Camera and trocar placement for robot-assisted radical and partial nephrectomy: which configuration provides optimal visualization and instrument mobility?

Proper camera and trocar placement is critical to the success of minimally invasive procedures. For robot-assisted renal surgery, two basic trocar configurations have been described. The medial approach, using a 30° downward-angled lens mimics a traditional transperitoneal laparoscopic configuration. An alternative configuration, using a 0° or 30° upward-angled lens approach locates the camera laterally, evoking a position sense similar to a retroperitoneal approach. Our objective is to compare the differences between these two standard approaches for robot-assisted renal surgery. After performing a review and analysis of available literature, our group tested both the medial and lateral camera approaches during robotic renal surgery performed in human patients. The medial approach provides a wide field of view, because of the relatively greater distance to the target structures and a horizon line closer to the patient's midline. The lateral configuration offers significantly different visualization. The relative proximity to the target structures and a higher horizon line results in a comparatively restricted field of vision. Instrument mobility is comparable between the two approaches. Meta-analysis of the literature reveals that both approaches provide comparable overall operative times for both radical and partial nephrectomy, though there is a trend towards shorter overall operative times for partial nephrectomy performed through a medial approach. The medial trocar configuration provides a familiar working environment for both surgeon and assistant; the wide-angle view enables enhanced visualization of surrounding structures and tracking of the instruments inserted by the assistant. The lateral approach offers the potential advantage of a closer view of the kidney, but does so at the expense of a significantly restricted field of view. In our experience, a medial trocar configuration offers significant advantages over the lateral trocar configuration, and is, therefore, the standard approach at our high-volume center.