da Vinci Xi® Setup (Intuitive Surgical, Sunnyvale, CA, USA)

The da Vinci Xi has sleeker arms with an extra joint for movement, which allows for closer arm positioning without concern for external collisions. The Xi instruments are longer than Si, and the camera is the same as the one used for da Vinci X (8 mm). Port placement for robotic right colectomy with the Xi system is in a diagonal line from a point to the left of the costal margin cephalad to the suprapubic region caudally (Fig. 15.3). Alternatively Xi ports can be clustered within the suprapubic region to improve cosmetic outcomes (Fig. 15.4). Most surgeons dock the Xi robot directly over the right side of the operating table.

Operative Technique : Surgical Steps

The abdomen is inspected laparoscopically to determine the feasibility of minimally invasive resection and to identify the extent of disease. The patient is placed in slight Trendelenburg position with the right side tilted up. This allows for the small bowel to be displaced to the left upper quadrant, exposing the cecum, terminal ileum, and right colon mesentery. The omentum is retracted over the liver. We prefer to use a robotic hook cautery on the left robotic arm, while other surgeons prefer to use robotic shears and a bipolar fenestrated grasper on the right robotic arm. Other surgeons will use either two instruments for the left hand or two for the right hand and swap them as needed. For example, two left-hand instruments could be a tip up/stapler and a fenestrated bipolar and one right-hand scissors/vessel sealer/needle driver. Depending on the surgeon’s comfort, training, and experience, an additional robotic port can be used for the swappable instrument. We typically proceed with a medial to lateral approach. If medial to lateral approach is not feasible because of anatomic variant or inability to expose the ileocolic pedicle, a lateral to medial approach can be used.

The cecum is grasped and retracted laterally, caudally, and anteriorly exposing the ileocolic pedicle. In most individuals, the second portion of duodenum can be visualized through a thin layer of parietal peritoneum. In the setting of visceral obesity, however, these anatomic landmarks may be more difficult to identify (Fig. 15.5a). The peritoneum inferior and posterior to the ileocecal pedicle is opened sharply, and blunt dissection is carried out along the retroperitoneal plane (Fig. 15.5b). Next, the ileocolic pedicle is controlled. The ileocolic artery is carefully dissected close to its origin (Fig. 15.6a). While visualizing the duodenum, the artery is ligated and divided using a suitable device (Fig. 15.6b). Available methods include vascular endostapling, clips, bipolar energy, or suture ligation with the robotic system. The robotic technique has been successfully applied to complete mesocolic excision (CME) for right-sided colon cancers . In this approach, the ileocolic vessels are dissected and ligated near their origin. Dissection continues cephalad along the ventral aspect of the superior mesenteric vein (SMV) . While following embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels and middle colic vessels. Depending on the location of the mass, one or both of the above vessels are divided at their origin. After transection of the terminal ileum, the remainder of the operation proceeds in the conventional fashion with mobilization of the colon from the gastrocolic ligament and from its lateral attachments.

The table is tilted to reverse Trendelenburg position to mobilize the hepatic flexure, although this is not mandatory, and often single docking is usually suitable. The omentum and transverse colon are retracted caudally thereby exposing the hepatocolic ligament . For this step, unless da Vinci Xi with table motion is used, the instruments may need to be removed and the robotic arms temporarily undocked from the ports before changing the OR table position. The transverse colon is retracted caudally and the hepatocolic ligament is divided with energy device to control the blood vessels within the ligament (Fig. 15.7). The dissection is continued toward the hepatic flexure, and the final attachments of the colon to the retroperitoneum are divided. The first and second portions of the duodenum should be visualized and protected. If necessary, the gastrocolic ligament is divided to achieve additional mobilization of transverse colon.

Depending on the surgeon’s skill and complexity of the procedure, the terminal ileum and its mesentery and transverse colon with its mesocolon are divided with the robotic bipolar energy device and/or stapler (Figs. 15.8a, b and 15.9a, b). An intracorporeal anastomosis can be constructed robotically with removal of the specimen through either a Pfannenstiel incision or by extending left upper quadrant 12 mm stapler trocar (Figs. 15.10 and 15.11). For more details on how to perform laparoscopic intracorporeal anastomosis, please refer to Chap. 14 on option for ileocolonic reconstruction.

Alternatively, the remainder of the operation can be performed via an open approach. After the robot is undocked, the incision for a camera port is extended superiorly to create a small midline mini-laparotomy. The mobilized right colon is then exteriorized through this incision and resected. A standard extracorporeal side-to-side ileocolic anastomosis is created.

Pitfalls and Troubleshooting