The laparoscopic portion of the procedure is completed using R1, L1, L2, and C ports. This approach is begun by placing the patient in steep Trendelenburg position with the left side tilted up to allow for the small bowel to be swept away from the root of the mesentery. The mesentery is elevated and the IMV is identified and the dissection is begun there just lateral to the ligament of Treitz. The IMV is skeletonized circumferentially via blunt dissection from its attachments to the left mesocolon. Once this is achieved, the vessel is then ligated using a vessel sealing energy device, stapler, or locking hemoclips (Fig. 7.2). The sigmoid colon is then elevated toward the abdominal wall and the overlying peritoneum medial to the right common iliac artery at the sacral promontory is incised. The upward traction is maintained and a plane is developed bluntly under the superior hemorrhoidal artery. The left ureter is again identified and swept posteriorly and the dissection is continued to the origin of the IMA at the aorta. The IMA is then skeletonized circumferentially and the critical ‘T’ shaped view of safety is achieved. This is comprised of the junction of the left colic artery and superior hemorrhoidal artery with the IMA. The IMA is then ligated using a vessel sealing energy device, stapler, or locking hemoclips per surgeon’s preference. The left colic artery is also divided in a similar fashion in most patients.

Attention is then direct toward laparoscopic mobilization of the left colon and splenic flexure; this is begun with retraction of the left colon superiorly and medially with atraumatic bowel graspers. At this point of the operation the patient must be moved in a reverse Trendelenburg position to take advantage of the effect of gravity on the transverse colon. Optimal exposure of the avascular white line of Toldt in the left paragolic gutter allows for a bloodless dissection between the mesocolon and retroperitoneum. The left ureter and gonadal vessels are identified and protected and then mobilization is continued superiorly via division of the phrenocolic and splenocolic ligaments toward the splenic flexure. The dissection maybe facilitated by dividing the omentum overlying the middle colic vessels to further mobilize the transverse colon toward the splenic flexure. Mobilization of the splenic flexure is achieved by first opening the lesser sac and continuing the dissection down to the root of the mesentery freeing the attachments of the mesentery to the tail of the pancreas. Dissection during this step has to be slow and meticulous with care taken not to damage the tail of the pancreas, splenic vessels, and spleen itself. Ensuring that the left and proximal transverse colons have been freed from their attachments finally completes the dissection.

The patient is placed again in Trendelenburg position and the four-arm surgical robot is docked via the patient’s left hip, which allows access to the patient’s anus during this portion of the procedure. The camera scope first inserted is a zero degree scope. Port and arm clutches are used to dock the arms to the camera and other three instrument ports. The robotic arms are docked as follows: R1 docks arm 1 and a hook cautery or monopolar scissors is placed through this port, R2 docks arm 2 and a bipolar grasper is placed through this port, and finally R3 docks arm 3 and a grasper is placed through this port. The first assistant remains on the patient’s right side and uses L1 and L2 to provide retraction and suction/irrigation as needed.

Attention is then directed toward the pelvis and the surgeon at the robotic console begins mobilization of the rectum in the avascular plane between the mesorectum and the presacral fascia posteriorly (Fig. 7.3). Arm 3 is used for anterior retraction, while arms 1 and 2 are used for dissection. It is crucial to avoid grasping the mesorectum during dissection as it is highly prone to tearing or bleeding. We prefer to use monopolar scissors during this portion of the dissection to develop the plane of dissection between the presacral fascia and mesorectal fascia with minimal use of electrocautery. Adequate retraction of the proximal rectum by the assistant superiorly and laterally is paramount during this step as the dissection is carried posteriorly through Waldeyer’s fascia (rectosacral fascia) all the way down to the level of the levator muscles. The dissection then proceeds by taking down the lateral rectal stalks with care to identify and avoid the lateral autonomic nerve plexus in this region. In this location, the middle hemorrhoidal vessels are usually encountered and can be easily controlled with bipolar cautery. The dissection is then shifted anteriorly opening the peritoneal reflection and continuing the dissection behind the seminal vesicles or the posterior vaginal wall (Fig. 7.4). This circumferential dissection of the rectum down to 1–2 cm distal to the tumor completes the total mesorectal excision (TME) and the rectum is then inspected at the level of the desired transection. Frequent digital rectal examination and endoscopic assessment are necessary to ensure adequate distal margin clearance. It is usually not necessary to divide any fat when the rectum is divided at the level of the pelvic floor since the mesorectum is nonexistent at this level.

A digital rectal examination or intraoperative colonoscopy is then used to assess the distal margin of resection. For tumors >2–3 cm from the anal verge, the articulating stapler is placed at R1 and fired by the first assistant sequentially to complete the transection with care not to cross the previous staple line (Fig. 7.5). For tumors that are <1–2 cm from the anal verge, an intersphincteric resection with a hand sewn colo-anal anastomosis maybe required. Once the rectum is divided the surgical robot is dedocked and pushed back away from the patient. The specimen is then extracted via a 5 cm Pfannenstiel incision and placing a wound protector to cover the incision edges. The proximal bowel is divided and the anvil of the EEA stapler is introduced and secured to the proximal stump with a purse string suture. The proximal colon and anvil are returned into the abdominal cavity and pneumoperitoneum is reestablished. The colorectal anastomosis is then completed in a standard fashion with the EEA stapler under direct vision laparoscopically.

After completion of the colorectal anastomosis the stapler is withdrawn gently out of the rectum and the distal and proximal “donuts” are inspected for completeness and sent to pathology. A flexible sigmoidoscopy is then performed to assess the integrity of the anastomosis and test for an air leak. If there are any defects or signs of compromised perfusion of the anastomosis the decision to redo versus reinforce the anastomosis is made based on the surgeon’s judgment. The abdomen and pelvis are copiously irrigated and suctioned. Routine Pelvic drain placement is not mandatory and is left to the surgeon’s preference. If a drain is to be placed, it is usually a round 19 Fr Blake drain that is placed within the pelvis in the vicinity of the anastomosis.