As an alternative, open laparoscopic entry (Hasson technique) or visual entry systems (Optiview/Visiport) can be used per surgeon’s preference. A total of four ports (three robotic ports and one assistant port) are placed as shown in Figs. 17.2 and 17.3.

An extra long 12 or 8.5 mm periumbilical port for the camera is placed. Usually 2 cm below and 2 cm lateral to the umbilicus (depending on the patient’s body habitus). A left upper quadrant and suprapubic 8 mm robotic trocars are placed for arms 1 (R1) and 2 (R2). Five mm robotic trocars and arms can be used, but this limits the instrument options and degrees of articulation with today’s available instrumentation, and, therefore, we prefer 8 mm ports at this time. In cases of polyps or tumors, the lesion is localized prior to docking the robot using a 5 mm laparoscope, which is always available. The table is then positioned in 10–20° of reverse Trendelenburg and 20–30° of right side up to allow the small intestine to fall away from the midline. The robot is docked from the patient’s right side or over the right shoulder. The robotic camera is inserted through the 8.5 mm periumbilical port. The assistant surgeon uses a lateral 12 mm port to introduce laparoscopic instruments, energy devices, and endoscopic staplers and suction as needed. Using the bipolar fenestrated grasper (R2) and the hot shears (R1), a medial-to-lateral dissection is realized. First, the assistant surgeon grasps the ileocecal junction to place the ileocolic vascular pedicle on tension. It is critical to identify the cecum and ileocecal junction; this step cannot be overemphasized. A small window is created posteriorly near the origin of the ileocolic vessels. The dissection is continued for 2–3 cm to reveal the duodenum. Typically, the duodenum identifies the origin of the ileocolic artery. A second window is created to isolate the base of the vascular pedicle. It is divided at the level of the duodenum with a vascular stapler, clips, or energy device, which are brought in through the left lateral 12 mm assistant port.

The medial-to-lateral dissection is continued. The right mesocolon is mobilized off the retroperitoneum. This dissection is mostly blunt and accomplished by pushing the mesocolon anteriorly and the retroperitoneum posteriorly. This can be advanced to the lateral attachments, to the liver and hepatic attachments, and to the duodenal sweep as needed. The ileal mesentery is divided with an energy source or cautery to a point 8–10 cm from the ileocecal valve. Typically, two small vessels or branches will be encountered and can be divided with the energy device. The mesocolic mobilization is then carried up to the duodenum and the transverse mesocolon. The terminal ileum is transected with an endoscopic stapler. Next the right branch of the middle colic is identified and transected with the energy device or stapler. The ascending colon can be left attached to the right paracolic gutter to keep it from falling medially or completely detached and the specimen placed above the liver for later retrieval (if the resection is for cancer, the specimen is placed in a bag). Lateral mobilization begins at the ileocecal junction along the right paracolic gutter and advanced to the hepatic flexure and along the right transverse colon. Sometimes omentum is removed with the specimen. Usually, the omentum is partially detached from the colon by dividing the gastrocolic ligament. The transverse colon is isolated by creating a mesenteric window and then divided with the endoscopic stapler.

Next, attention is turned to construction of an isoperistaltic, side-to-side anastomosis. For this purpose, the terminal ileum and the transverse colon stump are brought together side by side as shown in Fig. 17.4a, b.

A 20 cm nonabsorbable suture on a Keith needle is used to put a stay suture approximating the transverse colon and terminal ileum up to the abdominal wall to provide tension and elevate the site of the anastomosis (Fig. 17.5).

Prior to creating the enterotomies, an endoscopic intestinal clamp (bulldog) can be placed on the terminal ileum to prevent spillage. Using an energy device or hot shears, a colotomy and ileotomy are created (Fig. 17.6) through which the jaws of the endoscopic linear stapler are introduced to construct the common channel (Fig. 17.7).

The remaining common enterotomy is then closed with 2-0 Vicryl in two running layers using robotic suturing techniques (Fig. 17.8a, b).

Once complete, the stay suture is cut, and then attention is directed again to the specimen. As an alternative, a complete robotic-sewn anastomosis can be fashioned. If necessary, the remaining lateral and hepatic attachments are freed. A grasper with teeth or endoloop is introduced through the 12 mm left lateral port to hold the specimen (usually by the transected terminal ileum), and the robot is undocked. The 12 mm assistant port incision is then enlarged. Usually a 3–5 cm incision is necessary depending on the size of the pathology. A wound retractor is placed to protect the skin, and the specimen is extracted. The extraction incision site can be placed in the suprapubic region or at any site per surgeon’s choice as shown in Fig. 17.9a, b.

Finally, laparoscopy can be performed to visualize the anastomosis and confirm hemostasis. It is not necessary to close the mesentery defect in most cases. The extraction site is closed in two layers. Any 12 mm port site incisions are closed. The skin is closed in subcuticular fashion (Fig. 17.10).

A summary of the critical steps is shown in Table 17.1.

(See Figs. 17.11, 17.12, 17.13a, b, 17.14, 17.15, and 17.16a, b.) The first robotic right colectomies described were hybrid, in other words, an extracorporeal anastomosis was utilized. When we perform a robotic-assisted right colectomy with an extracorporeal anastomosis, the mobilization, devascularization, and transection are performed under robotic guidance. The specimen is brought out through an extraction site, and the anastomosis is realized through this same wound. We found it useful to perform right colectomies in hybrid fashion early in our learning curve. Specifically, our first four right colectomy cases were performed in this fashion emulating our laparoscopic technique. However, inspired by the robotic platform, we have since performed 50 robotic colectomies with intracorporeal anastomosis. Table 17.2 summarizes our experience with robotic colectomy with intracorporeal anastomosis.