Right Hemicolectomy and Ileocecectomy: Robotic Intracorporeal Anastomosis

Fig. 11.1

Port configuration. C: camera port. R1 and R2 working ports for arm 1 and 2. L: assistant port

The right-hand port site R2 is anywhere along a line drawn transversely from midcostal margins bilaterally as far cephalad from the camera as practical, noting the costal margin.

A suprapubic midline 15-mm port is always used. This is an extremely versatile step for all robotic colectomies as this is the ideal extraction site. And the 15-mm trocar can be used as an assistant site: an 8-mm robotic port R1 is telescoped into the 15-mm port for the left arm. This reduces the number of incisions by one. This extra-large port accommodates the stapler and later serves to deliver the extra-large specimen bag.

Alternatively, most useful prior to gaining proficiency in robotic right colectomy, the left arm R1 is needed elsewhere. A right lower quadrant 8-mm da Vinci trocar is possible. This location is least useful for dissection in the pelvis. The option of a left-hand port R1 in the left lower quadrant (as lateral as feasible) facilitates pelvic dissection such as for mobilization of tethered or deep terminal ileum.

The 5-mm assistant port L1, also essential, is left sided, as lateral as feasible to accommodate instrument insertions without interference from the unseen intestine. This 5-mm trocar can be in the upper or lower quadrant based on the location with the most space between camera and robotic arm.

Intracorporeal anastomosis has the benefit of giving the surgeon the choice to move the extraction site off midline by a small Pfannenstiel incision or enlarging one of the lateral port sites.

Operative Steps (Table 11.1)

Table 11.1

Operative steps

Operative steps	Degree of technical difficulty (scale 1–10)
1. Exploratory laparoscopy and docking	2
2. Identification and ligation of the ileocolic vessels	3 (medial to lateral)
2. Identification and ligation of the ileocolic vessels	3 (lateral to medial)
3. Dissection of the retroperitoneal plane and identification of the duodenum	3 (medial to lateral)
	3 (lateral to medial)
4. Mobilization of the right colon and terminal ileum	2
5. Mobilization of the proximal transverse colon and hepatic flexure	4
6. Identification and ligation of the middle colic vessels	6
7. Division of the ileal mesentery and transverse mesocolon	3
8. Intracorporeal anastomosis	3

It is imperative to mobilize sufficient ileum and colon more than that required for a tension-free anastomosis. There must be sufficient proximal and distal length to freely align the ileal and colonic segments as intracorporeal reconstruction must be very efficient regarding the need to retract and stabilize the limbs to be joined by stapling, suture, or both.

The following steps are the same as for extracorporeal anastomosis as described in the previous chapter:

Exploratory laparoscopy

Identification and ligation of the ileocolic vessels

Dissection of the retroperitoneal plane

Mobilization of the right colon

Mobilization of the proximal transverse colon and hepatic flexure

Identification and ligation of the middle colic vessels

Division of the Ileal Mesentery and Transverse Mesocolon

The ileal and colonic mesentery is divided completely intracorporeally. The specimen is then placed over the liver or in the pelvis. Later it will be placed in a specimen bag to be delivered through the suprapubic 15-mm fascial defect or a lateral extraction site, which has been enlarged to 3 cm or as needed.

Intracorporeal Anastomosis

Most surgeons prefer utilizing the ever-evolving stapling instruments for minimally invasive intracorporeal anastomoses. Three stapler-based options are now presented serving the majority of ileocolic intracorporeal robotic reconstructions. The three options include two isoperistaltic referred to here as the “I” and “M” anastomoses and an antiperistaltic approach “V” anastomosis.

There are multiple configurations, stapler types, and suture types and techniques – too numerous to detail as no individual surgeon is aware of the entirety of choices. There are aspects shared by all.

Commonalities of Constructing Intracorporeal Anastomoses

The ileocolostomy may be fully sutured, stapled, or a combination of both.

The stapling instruments may be surgeon (console) or assistant controlled.

Staple height is typically 3.5 mm (blue load) unless special in circumstances.

Luminal dimension is surgeon’s preference.

Stay suture(s) are placed, allowing sufficient length of ileum to create the desired common channel. These sutures also serve to orient anti-mesocolic transverse colon juxtaposed to antimesenteric terminal ileum.

Anchoring sutures are used to temporarily anchor the nascent reconstruction to the falciform ligament or parietal peritoneum to stabilize and retract; this is the equivalent of placing an extra port for a bedside assistant-controlled grasper. These are released subsequently.

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