After intubation and administration of general anesthesia the patient is placed in a lateral right or left decubitus position according to the side of the mass (Fig. 25.1).

The first optical 12 mm trocar is introduced midway between the umbilicus and the costal margin. After CO₂ insufflation, two 8 mm and one 15 mm robotic trocars are placed beneath the costal margin. The trocar placement should be configured to give enough space for the first assistant to use the suction-irrigator and the clip applier when necessary (Fig. 25.2). This is usually the most medial port for right-sided and the most lateral port for left-sided masses. In special circumstances such as obese individuals, or patients with short stature, the position of the first assistant port might need to be changed depending on the anatomy.

The robot is docked coming to position from the ipsilateral shoulder of the patient and robotic trocars are connected (Fig. 25.3). The table might need to be rotated clockwise according to the patient’s anatomy. Close cooperation with an experienced anesthesia team is very important for a fast docking.

For right adrenal tumors, first, the liver is mobilized by dividing the right triangular ligament. For left-sided tumors, the splenocolic and splenorenal ligaments are divided using electrocautery (Fig. 25.4a, b). Then, laparoscopic ultrasound is performed to identify the lesion and establish its relationship with adjacent organs. These steps are done laparoscopically. Then the robot is docked. The dissection is performed along the lateral and superior borders of the mass initially, followed the inferior and medial dissection (Fig. 25.5). The adrenal vein is divided either using the harmonic scalpel or between clips based on its size (Fig. 25.6). After the dissection is completed, the robot is undocked. The tumor is removed using a specimen retrieval bag and morcellated if >3 cm (Fig. 25.7). The operative site is irrigated and suctioned laparoscopically. Then, the trocars are removed. Fascial holes for the 12 mm trocar sites are closed, followed by skin closure.

The laparoscopic portion of the case includes the hepatic/splenic mobilization and extraction of the specimen steps. The robot is used for the dissection of the mass. We believe that this approach saves time and also determines the exact angle of approach for robotic docking.

After the intubation and administration of anesthesia on a gurney, the patient is placed in prone jackknife position on a Wilson frame (Fig. 25.8).

First, an optical trocar is inserted inferior to the 12th rib through a cm incision. Once in the Gerota’s space, this optical trocar is replaced by a balloon trocar and a potential space is created by inflating this trocar under direct vision (Fig. 25.9). The balloon dissector is then removed and this space is insufflated with CO₂. Two 5 mm trocars are inserted medial and lateral to the initial trocar.

The robot is brought in from the head of the table, between the shoulders, with the final alignment depending on the location of the adrenal gland (Fig. 25.10). The operating table might need to be rotated, depending on the patient’s anatomy.