Fig. 16.1
Port placement
The da Vinci camera port (12 mm) is placed 5 cm to the left of and 2.5 cm below the umbilicus. The distance to the symphysis pubis should be ~16–18 cm.
The da Vinci arm port ① (8 mm) is placed 7–8 cm below the left costal margin and on the left midclavicular line.
Fig. 16.2
Configuration of the operating room after docking the patient cart
The da Vinci arm port ② (8 mm) is placed on the midline and 4 cm above the symphysis pubis.
The da Vinci arm port ③ (8 mm) is placed 2–3 cm lateral to the midclavicular line and 2–3 cm above the anterior superior iliac spine.
The assistant’s port (5 mm) is placed 8–10 cm caudal and 1–2 cm lateral to the da Vinci arm port ①. This port is used for suction/irrigation, ligation, and additional retraction.
The distance between all ports should be at least 8 cm.
The location of the camera port should be consistent. The instrument arm ports need to be adjusted based on the tumor’s location (cecum to transverse colon) and the patient’s height.
Patient Cart Docking
The patient is placed in a Trendelenburg position and tilted to the left before introduction of the patient cart. This is positioned obliquely at the right upper quadrant of the abdomen. It is angled 45° from the perpendicular relative to the patient. The robot arms are docked to the trocars.
Figure 16.2 shows an overhead view of the recommended operating room setup for robotic right colectomy after introducing the patient cart. There should be a clear view of the patient from the surgeon’s console, a tension-free cable connection to the equipment, and clear pathways for the operating team to move freely.
The patient-side assistant is on the patient’s left side.
The scrub nurse is at the patient’s feet but can stand at the right side of an assistant surgeon according to the arrangement of the operating room.
The main assistant monitor is located at the right of the patient toward the feet.
An anesthesiologist is positioned at the head of the patient. Alternatively, an anesthesiologist can be positioned at the patient’s feet by fixing the lines of the ventilator along the operation table.
Surgical Techniques
A 0° endoscope, monopolar curved scissors (arm ①); bipolar Cadiere forceps (arm ②); and double-fenestrated grasper (arm ③) are used. Robot arm ① is used for dissection, robot arm ② for major retraction or countertraction, and robot arm ③ for minor retraction.
Fig. 16.3
Exposure of the peritoneal attachment by retracting the appendix and terminal ileum with the grasper in the robotic arm
Mobilization of Ascending Colon and Terminal Ileum
The small intestine is placed toward the left upper abdominal quadrant, and the inferior dissection starts at the retrocecal recess. This work is continued over the duodenum to the head of the pancreas. At the same time, the lateral attachments of the ascending colon are taken down starting at the right paracolic gutter and moving cranially to the hepatic flexure until the ascending colon is mobilized completely.
1.
Lifting and retracting the appendix and terminal ileum caudally and superiorly with the grasper in arm ③ provides major retraction to expose the peritoneal attachment along the right iliac vessels (Fig. 16.3).
2.
Additional exposure can be gained by retraction of the grasper in arm ② and by the assistant using a laparoscopic port.
3.
Dissection through the avascular plane between the ileocecum and the retroperitoneal layer is done with the monopolar scissors in arm ①. The right gonadal vessels and the ureter should be identified and preserved retroperitoneally.
4.
Lifting the mesentery of the terminal ileum exposes the avascular plane over the duodenum and the head of the pancreas (Fig. 16.4).
Vascular Control and Lymphadenectomy
When the colonic mobilization is completed, vascular control is initiated by placing the bowels in the normal anatomical position. The extent of any necessary vascular control depends on the tumor location, planned anastomosis location, and the patient’s anatomy. All lymph nodes and adipose tissue at the right side of the superior mesentery artery are removed sequentially from the ileocolic artery to the middle colic artery. The right colonic branches of the superior mesentery artery and vein are ligated with a Hem-o-Lok clip™ or sealing device (e.g., EndoWrist One Vessel Sealer™ or LigaSure™ or EnSeal™). Our recommendation for lymphadenectomy in this area is to maintain tension in the right mesocolon by elevating the ileocolic vessels using a grasper through arm ③ and in the middle colic vessels with a grasper through the assistant port while this procedure is being finished.
Fig. 16.4
Lifting the mesentery of the terminal ileum to expose the avascular plane over the duodenum and the head of the pancreas
2.
The ileocolic vessels are skeletonized up 1–2 cm above the root and ligated at 1–1.5 cm from the root (Fig. 16.6).
3.
Once the ileocolic vessels have been divided, lymphadenectomy is continued along the superior mesenteric artery to the root of right colic and middle colic arteries. Ligation of the right colic and middle colic vessels depends on the tumor location (Fig. 16.7).
4.
The assistant’s port can be used to introduce hemostatic instruments (e.g., clips, LigaSure™, or EnSeal™) for ligating vessels. The assistant can use a laparoscopic bowel grasper to push the middle colic pedicle superiorly for additional exposure to the superior mesenteric axis during lymphadenectomy.
Final Mobilization
After all vessels have been securely divided and lymphadenectomy is completed, the transverse mesocolon is opened just above the head of the pancreas to enter the lesser sac. The transverse mesocolon is divided from its root to the colon. The marginal artery and vein are controlled with clips or a sealing device. Colon mobilization is completed with partial omentectomy along the colon up to the resection site.
Ileocolic Anastomosis and Specimen Extraction
Two approaches can be used to create the anastomosis: extracorporeal and intracorporeal anastomosis. In an extracorporeal anastomosis, the mobilized right colon and terminal ileum are extracted through a 5–7 cm minilaparotomy. The skin incision is covered using a wound protector. Side-to-side anastomosis is created using a standard linear stapler. However, as generally used in a laparoscopic approach, extension of the camera port (normally a transumbilical incision) for extraction of specimens and creating an anastomosis is not indicated in the robotic approach because the camera port is far lateral to the umbilicus. This is why most surgeons prefer an intracorporeal anastomosis to the cosmetically inferior extracorporeal one.
Fig. 16.5
Robot arm ③ is used to lift up the ileocolic pedicle and perform a lymphadenectomy around the ileocolic vessels
Fig. 16.6
Division of the ileocolic vein
Intracorporeal Anastomosis
1.
For this, the mesentery of the ileum and transverse colon is divided at the selected anastomosis location. A sealing device is used for dividing the mesentery to control bleeding. The ileum is then skeletonized in preparation for anastomosis in a well-vascularized area.
2.
The monopolar curved scissors in arm ① are replaced with a needle driver. The transverse colon and ileum are approximated with double stay sutures placed near the planned enterotomy site. Additional single stay sutures are placed about 7–8 cm distal to the initial double stay sutures, approximating the free taenia of the transverse colon to the antimesenteric border of the ileum (Fig. 16.8). Monopolar curved scissors in arm ① are used to create enterotomies.
