Fig. 8.1
Parallel docking
Only three arms are used in these techniques, one for the camera and two to operate. The fourth arm should be positioned away from the surgical field to avoid collisions (Figs. 8.2, 8.3, and 8.4).
Fig. 8.2
Arm setup
Fig. 8.3
Port and arm setup
Fig. 8.4
Lateral placement arm #3
For R-TME all patients should be in the lithotomy position as this allows for both transanal and conventional laparoscopic approach . The bed should be angled right before docking the robot so the abdominal team will have a good access to the left pelvis.
Ports and Trocars
There is not a unique transanal access port. There are many different brands offered on the market today ranging from SILS© to GelPOINT©. Some studies have discussed the use of a latex glove covering an Alexis© laparoscopic system as a viable alternative. Anyhow, the ideal port would be one which provides a perfect pneumorectum and allows for broad movement of the robotic arms with minimal collisions of the trocars.
Before inserting the port, a gentle anal dilatation has to be performed. Fingers covered with profuse lubricant are used applying continuous and opposing pressure over the rectal sphincters symmetrically. Dilation devices may also be used if available.
An example is GelPOINT© path transanal access platform (Applied Medical, Rancho Santa Margarita, CA, USA). It consists of a rigid cylindrical sleeve, which helps protect against injury to the sphincter mechanism. After lubricating, it can be introduced into the anal canal using an obturator, but you may also grasp the distal part of it with a Kocher clamp through the sleeve orifice applying traction giving it a bullet shape easier to introduce . Once in position above the anorectal ring, the sleeve has to be sutured to the skin.
After inserting the transanal port, it is important to ensure proper fixation to avoid backward movements. The insufflation pressure recommended is between 12 and 15 mmHg. CO2 leaks are also common, either from the port sides or from the trocars. An assistant should help avoid these leaks through the procedure. If AirSeal insufflation is available, this has been seen to be helpful in maintaining the view. If a GelPort is used, reinforcement with a transparent adhesive over its surface can be used to reduce CO2 leaks or gel tears from trocar movement. This coating should be applied before the robotic ports are drilled into the GelPort. As the technique develops, so do the materials used, and in the future we should expect better ports to be out on the market.
In a regular R-TAMIS or R-TME surgery , three trocars are placed. Facing the surgical field, an 8 mm robotic trocar is placed at 12 o’clock (mid-superior), and two 8 mm robotic trocars will be placed accordingly at 4 and 8 o’clock (inferior-lateral) in a triangle fashion (Fig. 8.5). At least a 4 cm separation between the trocars must be achieved. A 30° angle-up camera will be used through the 8 mm trocar. Another extra 12 mm trocar can be placed at 6 o’clock (mid-inferior) for assistance. The other way to insert the trocars is through the trocars provided by the vendor which gives the robotic arms the best angulation outside of the surgical field and therefore less collisions.
Fig. 8.5
Port placement
For evacuation of smoke, a 5 mm laparoscopic suction-irrigation device can be used directly into the GelPOINT©, without the need for a trocar . Suction was operated by the bedside assistant. Again, AirSeal can keep area clear of smoke without the need for constant suction.
Operative Steps
TAMIS
To operate a Maryland grasper is placed on the robotic arm 1 (R1) and electrocautery in robotic arm 2 (R2).
The first step is to locate the tumor and mark its margins with electrocautery. Wide resection margins of 1 cm are recommended; however even margins as narrow as 5 mm have proven to be safe [24, 25].
Dissection should be initiated from proximal rectum advancing distally toward the anus. By doing it this way, we avoid creating defects greater than the marked resection limits. The depth of the dissection is also important. Given the curative intention of this procedure, a full thickness resection of the tumor is recommended. This also allows for more accurate pathology staging.
Now set needle drivers on R1 and R2. The needle can be placed in the field by opening the GelPort or through one of the trocars by the assistant.
Closure of the defect should be performed if possible. Just like dissection, closure should be performed from the proximal rectum to the anus. The use of barbed sutures can be useful [26]. Some authors however defend that defect closure is not needed [27].
The advantages of this robotic approach in such a confined space make this surgery technically less demanding and more precise and allow treating more than one lesion without the need to change the patient’s position. Also, the assistant needs less training than the required when driving the laparoscopic camera.
Operative Steps TAMIS-TME (Transanal Stage)
This procedure is done in two surgical times, but it can be performed simultaneously by two surgical teams. Given how new this technique is a concurrent double robotic approach, very few reports are described in the literature, and standardization of this technique is not yet available.
The abdominal time consists of a low anterior resection of the sigmoid and the left hemicolon. Sometimes the splenic flexure of the colon also needs to be mobilized for a tension-free and better reach for the anastomosis. For the purpose of this chapter, however, we will focus on the transanal time.
For the transanal operation, we will place needle drivers on R1 and R2 at first. The next step is to locate the tumor; gauze can be used to push the tumor out of the surgical field but remember it will remain with the specimen.
Distal to the tumor a circumferential purse string is created. Thorough closure is very important to avoid future pressure losses of the pneumorectum. It is also necessary as fecal material may progress as a result of the colonic mobilization during the intra-abdominal phase of the surgery.
Once the circumferential suture is tied up, the new transanal surgical field is seen looking like a closed donut shape with a dot in the middle.
Needle holder from R1 is changed for an electrocautery and R2 to a Maryland grasper or dissector. Dissection will start around the middle dot on the pouch’s center, but before, the circumference over which we will be working must be marked using the electrocautery 1 cm away around the dot. This way we reduce the risk to create corkscrew sections as a result of loosing references once the dissection has started.
For low rectal tumors, no dissection should be done less than 1 cm away from the dentate line. It is advisable to start dissecting posteriorly. The incision must be full thickness including muscular plane to enter the mesorectal plane. Pressure from the pneumorectum will help advance the dissection and show us the “holy plane” [28]. After the posterior mesorectal plane is opened, dissection is done anteriorly and lastly the lateral planes.
It is not advisable to go too deep in one single plane as it is done on conventional laparoscopy or the rectum will tend to retract. Uniform dissectional depth must be pursued throughout the whole circumference.
When dissecting the posterior rectal plane, going too deep may cause hemorrhagic complications from the sacral vascular plexus.
In male patients while dissecting the anterior plane, as usual, Denonvilliers’ fascia must be respected. We should avoid entering the prostatic plane and damaging the seminal vesicles. In females special care must be put not to perforate the posterior wall of the vagina. An assistant can apply manual traction to the vagina to facilitate dissection. Usually this approach will let you see and dissect the structures much easier than the transabdominal classic one.
The lateral planes are the most complex; however, robotic maneuverability highly aids this process. If the mesorectal plane is not respected and dissection is done too deep, the hypogastric nerve plexus can be damaged.
Dissection is symmetrically continued until the peritoneal cavity is reached. If the abdominal team has already done the sigmoid and upper rectum mobilization, they would guide this final dissection from the peritoneal cavity. The intra-abdominal phase can also be performed robotically.
The robot can be docked out and the next part can be performed either hand or conventional laparoscopically assisted.
The specimen can be extracted either transanally or using the future ileostomy orifice if this will be necessary or performing a Pfannenstiel incision. If the specimen is taken out through an abdominal incision, it is recommended to use an Alexis wound retractor. It will protect the incision while the tumor is extracted allowing for effective pneumoperitoneum afterward.
Once the specimen is taken out, the device of choice may be used to allow proper anvil placement. It is important to make sure the anvil is correctly placed and that the anastomotic margins are free of adipose pedicles. This will facilitate a proper wall-to-wall anastomosis. It is our current practice to perform immunofluorescence of the proximal colon using 10 mg of indocyanine green to determine appropriate vascular flow.
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