The Veress technique is utilized to establish pneumoperitoneum. Palmer’s point, 3 cm below the left subcostal border in the midclavicular line, is generally chosen for Veress needle insertion. A five-port approach is employed: four robotic ports and an accessory port. The umbilical port is placed first. Ports are generally placed midline or to the left of the midline. There is slight variation depending on whether intracorporeal stapling is planned (Fig. 11.2). For intracorporeal anastomosis, a robotic or laparoscopic stapler is introduced via a larger, 12- to 15-mm, supraumbilical port that is later extended to become the extraction site. For extracorporeal anastomosis, the specimen is generally extracted via the supraumbilical port site.

Prior to robotic docking, the bed is tilted left side down with slight Trendelenburg positioning. The peritoneal cavity is inspected, and the omentum and the transverse colon are placed cephalad over the liver tip. The small intestine is positioned to the left abdomen, exposing the ileocolic pedicle.

The robotic cart approaches from the right, perpendicular to the bed. When docking, automatic targeting by focusing the camera on anatomy ensures proper arm alignment to maximize the range of motion and limits arm collision. A robotic 0° endoscope is inserted into the #2, supraumbilical port. Arm 1 is typically paired with monopolar curved scissors or the robotic vessel sealer. Arm 3 is paired with the fenestrated bipolar instrument, and arm 4 is paired with the Cadiere grasper. A 5-mm assistant port accommodates the suction irrigator or laparoscopic bowel grasper controlled by the bedside assistant during the procedure. For obese patients, a second 5-mm assist port can be utilized to facilitate exposure to the base of the mesentery.

Using a medial-to-lateral approach, the terminal ileum/cecum is retracted with arm 4 to the right lower quadrant, elevating and placing tension on the ileocolic pedicle. This maneuver exposes the vascular pedicle for dissection (Fig. 11.3). With the fenestrated bipolar grasper in arm 3 and the bipolar scissor in arm 1, the peritoneum below the ileocolic pedicle is incised. Using arms 1 and 3 in a scissoring fashion, submesenteric dissection is initiated just below the level of the duodenum. Dissection continues exposing the retroperitoneal structures including duodenum, Gerota’s fascia, gonadal vessels, and ureter (Fig. 11.4). The dissection continues laterally to the abdominal wall, inferiorly to the level of the sacral promontory, and superiorly exposing the duodenum and head of pancreas.

Once the right colon mesentery is dissected off the retroperitoneum, the vascular pedicles are dissected, ligated, and divided. Dissecting the anterior wall of the superior mesenteric vein inferior to the ileocolic vein facilitates total mesocolic excision and high pedicle ligation. Wristed instruments expedite this dissection. The ileocolic vein and artery, which courses over the vein, are ligated and divided sequentially, maintaining an intact mesocolon envelope. The middle colic pedicles are then addressed. The bedside assistant provides anterior and cephalad retraction on the transverse colon mesentery, exposing the middle colic pedicle. Dissection continues along the superior mesenteric vein to the level of the middle colic vein. Again, the artery is lateral. The right branch of the middle colic pedicle is ligated and divided in a standard right colectomy. The right colic pedicle is generally not encountered, as it is most commonly a branch of the ileocolic pedicle. On occasion, however, there is a right colic vein with a separate takeoff from the superior mesenteric vein between the ileocolic and middle colic pedicles. For proximal transverse colon lesions, the base of the middle colic pedicle is ligated and divided, and the gastrocolic vein (gastrocolic trunk of Henle) is divided for resection of the proximal omentum en bloc with the right colon. Finally, the mesentery is divided to the transverse colon.

Next, the omentum is dissected off the distal transverse colon with entry into the lesser sac. The omentum attached to the proximal transverse colon is generally resected and divided outside the gastroepiploic arcade. For proximal transverse colon lesions, the arcade is dissected with the specimen. Next, the transverse colon is placed on caudal tension, and the remaining omental and retroperitoneal (hepatic flexure) attachments are divided in a medial-to-lateral fashion. This dissection is facilitated by previous submesenteric dissection. The scissor or vessel sealer divides tissue, while arms 2 and 3 provide retraction and open the plane. Finally, the cecum, appendix, and terminal ileum are mobilized by dividing the peritoneal attachments in the right lower quadrant. Previous medial-to-lateral submesenteric dissection ensures that the ureter, kidney, and gonadal vessels remain in the retroperitoneum. The small bowel mesentery is freed to the level of the duodenum. Lastly, the terminal ileum mesentery is divided to the small bowel wall.