Fig. 18.1
Configuration of operating room for robot, console, and instrument table
Patient Positioning
The patient is positioned in modified lithotomy position with legs abducted and slightly flexed. The patient’s arms are tucked along the side of the body, and pads are placed in possible pressure points. This position is fixed with a vacuum-assisted mattress device. Once the patient is secure, the patient is placed with a 15°–20° Trendelenburg position and with a tilt of 15° to the right side of the patient. After adequate patient positioning, we perform the robotic cart docking.
Port Placement and Robotic Position
Currently we are performing the robotic left colectomy with the following options depending on case selection and body habitus.
1.
Trocar placement for single docking (Fig. 18.2a, b)
Fig. 18.2
(a) Trocar placement for single-docking technique. (b) Configuration of operating room for robot, console, and instrument table for single-docking technique
This trocar placement configuration is best when using the da Vinci vessel sealer, which is wristed and provides the range of motion for the splenic flexure to be reached from the first and the third arms.
2.
Trocar placement for hybrid technique (Fig. 18.3a, b)
Fig. 18.3
(a) Trocar placement for hybrid technique. (b) Configuration of operating room for robot, console, and instrument table for hybrid technique
This trocar placement is used when anticipating pelvic adhesions and/or rectal surgery. The first portion of the procedure (splenic flexure takedown) is done laparoscopically, and then the second portion (pelvic dissection) is done with the robot docked from the left side.
3.
Trocar placement for double docking totally robotic approach (Fig. 18.4a, b).
Fig. 18.4
(a) Trocar placement for double-docking technique. (b) Configuration of operating room for robot, console, and instrument table for double-docking technique
With this trocar configuration the robot is docked at the left upper quadrant to start the mobilization of the splenic flexure. Once that is accomplished the robot is then docked at the left lower quadrant for the pelvic portion of the procedure.
Instrument Allocation to the Robotic Arms
Instrument arm 1 with monopolar curved scissors or da Vinci vessel sealer: docked to the RLQ port as a surgeon’s right hand
Instrument arm 2 with Maryland bipolar forceps: docked to the LUQ port as a surgeon’s left hand
Instrument arm 3 with bowel grasper: docked to the RUQ port as a surgeon’s second left hand
Initially, the surgeon makes an assessment of what seems easier either the medial or lateral approach. If the medial approach is chosen, the mesocolon over the inferior mesenteric artery (IMA) is retracted upwardly with the bowel grasper forceps. The peritoneum around the base of the IMA is incised and dissected with monopolar scissors. The periaortic hypogastric nerve plexus is carefully preserved. The left gonadal vessels and the ureter are identified and preserved. The IMA is divided near the root with Hem-o-lok® clips (Weck Closure System, Research Triangle Park, NC, USA) or with the da Vinci vessel sealer. The inferior mesenteric vein is identified by dissecting superiorly toward the ligament of Treitz and is divided near the inferior border of the pancreas.
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