A 12 mm × 130 mm Applied Kii^® balloon blunt tip system (author preference) is placed in the right middle quadrant using an open technique, lateral to the rectus sheath, a 0° laparoscope is introduced, and the abdomen is explored. Some authors prefer midline camera placement for aesthetic benefit, but in this author’s experience, camera proximity to the root of the IMA may be an issue during medial-to-lateral dissection if the port is placed midline. If an ileostomy is likely, this location can be used for the camera port. Before any further port placement, it is useful to identify the location of intra-abdominal adhesions, the extent of colon redundancy, splenic flexure position, and the location and extent of the pathology to be addressed. Advantages and disadvantages of medial-to-lateral and lateral-to-medial dissection are considered based on the patient’s anatomy and pathology. The patient is placed in Trendelenburg position with the right side of the patient tilted toward the floor. The goal is for the abdominal contents to clear out of the pelvis allowing the medial aspect of the rectosigmoid mesentery to become visible and accessible.

Ports are placed according to Fig. 12.2, with minor adjustments based on the findings of the laparoscopic exploration. This port placement is intended for a single-dock procedure. Port 1 (P1) is placed in the right lower quadrant (RLQ ), more cephalad for lower pelvic cases and more lateral for rectosigmoid pathology. Using an 8 mm port nested in a 12 mm port allows use of both standard instrumentation and the da Vinci EndoWrist Stapler. Placement of P2 in the right upper quadrant (RUQ ) enables it to be useful both during the pelvic dissection and mobilization of the left colon including the splenic flexure. Placement of P3 in the left middle quadrant (LMQ ) allows it to be useful primarily during the pelvic phase, but if placed medial enough (i.e., midclavicular line), it will also be useful during sigmoid colon mobilization. The assistant port (A1) is placed lateral to the camera port, along the right anterior axillary line. Modifications to this set-up include:

Again, taking a few moments to laparoscopically assess at the beginning of the procedure will allow the surgeon to modify port placement according to the specifics of the patient’s anatomy, to plan single or double-docking, medial or lateral approach, and consider other potential operative issues before docking and sitting down at the surgeon’s console.

For single-docking RobLAR, the patient cart is docked over the left lower corner of the operating room table, with the legs of the patient cart straddling the corner of the table. For lower pathology, the patient cart is parallel to the patient’s left lower extremity; for higher pathology, an angle more perpendicular to the patient’s body is preferred. For double-docking, the splenic flexure mobilization is best achieved with the patient in reverse-Trendelenburg and docking at a 45° angle over the patient’s left shoulder.

Many surgeons prefer to dissect with the Monopolar Curved Scissors via R1P1, while others utilize ether a Monopolar Cautery Hook or Spatula. The scissors is quite efficient at opening the peritoneum, dissecting around vessels, developing avascular planes along the line of Toldt, developing the “golden plane” posterior to the rectum, and incising Waldeyer’s and Denonvilliers’ fascia. In addition to dissecting with the tip of the scissors, the flexed heel is excellent for providing exposure in an atraumatic fashion.

At times, the monopolar instrument can be swapped for the da Vinci EndoWrist One Vessel Sealer , which is particularly useful for blunt dissection and ligation of mesenteric vessels in obese patients. The vessel sealer uses bipolar energy (radiofrequency) and compression force to weld tissues together and seal. It has a 20 mm jaw length with 16 mm of sealing surface and 13 mm of cut length. It has computer-controlled closing pressure, minimal thermal spread of 1–2 mm, >600 mm HG burst pressure and independent seal and cut functions [54]. When needed, one can remove the 8 mm trocar nesting in the 12 mm sleeve, enabling P1 to be used for the da Vinci EndoWrist Stapler. The EndoWrist Stapler’s “smart-clamp technology” takes a series of measurements and provides audio and visual feedback prior to firing. If the stapler detects inadequate jaw closure for a proper “B-staple form”, firing is prevented and the surgeon is obligated to open and re-clamp the tissue until appropriate parameters for safe transection are met [55]. Data is lacking, but early experience suggests this may help surgeons avoid forcing a stapling that should not occur. The Fenestrated Bipolar Forceps is used via R2P2 and the Cadiere via R3P3. The EndoWrist One Suction/Irrigator and/or EndoWrist Grasping Retractor may be helpful, particularly during the pelvic dissection. At times it is helpful for the assist to suction and the surgeon to use an arm to retract, whereas in other circumstances, the reverse is true – the approach should be individualized to the particular situation, and creative thinking and flexibility is required from the surgeon. Appropriate instrument selection and attentiveness are critical to avoiding bowel injury during the procedure. Whereas Fenestrated Bipolar Forceps and Cadiere Forceps are considered safe for grasping the colon and small bowel, the ProGrasp™ closes with a higher compression force which increases the risk of serosal injury.

A standard disposable 5 mm port is often used as A1, although a 12 mm port allows the assistant surgeon to utilize laparoscopic endostaplers available from Covidien or Ethicon. Another option, which this author prefers, is to use the AirSeal system (available in 5 mm, 8 mm and 12 mm), which maintains stable pneumoperitoneum and efficient smoke evacuation, including during proctotomy or vaginotomy.

First, the surgeon uses the Fenestrated Bipolar Forceps and the assistant uses an atraumatic bowel grasper (author preference Epix laparoscopic grasper) to retract the left colon and sigmoid colon medially. Dissection along the Line of Toldt is carried out proximally up to the splenic flexure and distally to the upper 1/3 of the rectum, being careful to identify and preserve the left ureter. Fine dissection is possible with the Monopolar Curved Scissors. When significant progress has been made, the Cadiere is used to retract the rectosigmoid anteriorly and laterally so as to put the medial peritoneum on tension. The peritoneum is incised with the Monopolar Curved Scissors, which allows CO₂ insufflation to enter the retroperitoneum and reveal the plane between the mesorectal fascia and presacral fascia. This avascular plane is sharply dissected with the Monopolar Curved Scissors (see Video 12.1). Posterior mobilization of the rectum is performed with the scissors and bipolar forceps using the “Saturday Night Fever” move (described below). The inferior hypogastric nerves and, distally, the pelvic nerve plexus are identified and preserved. Dissection proceeds until retraction is no longer sufficient, then the right lateral attachments are divided in a similar fashion. During this phase of the procedure, it is helpful to bring the third arm posterior to the rectum and use it to push the rectum anteriorly. It is now easy to continue dissecting in the posterior plane, down to the levator muscles if needed. Final attachments along the right side and right posterolateral aspect may be divided in the low pelvis with the same exposure. Throughout this phase, the assist should evacuate smoke, suction bleeding, and/or provide atraumatic retraction.

Next, the surgical assistant uses an atraumatic grasper to pull the rectum cephalad and right, the Cadiere is used for lateral wall counter-traction or to assist with pushing the rectum to the right, and the surgeon dissects down the left side using the scissors and bipolar forceps. As progress is made, the Cadiere is shifted to provide anterior counter-traction by pushing up and out on the vagina (or seminal vesicles), enabling completion of the dissection from the left posterior pelvis to the left anterior plane. Lastly, the assistant retracts the rectum cephalad and posterior, while the surgeon dissects anteriorly, connecting the two lateral dissections. Again, the Cadiere is used to provide counter-traction by pushing the anterior pelvic organs “up and out”. When transecting the mesorectum, the scissors is quite useful for scoring the mesorectal envelope and dissecting around mesorectal vessels, while the bipolar forceps and vessel sealer are efficient for transecting the vessels.

Division of the large intestine can be achieved with standard laparoscopic stapling devices, of which there are multiple vendors, lengths, staple-heights, and handle systems. The da Vinci EndoWrist Stapler is preferred by some surgeons as it allows precise placement and fine adjustments to be in the hands of the operating surgeon. The EndoWrist Stapler offers 108° of lateral articulation and 54° of vertical articulation. At the time of this writing, staple loads of 45 mm length are available with two options for staple height: A blue load is 3.5 mm open and 1.5 mm closed, while a green load is 4.3 mm open and 2.0 mm closed. At times, two or three “fires” are required to completely transect the rectum, a change in practice for many surgeons accustomed to striving for a single staple line with no junctions. Although there are data that suggest increased complications at the anastomosis may occur with numerous firings of laparoscopic stapler [56], no clinical data exist regarding outcomes after multiple fires of the EndoWrist Stapler.

This step may be accomplished before dissection of the lateral attachments or the pelvic dissection, or as part of either of those steps. The Cadiere is used to retract the rectosigmoid anteriorly and laterally, exposing the IMA at its origin from the aorta. Monopolar Curved Scissors and Fenestrated Bipolar Forceps (or Maryland Bipolar Forceps ) are now used to dissect the mesocolic tissues around the base of the IMA. The left ureter and aortic hypogastric nerve plexus are clearly visualized and protected during this dissection due to the superior image afforded by the da Vinci system. The IMA is divided with a Large Clip Applier or EndoWrist Stapler, and medial to lateral dissection may proceed up to the inferior border of the pancreas (see Video 12.2).

The surgical assistant can retract the colon superiorly (anteriorly) by positioning an instrument posterior to the mesocolon and lifting. The inferior mesenteric vein (IMV ) is selectively transected close to the fourth portion of the duodenum, with either the Large Clip Applier, vessel sealer, or bipolar forceps. Dissection continues medial to lateral until the left colon is free from the retroperitoneum. The left ureter and gonadal vessels are identified and preserved. Although this author finds complete mobilization is needed in fewer than 20% of these procedures, if further mobilization of the splenic flexure is required, re-docking over the LUQ with the patient in reverse Trendelenburg is helpful with repositioning of the robotic arms according to any of the appropriate set-ups described above. The omentum is retracted by rolling it over the transverse colon, allowing its weight to fall cephalad, thus exposing the correct plane. The scissors or vessel sealer can be used to develop a plane between the transverse colon and the omentum. During this phase the assistant retracts caudad on the colon while the surgeon uses the bipolar forceps for micro-retractions of the omentum. The omentum is completely separated from the transverse colon, followed by division of the splenocolic and renocolic ligaments ensuring complete splenic flexure mobilization.

When adequate mobilization for a tension-free anastomosis has been achieved, an appropriate proximal transection point is chosen. Using scissors, a window is created adjacent to the colon wall, the EndoWrist Stapler is used to divide the bowel and either the bipolar forceps or vessel sealer may be used to harvest the remaining mesocolic vessels.

The specimen is delivered through a low midline or Pfannensteil incision, and the anastomosis is performed via hand-assisted, laparoscopic-assisted, or mini-laparotomy techniques.

From the author’s personal experience, the following tips are provided: