with an estimated blood loss around 50 mL. The patient had an uneventful recovery postoperatively, and was discharged on post-operative day 2. The patient is currently doing well at 9 months postoperatively and will be followed up as needed. Conclusion: Robotic hepaticojejunostomy stricture revision post-pancreatoduodenectomy feasible procedure. Previous open surgery should not contraindicate an attempt at minimally invasive repair if appropriate MIS/HPB skills and expertise is available.Robotic approach is had additional advantages in surgical dexterity due to increased range of motion/degrees of freedom, reduced surgeon fatigue and enhanced 3D visualization. Both access to a surgical robot and appropriately trained HPB surgeons are necessary to perform this procedure. This is often limited to large tertiary hepato-pancreato-biliary (HPB) surgery centers.

Simultaneous treatment of ureteropelvic junction obstruction complicated by renal calculi with robotic laparoscopic surgery and flexible cystoscope.

To present our experience of combining transperitoneal robot-assisted laparoscopic pyeloplasty (RALP) and concomitant flexible cystoscope lithotomy for ureteropelvic junction obstruction (UPJO) complicated by renal caliceal stones in the same session. Between October 2014 and November 2017, RALP combined with flexible cystoscope lithotomy was performed in 16 patients with UPJO and ipsilateral renal caliceal stones. Stone location and size were preoperatively assessed. After pyelotomy with appropriate length (about 8-15mm), a 16F flexible cystoscope through the assistant trocar or robotic trocar was introduced directly into the renal pelvis under laparoscopic vision. Holmium laser lithotripsy and pressure irrigation via a pump were used for caliceal stone removal. Subsequently, robot-assisted laparoscopic pyeloplasty was undergone in a standard fashion. The calculi sizes ranged from 5 to 34mm (mean 18.6mm) and an average of 3.4 stones per patient was removed (range 1-8 stones). Complete stone clearance confirmed by postoperative imaging was achieved in all patients. Mean operative time was 204.6min and estimated blood loss was 55.6mL. Mean hospital stay was 6.7days (3-17). The stent was removed after 8weeks. No major intraoperative or postoperative complications were noted during a mean follow-up of 10.4months (range 6-27months). RALP combined with flexible cystoscope lithotomy is safe and effective alternatives for the simultaneous management of UPJO complicated by renal caliceal stones.

Intraabdominal Trocar-Free Vacuum Liver Retractor for Laparoscopic Sleeve Gastrectomy (Video)

Retraction of the liver is essential in laparoscopic sleeve gastrectomy. Recently, a new internal liver retractor, the LiVac® device, has been introduced. The current video report (run-time 7:26min) seeks to demonstrate the efficacy and safety of the LiVac® trocar-free liver retractor in laparoscopic sleeve gastrectomy. The LiVac® retractor is inserted besides an abdominal trocar and uses the vacuum system of the operating room without the need for specific devices. The liver is retracted without the need of an assistant or extra trocars. The present case is a laparoscopic sleeve gastrectomy in a 30-year-old woman with morbid obesity (BMI 45.3kg/m(2)). The LiVac® retractor provided an excellent view of the operative field. No problems or device-related complications occured during the procedure. The LiVac liver retractor was easy to applicate in the presented case and provided a good exposure of the operative field.