An electronically controlled carbon dioxide insufflator is used to establish and maintain pneumoperitoneum (Fig. 3.3). This system consists of the following: an intra-abdominal pressure display, an adjustable pressure selector, and digital flow and volume displays. Once pneumoperitoneum is initially established, high flow settings (20–40 L/min) are generally used to maintain the pneumoperitoneum. The system self-regulates to maintain the desired pneumoperitoneum.

A number of instruments have been designed specifically for use during laparoscopy. Many come in both reusable and disposable forms. The basic instruments that we advise having available for minimally invasive operations are the following:

Another technique for minimal access surgery is via a hand-assist technique. As with straight laparoscopy, laparoscopic instruments are used as well as a laparoscopic camera. A hand-assist port (GelPort Laparoscopic System, Applied Medical, USA) is inserted through a 6–7 cm abdominal wall incision through which the surgeon can pass one hand. The surgeon’s hand is then used to retract, dissect, etc. as needed.

A single-incision technique is also available wherein a 2–3 cm incision is made through the abdominal wall and a single-port device is inserted (GelPoint, Applied Medical, USA; TriPort and QuadPort, Olympus, Japan; SILS Port, Covidien, USA; Single Site Laparoscopic Access System, Ethicon Endosurgery, USA). All ports/instruments as well as the camera are inserted through this port and the procedure is completed without further incisions.

Most robotic operations are hybrid techniques that involve the concurrent use of laparoscopic and robotic instruments. As such, availability of the laparoscopic instruments described in the prior section is essential to robotic cases. In addition to this, however, there are several robot-specific technologies which merit review.

The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, USA) is the only robotic system currently available for surgical use. The system consists of a three- or four-armed surgical robot that docks into position at a desired location adjacent to the patient. The initial setup requires obtaining intraperitoneal access as would be done for laparoscopic surgery. Thereafter, a 12-mm endoscopic port is inserted, which permits initial laparoscope and later robotic laparoscope placement. Three reusable robotic instrument ports (8 mm) are then placed intraperitoneally. Each of the ports is configured so that it can be docked to the robotic arms. The robotic camera contains two separate video chips to allow for a binocular image. It is introduced through the 12-mm trocar and captures three-dimensional video of the intraperitoneal contents. These images are then projected to a control console placed some distance away from the patient. The surgeon sits at the console and is able to remotely control the camera and the robotic instruments connected to the arms of the da Vinci robot. An assistant (who is scrubbed in) is required at the patient’s bedside to exchange robotic instruments when necessary and to assist with retraction and suction if needed. The robotic instrument attachments most commonly used are a grasper, shears attached to monopolar cautery, and a bipolar grasper. The main advantages of robotic surgery over laparoscopic surgery are felt to be (1) the superior three-dimensional images that can be obtained of the intraperitoneal contents using the robotic endoscope and (2) the freedom of movement and motion that the robotic instruments allow for. The later is particularly useful when performing complex tasks (i.e., dissecting or suturing) within anatomically confined space. An ongoing randomized trial comparing laparoscopic and robotic surgery for rectal cancer will shed more light on the comparison of the two techniques [12].

Figure 3.4 demonstrates a typical operating room setup for laparoscopic colorectal surgery. When available, ceiling-mounted booms help keep the various cords organized. We recommend that all cords and tubing enter and exit the sterile field from the same position whenever feasible. For example, for a laparoscopic low anterior resection, all tubes and cords could exit from the left side of the patient above the operative field. Figure 3.5 demonstrates a typical operating room setup for robotic colorectal surgery.

In the following section we will discuss general patient positioning for the most common laparoscopic and robotic operations. We will defer discussion of port placement to subsequent chapters of this textbook, which will elaborate upon this topic in detail.

Regardless of the type of operation that is to be performed, a few principles should be kept in mind. First, the patient must be positioned is a manner that precludes pressure or nerve-related injury. All pressure points must be adequately padded and cushioned. Second, the patients should be secured to the operating table and prevented from sliding off the table. This is particularly important in laparoscopic and robotic surgery, where the surgeon may need to incline, turn and recline the patient at extreme angles to facilitate the operation. At our institution we use the Pink Pad – Pigazzi Patient Positioning System (Xodus Medical, PA, USA) – which consists of a single use pink foam pad placed directly on top of the operating table, disposable liftsheet, and body strap – to achieve this objective (Fig. 3.6). Alternatively, the patient can be positioned on a beanbag secured to the operating room table or a gel pad without liftsheets and shoulder pads. Third, all patients must have appropriate IV lines, cardiac monitoring leads, and catheters (including a urinary catheter permitting monitoring of intraoperative urine output) positioned in such a manner that they do not obstruct the surgeon’s operative field. Finally, appropriate prophylaxis (IV antibiotics, sequential compression devices, and/or chemical deep venous prophylaxis) must be instituted prior to initiation of the operation and continued/repeated as needed during the operation.