After intubation and placement of a urinary catheter, orogastric tube, and IV access, the patient is positioned supine with the iliac crest centered over the flexion point joint (break) of the table. The patient’s arms are tucked alongside the body and padded to lessen the possibility of brachial plexus injury. This also allows for easier docking of the robot and provides extra space for the assistant at bedside. Pressure points and bony prominences are padded, and the body is secured to the operating table with straps around the legs and shoulders. We also prefer to use antiskid foam cushion in order to avoid the patient sliding with changes in position. Finally, the patient is covered with an upper body warmer to prevent hypothermia. Sequential compression devices are applied to the legs for DVT prophylaxis. (If needed, the table can be flexed 10–15° at the break to lower the patient’s legs, in order to prevent external collisions with the robotic arms after docking.) Final table adjustments should be made prior to draping, and an initial safety check performed with the bed rotated in all necessary planes—most importantly in Trendelenburg and left-sided tilt position.

When performing robotic-assisted right hemicolectomy, thought must be given prior to port placement and decisions made based upon the patient’s size and body habitus, extent of the dissection of the transverse colon, and whether an intra- or extracorporeal anastomosis is planned. In general, we recommend a 4-trocar approach (camera, two robotic trocars, and an auxiliary laparoscopic trocar) when an extracorporeal anastomosis is planned. In this case, the specimen is extracted by extending the incision used for the camera trocar. The intracorporeal anastomosis requires one additional robotic or laparoscopic large-bore trocar (12–15 mm) to introduce the stapler. Basic principles for port placement dictate that the camera port be 15–18 cm from the site of dissection, and the distance between ports, following insufflation, should be around 8 cm to prevent collisions.

A clear path for the patient cart free of all cords and other equipment should be made prior to driving the draped patient cart. The cart should approach the OR table from the right, at a 45° degree angle over the right shoulder.

When docking the arms, it is important to ensure that the camera port, target anatomy, and robotic cart center column are aligned. Port and arm clutch maneuvers should be used to dock the remaining instrument arms. Once the cart is docked, the position of the bed cannot be changed without undocking. While docking, the camera arm should be in the “sweet spot” to maximize range of motion for the camera and instrument arms. The blue arrow should align with the blue marker on the second joint or create a 90° angle between the first and third joint on the camera arm. When using all three instrument arms, it is useful to place the arm joints as lateral as possible away from the field, to avoid collision.