It is best to choose port placement based on ideal location for the utilization for the robotic platform. Although such placement may result in suboptimal location during the laparoscopic portions, it is most important to ensure proper placement for the robotic arms to optimize the range of motion of the robotic instruments and to avoid collision during the pelvic portions of the procedure. The exact port placement varies based on patient body habitus; thus, the following should be use as a general reference. The frame of reference in the vertical plane is adjusted based on the distance between the umbilicus and the pubic symphysis, whereas the frame reference in the horizontal plane is based on the distance between the midline and the anterior superior iliac spines. The port placement consists of a 12-mm camera port, which is located 2 cm above and 2 cm lateral to the umbilicus. We prefer direct abdominal entry utilizing the OptiView^® (Ethicon Endo-Surgery, Cincinnati, OH) bladeless trocar; however, the use of the Veress needle or other entry techniques is appropriate based on surgeon experience and preference. The additional ports are not placed until pneumoperitoneum is established and laparoscopic exploration is performed. This is important for three reasons: first, unexpected findings such as metastatic disease can be evaluated; second, adhesions at proposed port sites can be taken down before port placement; third, by establishing the pneumoperitoneum and enlarging the surface area of the abdominal wall, the port placement will be optimized. A total of three 8-mm ports for the robotic arms are then placed and the assistant 12-mm port as shown in Fig. 20.2. Port 1 is placed along in the right lower quadrant along a line between the anterior superior iliac spine and the camera port, at distance of 8 cm of separation from the midline in the horizontal plane (Fig. 20.2). Port 2 is placed at a variable height above the level of the camera port 1–2 cm above the camera port at the level of 8 cm in the horizontal plane. Port 3 is ideally placed 2 cm above the anterior superior iliac spine and 8 cm from port 2 in the horizontal plane (Fig. 20.2). However, the latter is the most difficult port placement to master and the one with highest variability: on one hand it has to be placed laterally in order to provide 8 cm of horizontal clearance with respect to port 2; on the other hand if placed far laterally, the iliac bone will impede instrument reach into the pelvis.

In our institution, we perform the left colon mobilization utilizing a medial-to-lateral approach. The lateral attachments of the colon help with retraction and dissection in the retroperitoneal plane, which allows early identification of the ureter and vascular structures. The procedure commences with laparoscopic exploration and, if needed, lysis of adhesions. The small bowel is retracted to the right of the midline and ligament of Treitz is identified. This is the initial stem and can be cumbersome, especially in the obese; however, this exposure is essential and must be performed to successfully initiate the procedure. Exposure is facilitated with right tilt (left side elevation) and slight Trendelenburg with traction of the small bowel superiorly out of the pelvis as well. With this exposure, the inferior mesenteric vein is readily identified running parallel to the ligament of Treitz before it enters deep to the pancreatic body (Fig. 20.3a). At this level, the medial peritoneum is incised just inferior to the vein, and the retroperitoneal plane is established using a triangulation lift technique (Fig. 20.3a, b, c). The inferior mesenteric vein is divided (Fig. 20.3d) and the retroperitoneal plane fully developed (Fig. 20.4a). Proper dissection in the retroperitoneal plane of dissection is carried superiorly along the inferior border of the pancreas, laterally to the white line of Toldt, and inferiorly to the level of the takeoff of the left colic artery from the inferior mesenteric artery. One will often be able to identify the ureter in this plane as well.

Once the retroperitoneal plane is fully developed (Fig. 20.4a), attention is then drawn to the gastrocolic ligament, which is detached from the colon at the level of the distal transverse colon (Fig. 20.4b). The lesser sac is entered and the splenic flexure takedown is performed (Fig. 20.4b, c, d). When maximum exposure and reach have been achieved, attention is drawn to the descending colon (Fig. 20.5a, b), which is released from the peritoneal attachments (white line of Toldt) in a caudal to cranial direction and the splenic flexure mobilization is then completed in this direction.

Once the left colon is mobilized, the patient is placed in steep Trendelenburg position with the left side elevated, the laparoscopic instruments are removed and the robotic instruments are placed and the robotic cart is then docked. It is important to recognize that once the robotic cart is docked, further patient position modifications are precluded.

The robotic cart is ideally docked in left side of the patient, in an acute angle (Fig. 20.6). Alternatively, some prefer robotic docking between the patient’s legs; however, this patient-cart configuration hinders access to the perineum, which is needed for a transanal approach or transanal specimen extraction, unless the robot is undocked. Furthermore, we do not recommend complete robotic undocking as we favor to perform the anastomosis under direct robotic visualization, since the dexterity and maneuverability provided by the robotic instrumentation would afford a more reliable suture repair in cases in which an anastomotic defect is encountered.

The robotic pelvic segment of the procedure is commenced with retraction of the small bowel superiorly out of the pelvic cavity. The rectosigmoid is retracted anteriorly with the utilization of the third robotic instrumentation arm, and the peritoneum is incised medially at the level of the sacral promontory, and the retroperitoneal plane is identified (Fig. 20.7). Careful and meticulous dissection in this plane is paramount to remain in the proper plain and avoid injury to the hypogastric nerves and iliac vessels. Once the plane is developed, the left ureter is identified and the tissue planes are further developed. The superior rectal artery is readily visualized and is lifted to facilitate ongoing dissection in the retroperitoneal plane (Fig. 20.7d). The extent of the plane is carried out laterally to the peritoneal reflection, inferiorly to the presacral plane, and superiorly to the confluence of the superior rectal and inferior mesenteric artery (Fig. 20.8). At this level, continuity is established with previously exposed retroperitoneal plane during the laparoscopic portion of the procedure, thus fully exposing the anatomy of the pedicle. This exposure results in the “eagle sign” with the superior “wing” representing the left colic artery, the inferior “wing” representing the superior rectal artery, and the “body” representing the inferior mesenteric artery (Fig. 20.8a). The inferior mesenteric artery is then divided with the use of an endoscopic stapler or energy device placed through the assist port or with robotic application of clips (Fig. 20.8b). The third arm now elevates the divided portion of the pedicle to expose any remaining retroperitoneal attachments, which are then readily divided. Attention is then drawn to the lateral attachment, which is then divided from the level of the laparoscopic dissection to the upper portion of the rectum.