Robotic Left Colectomy

INDICATIONS AND CONTRAINDICATIONS

Left colectomy may be indicated for a variety of benign and malignant conditions; however, the most common indications are carcinoma, polyps not amenable to endoscopic resection, and Crohn’s disease. Other less common indications for resection include hemorrhage and ischemia. The robotic approach is generally indicated whenever laparoscopy is appropriate, when the surgeon is experienced and comfortable with the robotic platform. The standard contraindications for laparoscopy, including pulmonary disease precluding pneumoperitoneum, uncontrolled coagulopathy, and hemodynamic instability remain true for robotic surgery as well. Extensive intra-abdominal adhesions that may preclude safe minimally invasive entry into the abdominal cavity are a relative contraindication.

PREOPERATIVE PLANNING

Patients being considered for surgical management of malignancy should have careful review of preoperative imaging, which generally includes computed tomography (CT) scans of the chest, abdomen, and pelvis. Review of the preoperative imaging serves several important functions. First, it can assist in the localization of the tumor and confirm the location of malignancy in the left colon. Owing to the redundancy of the sigmoid colon, endoscopic length measurements and the impression of the endoscopist may not provide accurate tumor localization. Second, careful review of the imaging can sometimes reveal suspicious lymph node disease, which the surgeon should plan to include in the surgical specimen. Lastly, contrast-enhanced CT scans provide critical anatomic information that may affect surgical planning and can assist with dissection. We recommend careful review of the mesenteric vascular anatomy found on CT scanning before embarking on dissection, because this imaging provides a roadmap of the operation that lies ahead.

All endoscopy reports should be reviewed before surgery; and if there are questions regarding the location of the tumor, the original endoscopist should be contacted. If the lesion was not tattooed initially, we strongly advise that the patient be referred back to the original endoscopist for tattooing of the lesion.

The role of mechanical bowel preparation remains controversial. Our current practice is full mechanical bowel preparation for all patients, unless a contraindication exists. One important consideration regarding bowel preparation for robotic surgical cases being performed for malignancy is that the tactile sensation of the surgeons’ fingers to palpate the tumor is diminished. If there is a question as to the location of the tumor, it can be very difficult to feel the mass robotically if the colon is filled with stool. For this reason, the authors and editors strongly recommend bowel preparation for minimally invasive operations whenever clinically feasible.

SURGERY

Positioning

The patient is generally positioned supine for robotic left colectomy, although the lithotomy position can be utilized if the surgeon is planning to perform intraoperative colonoscopy. The patient should be positioned on an anti-slip surface, such as a gel pad or an egg crate foam, for example. We recommend an atraumatic chest strap as well as leg strap to safely secure the patient to the operating table. Both arms of the patient are tucked and all bony prominences are carefully padded.
The patient should then be placed in steep Trendelenburg with right side down before draping to ensure that the surgical table is functioning as expected and that the patient should ideally not slide when in this extreme position.

Room Setup

Proper organization and setup of the operating room is critical for the efficient performance of robotic surgery. For left colectomy, the patient cart of the surgical robot should be on the left side of the patient. We recommend the vision tower to be located on the left side of the patient for this operation, because it provides a direct view of the monitors for the bedside assistant located on the patient’s right side. The availability of appropriate instruments should be confirmed before incision, including the robotic vessel sealer as well as the robotic stapler, if intracorporeal division of the bowel is planned. The operating room staff should ensure that the Table Motion feature, if available, is paired with the robot and correctly functioning.

Port Placement and Instruments

The camera port is generally placed in either a supraumbilical or slightly infraumbilical location, depending on the patient’s body habitus. If more working room and a broader view of the abdomen are desired, the camera port can be placed off to the right side, at approximately the level of the umbilicus. The operation is typically performed using all three arms of the robot and one laparoscopic assistant port, although some surgeons do omit the use of the third arm at their own preference. If an intracorporeal anastomosis is planned, we strongly advise utilizing the third arm. The third arm is generally positioned cephalad to the camera port, just off the midline. One working arm is placed below the camera port and one above, spaced approximately 7 cm apart for maximum clearance. If intracorporeal division of the bowel is planned, it is often useful to place the 12-mm stapler port in the plane of the anticipated Pfannenstiel incision, to limit the number of fascial closures necessary. Several port placement options are pictured (Figs. 11-1 and 11-2), including configurations that
do not utilize the third arm. The laparoscopic assistant port is typically positioned in the mid-right abdomen, far enough away from the robotic trocars to prevent interference of the arms with the assistant’s hand.

FIGURE 11-1 Port placement for left colon/sigmoid resection.

FIGURE 11-2 Port placement for one cart position low anterior resection (with permission, Hellan M, Stein H, Pigazzi A. Totally robotic low anterior resection with total mesorectal excision and splenic flexure mobilization. Surg Endosc 2009;23:447-51).

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