Fig. 6.1
Hybrid technique versus totally robotic technique
Hybrid Technique
Hybrid technique was adopted during the early stages of robotic rectal surgery and has been the most widely used procedure to date. One important reason that the utilization of a robot during rectal surgery was relatively delayed was that the range of the operation is wide over the pelvis to splenic flexure [3–7]. The up-and-down and left-to-right movements over a wide dissection field frequently resulted in the external collision of robotic arms during the surgery . Moreover, multiquadrant operations such as a low anterior resection require the relocation of the robotic cart, a time-consuming and difficult procedure as the robotic devices are heavy and bulky. Consequently, surgeons felt stressed and hesitated to apply a robot system toward rectal surgery. However, a hybrid technique, which concentrated solely on the pelvic dissection, otherwise known as total mesorectal excision (TME) , was developed to facilitate the whole procedure more effectively and to reduce overall operation time by eliminating the need for repositioning of the robotic cart [4, 5, 7]. As a result, this technique lowered the barrier to entry for many surgeons and enabled the robotic system to be rapidly adopted in the field of rectal surgery.
Port placement in the hybrid technique is designed not only to focus on robotic pelvic dissection but also to be available for laparoscopic colonic mobilization during the second phase of a low anterior resection. The current recommendations are as follows:
Patient Positioning and Preparation
This is the step common to all approach methods.
Patient is in 15°. Trendelenburg position with legs in adjustable stirrups (stirrups mounted at most distal point on operation room (OR) table rail) (Fig. 6.2).
Fig. 6.2
Patient positioning ©2015 Intuitive Surgical, Inc. used with permission
Patient is tilted right-side down 10–15°.
Use pads for pressure points and bony prominences , and secure body position, especially on the right side, to avoid shifting.
Port Placement
All port placement measurements must be made after insufflation is achieved. Make sure to position the remote center (thick black band) of the da Vinci cannula at the level of peritoneum, making the band invisible on either side of the abdominal wall.
da Vinci Camera Port, 12 mm (blue): Place port 3–4 cm to the right of and 2–3 cm above the umbilicus. Distance to symphysis pubis should be approximately 22–24 cm (Fig. 6.3).
Fig. 6.3
Port placement for hybrid technique ©2015 Intuitive Surgical, Inc. used with permission
da Vinci Instrument Arm ① Port, 8 or 13 mm (yellow): Place a minimum of 8 cm from the camera port, on the right midclavicular line (MCL), 2–3 cm above the right spinoumbilical line (SUL). If stapler access from this location is deemed necessary, dilate this port to a 13 mm da Vinci cannula.
da Vinci Instrument Arm ② Port, 8 mm (green): Place port at the level of the camera port on the left MCL. The distance to the other instrument ports and camera port should be at least 8–10 cm.
da Vinci Instrument Arm ③ Port, 8 mm (red): Place approximately 4 cm above the left anterior iliac spine. The distance to Instrument Arm ② Port should be at least 8 cm.
Assistant Port (A), 5 mm (black): Place port 8–10 cm superior to Instrument Arm ① on right MCL (a minimum of 8 cm from camera port).
Assistant Port (B), 5 mm (white): Place port 6–8 cm inferior to xiphoid process on the midline. The distance to the other instrument ports and camera port should be at least 8–10 cm.
*Slight modifications to the port locations may be necessary due to patient’s anatomy.
Patient Cart Positioning and Docking
After the colonic phase is finished using standard laparoscopy, the patient cart is positioned and docked with all instrument arms.
Position camera arm setup joint on the opposite side of the da Vinci Instrument Arm ③.
Lower OR table and raise all of the arms high enough to clear the patient’s abdomen. Push all overhead lights and equipment aside.
Align the center column and camera arm with the camera port along a straight line following over the left stirrup mounting clamp on the OR table (Fig. 6.4a). The sterile person directing the roll-up can use a straight laparoscopic instrument to line up the camera port and stirrup clamp as an aid in directing the person rolling up the patient cart.
Fig. 6.4
Patient cart alignment (a) and docking (b) ©2015 Intuitive Surgical, Inc. used with permission
Roll up the patient cart at approximately a 45° angle. The patient cart base should straddle the corner of the OR table (depending on OR table model).
Use port and arm clutch maneuvers to dock the camera and instrument arms (Fig. 6.4b).
Maximize spacing between all instrument arms.
CAUTION: Once the patient cart is docked and connected to the cannulae, the operating room table cannot be moved.
Procedure Steps
In hybrid technique, standard laparoscopy is used in steps 1–4, and then robotic procedure is performed in steps 5–6:
Step 1: Initial exposure—Flip the greater omentum over the transverse colon toward the liver. Retract small bowel loops out of the pelvic area into the right upper quadrant. Suspend uterus in female patient.
Step 2: Primary vascular control—Primary vascular control is achieved by dividing the inferior mesentery artery (IMA) and the inferior mesenteric vein (IMV) .
Step 3: Medial to lateral mobilization of sigmoid and descending colon—Extent of the dissection is superior to the inferior border of the pancreas, laterally following Gerota’s fascia and inferior to the psoas muscle where the ureter crosses the iliac vessels.
Step 4: Splenic flexure mobilization—To achieve a tension-free anastomosis, the splenic flexure is mobilized in a medial approach.
Step 5: Rectal dissection—The rectal dissection is performed using an elliptical dissection pattern of the posterior first, continuing laterally to the left side, then to the right, and finally to the anterior side of the rectum down to the levator ani muscle level.
Step 6: Rectal division and anastomosis—Performed in standard laparoscopy or alternatively with robotic assistance. Prep through minilaparotomy at left lower quadrant port location.
Operative Outcome
Because the procedure was developed early and has been widely used, there are many reports for low anterior resection using the hybrid robotic technique . Most operative outcomes, such as blood loss, conversion rate, hospital stay, and complications, after robotic low anterior resection using hybrid technique were similar or better than results after laparoscopic or open low anterior resection with the exception of operative time (Table 6.1) [3–18]. Moreover, several articles have reported comparative operative time results between the robot and laparoscopic groups, which may reflect upon the merit of hybrid robotic technique in the matter of time saving [19–25]. Recently, long-term oncologic outcomes were reported to indicate comparable overall and disease-free survival between robot and laparoscopic procedures [26].
Table 6.1
Operative outcomes after robotic low anterior resection using a hybrid technique
Author (year) | Type of article | Cases | Operative time (mean(±SD), min) | Estimated blood loss (mean(±SD), ml) | Conversion rate (%) | Hospital stay (mean(±SD), days) | Complication (%) | Mortality (%) | Note |
|---|---|---|---|---|---|---|---|---|---|
Pigazzi et al. (2006) [3] | Comparative case report (robot vs. laparoscopy) | 12 (R, 6; L, 6) | R, 4.4; L, 4.3 (p = NS) | R, 104; L, 150 (p = NS) | – | R, 45; L, 3.6 (p = NS) | R, 16; L, 16.7 (p = NS) | – | First report |
Hellan et al. (2007) [8] | Case series | 39 | 285 | 200 | – | 4 | 12.8 | 0 | |
Baik et al. (2008) [9] | Comparative analysis (RCT) (robot vs. laparoscopy) | 36 (R, 18; L, 18) | R, 217.1 (51.6); L, 204.3 (51.9) (p = 0.477) | – | R, 0; L, 11.1 (p = 0.486) | R, 6.9 (1.3); L, 8.7 (1.3) (p < 0.001) | R, 16.7; L, 5.6 | ||
Baik et al. (2009) [10] | Comparative analysis (robot vs. laparoscopy) | 113 (R, 56; L, 57) | R, 190.1 (45.0); L, 191.1 (65.3) (p = 0.924) | – | R, 0; L, 10.5 (p = 0.013) | R, 5.7 (1.1); L, 7.6 (3.0) (p = 0.001) | R, 10.7; L, 19.3 (p = 0.202) | – | |
Park et al. (2010) [12] | Comparative analysis (robot vs. laparoscopy vs. open) | 263 (R, 52; L, 123; O, 88) | R, 232.6 (52.4); L, 158.1 (49.2); O, 233.8 (59.2) (p < 0.001) | – | R, 0; L, 0; O, NA | R, 10.4 (4.7); L, 9.8 (3.8); O, 12.8 (7.1) (p < 0.001) | R, 19.2; L, 12.2; O, 20.5 (p = 0.229) | R, 0; L, 0; O, 1.1 (p = 0.373) | |
deSouza et al. (2011) [13] | Comparative analysis (robot vs. open) | 82 (R, 36; L, 46) | R, 337.9 (81.8); L, 273.8 (10.8) (p = 0.003) | R, 187.5 (98.1); L, 273.8 (165.4) (p = 0.036) | – | R, 7.0 (5.8); L, 7.3 (4.1) (p = 0.74) | R, 30.6; L, 32.6 (p = 0.84) | R, 2.8; L, 2.2 | |
Park et al. [26] (2014) | Comparative analysis (robot vs. laparoscopy) | 217 (R, 133; L, 84) | R, 205.7 (67.3); L, 208.8 (81.2) (p = 0.766) | R, 77.6 (153.2); L, 82.3 (185.8) (p = 0.841) | R, 0; L, 7.1 (p = 0.003) | R, 5.86 (1.43); L, 6.54 (2.65) (p = 0.035) | R, 7.5; L, 9.5 (p = 0.602) | – | 5-year OS, R, 92.8 %; L, 93.5 % (p = 0.829); 5-year DFS, R, 81.9 %; L, 78.7 % (p = 0.547); 5-year cumulative LR, R 2.3 %; L, 1.2 % (p = 0.649) |
Totally Robotic Technique
Single Docking Method
The hybrid technique has contributed much toward the adoption of the robot system in rectal surgery. However, there are some limitations of forgiving the advantages of using a robot system during the colonic phase, which provides better visualization during lymphovascular dissection around the inferior mesenteric artery (IMA) and the convenience of splenic flexure mobilization [27–29]. Thus, other procedure was independently developed to utilize the robotic system throughout both phases of a low anterior resection.
Initially, the totally robotic procedure was performed as a two-stage or a three-stage technique, which necessitated multiple cart repositionings, a time-consuming process . Subsequently, a single docking totally robotic technique was developed and has been widely used to date. This method consists of stationing the robotic cart beside the left lower quadrant of the patient’s abdomen, allowing complete coverage of the wide operative field, from the stage of splenic flexure mobilization to pelvic dissection, without requiring cart repositioning [27–29]. As a result, the advantages of robotic system could be maximized both in colonic and pelvic phase, and operative time could be saved compared to a two- or a three-stage technique. Moreover, this approach allows for a transanal procedure such as colonoscopic examination, even in the situation that the robotic cart is docking [29]. In the hybrid technique, the robotic cart was initially located between the patient’s legs, but has recently been repositioned to the left lower quadrant of the patient’s abdomen because of the advantages described above.
Port placement in single docking method was designed to cover the entire operation, including colonic mobilization and pelvic dissection (steps 1–6). The current recommendations are as follows below. Note that patient positioning, preparation, cart positioning, and docking are the same as in the other techniques.
Port Placement
Position the remote center (thick black band) of da Vinci cannula at the level of the peritoneum. Maintain at least 8 cm between robotic ports and Assistant Ports:
da Vinci Camera Port, 12 mm (blue): Place the port 3–4 cm to the right of and 3–4 cm above the umbilicus. Distance to symphysis pubis should be approximately 22–24 cm (Fig. 6.5).
Fig. 6.5
Port placement for single docking method ©2015 Intuitive Surgical, Inc. used with permission
da Vinci Instrument Arm ① Port, 8 mm (yellow): Place the port a minimum of 8 cm from the camera port, on the right spinoumbilical line (SUL) at the crossing of the midclavicular line (MCL). Distance to symphysis pubis should be approximately 14–16 cm. Alternatively, the 13 mm stapler cannula with a 13–8 mm reducer can be used in this port location for introduction of the linear stapler.
da Vinci Instrument Arm ② Port, 8 mm (green): Place the port a minimum of 8 cm from the camera port, on the left spinoumbilical line (SUL) at the crossing of the midclavicular line (MCL) . The distance to the symphysis pubis should be approximately 14–16 cm.
da Vinci Instrument Arm ③ Port, 8 mm (red): Place the port approximately 3 cm below the right costal margin and approximately 2 cm medial to the right MCL.
da Vinci Instrument Arm ②/③ Port, 8 mm (green-red): Place the port 7–8 cm below the left costal margin, slightly medial to the left MCL. Place the port a minimum of 8 cm from the other instrument ports and the camera port.
Assistant Port (A1), 5 mm: Place the port 8–10 cm cephalad to the Instrument Arm ① Port and approximately 4 cm lateral to the right MCL (a minimum of 8 cm from the camera port). This port is used for suction/irrigation, ligation, and retraction.
Port Usage and Instrument Arm Setup per Procedure Step
Initial procedure steps 1–3 on patient’s left side are performed in a four-arm setup with arms 1, 2, and 3 connected (Fig. 6.6a).
Fig. 6.6
Left lateral setup (steps 1–3) (a), splenic flexure setup (step 4) (b), and pelvic setup (steps 5 and 6) (c) ©2015 Intuitive Surgical, Inc. used with permission
Splenic flexure mobilization (step 4) is performed in a three-arm setup with only instrument arms 1 and 3 connected to minimize external collisions (Fig. 6.6b).
Pelvic procedure steps 5 and 6 are again performed in a four-arm setup with instrument arms 2 and 3 reconnected in the lower and upper left da Vinci instrument ports (Fig. 6.6c).
Operative Outcome
Similar to the hybrid technique, most results from totally robotic low anterior resection with single docking method were comparable or better than results from a conventional laparoscopic or open low anterior resection (Table 6.2) [27–35]. Again, it was found that operative time was significantly longer than conventional surgery. However, based on recent studies, the operative time has decreased after an initial learning curve [36–40]. To date, favorable mid- and long-term oncologic outcomes have been reported, and long-term outcomes for totally robotic low anterior resection with single docking method are currently being studied [41–43].
Table 6.2
Operative outcomes after robotic low anterior resection using a single docking method
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