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Proper positioning increases the working space by allowing the retroperitoneum to open purchase 100mg extra super levitra mastercard impotence guilt. All other steps of retroperitoneal positioning are the same as described for transperitoneal laparoscopic access purchase extra super levitra line erectile dysfunction yohimbe. For transperitoneal approaches generic 100mg extra super levitra overnight delivery erectile dysfunction doctor orlando, we prefer a similar position but with the 47 umbilicus positioned over the edge of the table Hand-assisted laparoscopic renal surgery 23 the patient position is the same as for transperitoneal renal surgery. Most surgeons apply a modified flank position at 70° or a full flank 90° position. As with “pure” laparoscopic transperitoneal cases, it is important that the patient be positioned at the edge of the surgical table to prevent the instruments and camera from striking the surgical table, which may significantly limit movement during the case. Prostatectomy the positioning for both pure laparoscopic and robotic assisted prostatectomy is similar. After the induction of anesthesia and appropriate vascular access is obtained, a nasogastric or an orogastric tube is placed. The Foley catheter is placed in sterile fashion after prepping and draping are complete. For robotic-assisted laparoscopic prostatectomy, the patient must be placed in a modified lithotomy position to allow the robot access to the surgical table. The head is placed in extreme Trendelenberg so that the intra-abdominal contents can be kept out of the pelvis. If the supine position is chosen, the thighs and legs should be slightly abducted to allow access to the perineum. Robotic Prostatectomy positioning When utilizing lithotomy position, the foot of the bed is dropped and the buttocks are brought to the end of the table. The legs are placed in the low lithotomy position with the ankle, knee, hip, and contralateral shoulder in line. The weight of the leg should rest on the heel rather than the back of the knee or the lateral surface of the lower leg, because this may cause popliteal artery 48 occlusion or peroneal nerve injury, respectively. The arm board increases the distance of the surgeon from the surgical field, thereby increasing the length he or she must reach across the patient and may further complicate intracorporeal suturing. For obese 25 patients, it may be necessary to place an arm board on the side of the table to support the arms. The drapes should be placed with the following boundaries: superiorly – epigastric area; laterally – patient‟s arms; inferiorly – anterior margin of the anus. The perineum must be exposed to allow a “perineal push” to advance the urethral stump into the surgical field during the vesicourethral anastomosis if necessary. Conversely, with retroperitoneal access, both the surgeon and the assistant stand on the dorsal aspect of the patient. The laparoscopic “tower” (shelves containing the insufflator, camera box, and light source), should be in the surgeon‟s line of view. The monitor should be place at a slight angle toward the surgeon, like reading a book. In new dedicated laparoscopic/endoscopic suites, the “tower” and the monitors are usually placed on booms originating from the ceiling. Thoughtful positioning of the booms will optimize the surgeon‟s view of the working monitor and the “tower” components.

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