Hybrid Robotic and Fully Robotic Procedure

Cigdem Benlice

Emre Gorgun

INDICATIONS/CONTRAINDICATIONS

Since the introduction of laparoscopic colectomy, colorectal surgery practice has dramatically changed over the past three decades by growing use of minimally invasive techniques. Minimally invasive techniques have improved postoperative recovery and reduced morbidity and length of hospital stay after colorectal surgery compared to open surgery.

Surgical resection remains the most important treatment modality in the management of rectal cancer in terms of curative resection, staging, prognosis, and subsequent therapeutic decisions. However, rectal cancer surgery is technically challenging because of the limited boundaries and the complex nature of the pelvis with close proximity to the presacral veins and autonomic, sexual nerves and organs. Challenges during rectal surgery, however, are likely magnified when the additional difficulties of the laparoscopic technique are added to the procedure because of the ergonomic limitations of the instruments. The laparoscopic surgeon is required to undertake the same multi-quadrant operations as open surgery but with limited tactile feedback under the two-dimensional visualization that reduces in-depth perception as well as hand-eye coordination.

Accordingly, two recent randomized trials, the American College of Surgeons Oncology Group (ACOSOG) Z6051 and Australasian Laparoscopic Cancer of the Rectum (AlaCaRT), failed to prove non-inferiority of the laparoscopic technique for rectal cancer. Interestingly, Fleshman et al. stated in the discussion of the ACOSOG trial that one explanation for their findings is that proctectomy is challenging at baseline, and it can be even more difficult to work in the deep pelvis with in-line rigid instruments from angles that require complicated maneuvers to reach the extremes of the pelvis. They also continued to state that it is possible that modification of instruments or a different platform such as robotics will improve efficacy of minimally invasive techniques. Furthermore, they indicated that wristed instruments may provide the needed control in the deep pelvis and placement of instruments in line with sidewalls of the pelvis and remote control of these instruments provide ergonomic feasibility to perform minimally invasive resection. Essentially, these are characteristics of the existing robotic platform and this justifies further investigation in the field.

Indeed, the robotic approach is an emerging technique in the setting of colorectal surgery. Three-dimensional visualization, endo-wristed instrumentations, tremor reduction, ergonomics, and physical comfort for the surgeon are several advantages of robotic surgery (RS) over laparoscopy.

There is still debate whether this technology will translate into clinical efficiency and value of care. This chapter discusses the role of robotic approach on low anterior resection by focusing on rectal cancer surgery and describes various approaches in robotic restorative proctectomy.

PREOPERATIVE PLANNING

Proper patient selection is crucial to preoperative planning, and patients should be both medically fit and able to tolerate minimally invasive surgery. All patients should undergo a detailed history and physical examination. Preoperative full colonoscopy is recommended for all patients with rectal lesions, especially for identification of tumor location and possible synchronous colorectal lesions. As part of the preoperative preparation for rectal surgery, patients should undergo a mechanical bowel preparation with oral antibiotics. In our practice, mechanical bowel preparation and oral antibiotics are compulsory to sustain low postoperative surgical site infection. Preoperative broad-spectrum intravenous antibiotics are given within 60 minutes of the incision time, to ensure adequate concentration
at the outset. Deep venous prophylaxis should include the use of sequential compression devices, as well as chemical prophylaxis (preoperative heparin).

Preoperative antibiotics are administered on the basis of the Surgical Care Improvement Project-related measures. Rectal irrigation and washout with saline is performed in rectal cancer cases. A Foley catheter and an intraoperative orogastric tube are placed in all cases during the operation.

SURGERY

The da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA), first introduced in 1999, is the sole robotic surgical system currently commercially available in the United States. It was first approved by the Food and Drug Administration for use in the United States in 2001. The initial prototype had three arms; in 2003, the company introduced a newer version with a fourth arm. Since then there has been three generational upgrades: the da Vinci S in 2006, the da Vinci Si in 2009, and the latest generation, the da Vinci Xi, which was introduced in 2014 (Fig. 17-1).

The system is comprised of three main components (Fig. 17-2):

Surgeon’s console
A patient-side robotic cart with four robotic arms (one for the camera and three for surgical instruments) that are manipulated by the surgeon at the console
High-definition three-dimensional vision system, controlled by the operating surgeon

Robotic systems were originally designed to allow dissection in confined spaces and have been widely used for prostatic surgery with good outcomes. Thus, the robotic approach became attractive in colorectal pelvic surgery explicitly in the management of rectal cancer surgery. Because restorative proctectomy requires a tension-free anastomosis, splenic flexure mobilization is generally required. The need for colonic mobilization separates robotic rectal surgery from prostatectomy, where extension of the operative field is required outside the confined pelvic space. However, limited range of motion of the robotic arms and surgical field compromising multiple quadrants challenge adeptness and efficiency of robotic rectal surgery, especially when using the previous robotic platforms such as the da Vinci S and da Vinci Si systems. To overcome these limitations, several techniques have been described for robotic restorative proctectomy: hybrid (with laparoscopic splenic flexure mobilization), fully robotic with single docking ([da Vinci Si: generally exchanging the second and third robotic arms for different parts of the surgery] or [da Vinci Xi]), or fully robotic with double docking (first docking from the left upper quadrant for splenic flexure mobilization and then docking to the left lower quadrant for the rest of the procedure) (Fig. 17-3A and B).

FIGURE 17-2 Operating room setup for robotic rectal surgery.

FIGURE 17-3 Operating room setup for (A) rectal surgery and (B) splenic flexure mobilization.

Operating Room Setup

Using both da Vinci Si and Xi Surgical Systems for the robotic restorative proctectomy, the patient is placed in a modified lithotomy position using adjustable lithotomy stirrups. The assistant surgeon remains on the right side of the patient to assist the console surgeon through one or two additional laparoscopic assistant ports. The operating room design during robotic splenic flexure mobilization is shown in Figure 17.3B. For procedures requiring pelvic dissection, the robot is typically docked at a 45 degree angle from the patient’s left side.

Patient Positioning

The patient should be correctly positioned on the modified lithotomy position, which allows access to the anus for the numerous purposes including intraoperative CO₂ colonoscopy and/or using circular stapling device. Intraoperative flexible sigmoidoscopy with CO₂ has been used in our practice for both tumor location and anastomotic evaluation. The lithotomy position provides additional space for the surgical team, especially when operating in the upper quadrants of the abdomen, by standing between the patient’s legs (Fig. 17-4). Padded stirrups or yellow fins are used and attention is given to preventing peroneal nerve injury. Both arms are tucked at the patient’s sides. A gel pad on the operating table can provide additional decubitus support and stability against extremes of table tilting. Changes in operation table position and subsequent patient sliding can lead to the stirrup applying
pressure to the posterior aspect of the lower extremity and constitutes risk for nerve injury. Thus, we prefer to secure patients on the operating table with a strong tape anteriorly surrounding the chest to prevent them from sliding during steep table positions.

FIGURE 17-4 Demonstration of the modified lithotomy position in robotic rectal surgery.

FIGURE 17-5 Demonstration of the trocar placement in robotic rectal surgery.

Port Placement and Docking

To perform robotic restorative proctectomy, five to six ports are required, including camera and assistant ports. Figure 17-5 shows the port placement for three robotic arms, camera, and assistant ports. When using the S or Si generations, a 12-mm camera port is placed in the supraumbilical area with an open technique. An 8-mm port is placed in the left lower quadrant lateral to the umbilicus 10 cm apart; two additional 8-mm ports are placed, one in the right upper and one in the right lower quadrant. One assistant port is inserted on the right lateral to the robotic ports and in equal distance from the right upper and lower quadrant trocars. A right upper quadrant robotic port (port 3) is used for the splenic flexure mobilization and left colectomy. An additional robotic port (port 3P) is placed in the left-mid abdomen, lateral to the edge of the rectus muscle. This port, 3P, is used for pelvic dissection (anterior resection, low anterior resection, abdominoperineal resection procedures). The assistant port can be used for small bowel/colon retraction and suction irrigation. After the da Vinci patient cart is docked as described, the arms are arranged according to Figure 17-2. For the purpose of the splenic flexure mobilization, monopolar curved scissors (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA) is inserted through right lower quadrant port (port 1). A bipolar grasper (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA) is inserted from the right upper quadrant port (port 3). A Cadiere grasper (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA) is placed at port 2 left to the camera port. Typically, the assistant instrument is entailed of a laparoscopic bowel grasper or suction.

Technique

Following pneumoperitoneum, the camera is inserted and additional trocars are placed under direct vision. The robot is docked using the two right-sided robotic trocars (8 mm and 8 mm) and two left-sided robotic trocars. The patient then is positioned in the right side down and slight Trendelenburg to facilitate displacement of the small bowel and the cecum out of the pelvis. At first using the robot, a medial-to-lateral mobilization of the left colon is accomplished and this is our preferred approach. However, depending on the comfort level of the surgeon, a lateral approach can also be utilized.

Important Steps for Mobilization of the Splenic Flexure and the Left Colon (Applies to Both Hybrid and Total Robotic Approaches)

We perform medial-to-lateral dissection and mobilization using embryologic planes between the mesocolon and the retroperitoneum (Video 17-1). The next steps in our novel splenic flexure takedown technique are as follows: