Troubleshooting in Robot-Assisted Surgery with Retroperitoneal Approach

<p>  In urologic surgery, it is helpful to have options for surgical approaches in terms of the indication for surgery, ease of the procedure, and mitigation of surgical complications. As to conventional laparoscopic surgery, there are some differences between the transperitoneal and retroperitoneal approaches, such as the width of the working space, the number of anatomical landmarks, and the risk of damage to surrounding organs. Robot-assisted surgery has improved some of the drawbacks of the retroperitoneal approach. In general, the transperitoneal approach has been selected for most cases of RARP. In contrast, the retroperitoneal approach is practical in cases where the transperitoneal approach cannot be chosen because of difficulty in 30-degree head-down tilt due to comorbidities or a history of abdominal surgery. In addition, since the degree of difficulty in dissection around and excision of the tumor differs greatly depending on the tumor location in RAPN, it is necessary to be familiar with both approaches.</p><p>  In contrast, a more skillful technique is required to operate forceps in the limited space of the retroperitoneum. It should also be noted that with the opening of the peritoneum, pneumoperitoneum may cause further narrowing of the working space, where bleeding may impair the visual field. In this article, we describe the current status and innovations regarding the port placement, expansion of the retroperitoneal cavity, and intraoperative procedures during the retroperitoneal approach in RARP and RAPN, as well as outline the points to note and countermeasures for intraoperative troubles. It is a prerequisite to avoiding troubles through adequate presurgical planning and simulations to anticipate possible troubles and select safe and reliable troubleshooting methods.</p>