Robotic colon surgery was developed to overcome some of the technical limitations of laparoscopic surgery. However, robotic systems have some disadvantages as well. Most notably, robotic techniques have limited intracorporeal range of motion impacting procedures that require a larger operative field such as colectomy. Since colectomy requires access to multiple quadrants of the abdomen, a laparoscopically assisted hybrid technique or multiple dockings of the robotic cart are necessary. Other options include utilizing different ports and redocking of only 1 or 2 arms versus fully redocking the robotic bedside cart.

The patient is placed in a supine, modified lithotomy position with adjustable stirrups. Bolsters are sometimes placed at both shoulders to prevent sliding toward the head of the bed with movement of the operative table, and both arms are tucked to the patient sides. Pneumoperitoneum is established via a needle, and the camera port is placed periumbilically. Careful inspection of the abdominal and pelvic contents is performed as described above. The placement of the trocars for the robotic arms and the assist port vary based on the surgeon’s preference and are well described by Rawlings et al. [9] and Baik [10]. The position of the robotic cart is to the left of the patient, either at the lower left side of the patient (Rawlings, left lower oblique) or at the level of the camera (Baik, left vertical). The patient is placed right side down. Baik describes a technique placing the patient in Trendelenburg position through the entire procedure, including mobilization of the splenic flexure. The robotic cart remains docked throughout, and there is no movement of the location of the robotic arms. Rawlings describes a technique starting in right side down in reverse Trendelenburg position for mobilization of the splenic flexure, and then the robotic arms are removed. The patient is then placed in the right side down Trendelenburg position, and the robotic arm locations are altered to facilitate dissection of the inferior mesenteric artery and the upper rectum. The technique reported by Baik appears to have the advantage of limited manipulation of the robotic system, but mobilization of the splenic flexure may be surgically more challenging in the Trendelenburg position. The operative time differential between these techniques has not been elucidated. The procedure details will be described in the following chapter. Some surgeons have advocated a hybrid approach for the ease of left colon mobilization, which is described below.

My preferred port placement for a sigmoid colectomy is to place the camera at the umbilicus, the number 1 port/stapler port in the right lower quadrant, the number 3 arm in the right upper quadrant/midclavicular line just two fingerbreadths below the costal margin, and the number 2 arm in the left upper quadrant just a few cm above the level of the camera. Sometimes, if a large amount of pelvic dissection is needed, I will place another 8 mm port in the LLQ where the number 3 arm will be moved after mobilization of the left colon/splenic flexure is done. Extraction is via the umbilicus or left lower quadrant if a port is placed there.

In rectal cancer surgery, total meso-rectal excision (TME) is the standard, regardless of the surgical technique. Laparoscopic rectal surgery is limited due to the narrow anatomy of the pelvis or in the presence of locally advanced disease. High conversion rates to an open surgical approach have been demonstrated from the laparoscopic approach [11, 12].