An extra long 12 or 8.5 mm periumbilical port for the camera is placed, usually 2 cm below and 2 cm lateral to the umbilicus (depending on the patient’s body habitus). A left upper quadrant and suprapubic 8 mm robotic trochars are placed for arms 1 (R1) and 2 (R2). Five mm robotic trochars and arms can be used, but this limits the instrument options and degrees of articulation with today’s available instrumentation, and, therefore, we prefer 8 mm ports at this time. In cases of polyps or tumors, the lesion is localized prior to docking the robot using a 5 mm laparoscope, which is always available. The table is then positioned in 10–20° of reverse Trendelenburg and 20–30° of right side up to allow the small intestine to fall away from the midline. The robot is docked from the patient’s right side or over the right shoulder. Although this chapter describes a three-arm technique below, a fourth arm can be added intraoperatively if needed. An additional port (R3) can be added to the right lower quadrant or the subxiphoid area (see Fig. 4.5a and b). In select cases, particularly in the obese patient, it may be advantageous to start with a four-arm technique to facilitate the procedure.

There are two port placement options that can be utilized with the Xi system depending on whether extracorporeal or intracorporeal anastomosis is performed. The port placement guidelines as published by Intuitive Surgical, Inc. for the da Vinci Xi is shown in Fig. 4.6. This is ideal for extracorporeal anastomosis. With this port configuration, any port site (typically the umbilical trochar site) can be extended and utilized as an extraction site. Incorporating trochar sites has cosmetic advantages.

For intracorporeal anastomosis , we recommend a modification as shown in Figs. 4.7 and 4.8. This diagonal orientation extends from a port placed midline and 4–6 cm above the pubis. The diagonal now proceeds to the splenic flexure at 6–8 cm intervals. The fourth port is the 13 mm stapler port. As will be shown, this port can later be used as the extraction site if cosmesis is not important. An assistant 5 mm port can be placed equidistant from ports 3 and 4 or 2 and 3 depending on the patient’s body habitus. For situations where the robotic EndoWrist^® Stapler 45 System is not available, only four 8 mm robotic ports and a 12 mm assistant port are used as shown in Fig. 4.8. In this case, a 12 mm assistant port is necessary for bowel transection and creation of the intracorporeal anastomosis utilizing standard endoscopic staplers.

With the Xi system , the port configurations when placed in a line allow the most consistent performance of the entire operation [16]. The line should extend from 4 cm above the pubis in the midline toward the splenic flexure with ports placed 6–10 cm apart (see Fig. 4.7). Slight angulation away from the hepatic flexure provides in-line viewing of and access to a greater length of the proximal transverse colon. Further, moving the line of ports off the midline to the patient’s left facilitates dissection of the ileocolic pedicle. For complete mesocolic excision with central vessel ligation moving the entire line of ports further toward the patient’s left will enable access to the middle colic vessels along with more length of the transverse colon. Midline ports (placed along the linea alba) would lie directly above the ileocolic origin and might make its dissection more challenging. The assistant port is placed in the left lateral mid-abdomen.

Since the robotic EndoWrist^® Stapler 45 System was not yet available for the Xi at the time of this publication, it is recommended to add a 12 mm assistant port in the left lateral mid-abdomen for an intracorporeal anastomosis with a laparoscopic stapler. For an extracorporeal anastomosis, the port placement line can be through the umbilicus and linea alba (Fig. 4.6) with the port for arm 2 being placed at the umbilicus (which can be extended later for bowel exteriorization/specimen extraction). When the robotic stapler is available, a 13 mm port for arm 4 placed in the left upper abdomen is needed for the insertion of the robotic EndoWrist^® stapler for intracorporeal anastomosis creation.

Xi instrumentation for robotic right colectomy includes EndoWrist^® Stapler 45 System, EndoWrist^® One™ Vessel Sealer, bipolar fenestrated grasper, Tip-Up fenestrated grasper, and needle drivers. With regard to instrumentation, we recommend the use of the fenestrated bipolar in arm 1; 30° down da Vinci endoscope in arm 2; Monopolar Scissors (hot shears), Permanent Cautery Hook, or EndoWrist^® One™ Vessel Sealer device in arm 3; and a Tip-Up fenestrated grasper or Small Graptor in arm 4 (see Table 4.1). The Xi has to a great extent eliminated issues with arm collisions. So, although we advocate a three-arm technique with the Si system, we have adapted our technique to include all four arms with Xi.

The robotic camera is inserted through the 8.5 mm periumbilical port. The assistant surgeon uses a lateral 12 mm port to introduce laparoscopic instruments, energy devices, endoscopic staplers, and suction as needed. Using the bipolar fenestrated grasper (R2) and the hot shears (R1), a medial-to-lateral (MtL) dissection is realized. The port placement is as shown in Fig. 4.3. First, the assistant surgeon grasps the ileocecal junction (IJ) to place the ileocolic vascular pedicle on tension. It is critical to identify the cecum and ileocecal junction; this step cannot be over emphasized (Fig. 4.9a). A small window is created posteriorly near the origin of the ileocolic vessels . The dissection is continued for 2–3 cm to reveal the duodenum (Fig. 4.9b). Typically, the duodenum identifies the origin of the ileocolic artery. A second window is created to isolate the base of the vascular pedicle. It is divided at the level of the duodenum with a vascular stapler load on the endoscopic stapler, clips, or energy device, which are brought in through the left lateral 12 mm assistant port or the EndoWrist^® One™ Vessel Sealer may be used.

The medial-to-lateral dissection is continued. The right mesocolon is mobilized off the retroperitoneum. This dissection is mostly blunt and accomplished by pushing the mesocolon anteriorly and the retroperitoneum posteriorly. This can be advanced to the lateral attachments, to the liver and hepatic attachments, and to the duodenal sweep as needed. The ileal mesentery is divided with an energy source or cautery to a point 8–10 cm from the ileocecal valve. Typically, two small vessels or branches will be encountered and can be divided with an energy device or EndoWrist ^® One™ Vessel Sealer. The mesocolic mobilization is then carried up to the duodenum and the transverse mesocolon. The terminal ileum is transected with an endoscopic stapler or EndoWrist^® Stapler 45 System. Next the right branch of the middle colic is identified and transected with the energy device or stapler. The ascending colon can be left attached to the right paracolic gutter to keep it from falling medially or completely detached and the specimen placed above the liver for later retrieval (if the resection is for cancer, the specimen is placed in a bag). Lateral mobilization begins at the ileocecal junction along the right paracolic gutter and advanced to the hepatic flexure and along the right transverse colon. Sometimes omentum is removed with the specimen. Usually, the omentum is partially detached from the colon by dividing the gastrocolic ligament. The transverse colon is isolated by creating a mesenteric window and then divided with the endoscopic stapler or EndoWrist^® Stapler 45 System.

Next, attention is turned to construction of an isoperistaltic, side-to-side ileocolic anastomosis. For this purpose, the terminal ileum and the transverse colon stump are brought together side by side as shown in Fig. 4.10. A 20 cm nonabsorbable suture on a Keith needle is used to put a stay suture approximating the transverse colon and terminal ileum up to the abdominal wall to provide tension and elevate the site of the anastomosis. Prior to creating the enterotomies, an endoscopic intestinal clamp (bulldog) can be placed on the terminal ileum to prevent spillage (not the author’s routine). Using an energy device or hot shears (author’s preference), a colotomy and ileotomy are created through which the jaws of the endoscopic linear stapler or EndoWrist^® Stapler 45 System are introduced to construct the common channel (Figs. 4.11 and 4.12). The remaining common enterotomy is then closed with 2-0 vicryl in two running layers using robotic suturing techniques (Fig. 4.13).

Once complete, the stay suture is cut and then attention is directed again to the specimen. As an alternative, a complete robotic sewn anastomosis can be fashioned. If necessary, the remaining lateral and hepatic attachments are freed. A grasper with teeth or endoloop is introduced through the 12 mm left lateral port to hold the specimen (usually by the transected terminal ileum) and the robot is undocked. The 12 mm assistant port incision is then enlarged. We like to use the largest port incision for the extraction site since it will require closure anyway. Typically, only a 3–5 cm incision is necessary depending on the size of the pathology. A wound retractor (Alexis™ wound retractor, Applied Medical, Rancho Santa Margarita, CA) is placed to protect the skin, and the specimen is extracted. The extraction incision site can be placed in the suprapubic region or at any site per surgeon’s choice as shown in Fig. 4.14. Specimen extraction is typically transabdominal. As mentioned, intracorporeal anastomosis allows the surgeon to choose the extraction site as shown in Fig. 4.15.

Finally, laparoscopy can be performed to visualize the anastomosis and confirm hemostasis. It is not necessary to close the mesentery defect in most cases (the authors do not close the defect). The extraction site is closed in two layers. Any 12 mm port site incisions are closed. The skin is closed in subcuticular fashion (Fig. 4.16). A summary of the critical steps of robotic right colectomy with intracorporeal anastomosis (ICA) and our preferred instruments is shown in Table 4.1.

In 2011, our initial series was published comparing 25 laparoscopic to 22 robotic right colectomies [17]. Outcomes were similar and no conversions to open were necessary. Operative times were longer in the robotic group; however, intracorporeal anastomosis was used in the robotic group, whereas an extracorporeal technique was used in the laparoscopic group. We used a three-arm robotic colectomy technique from the start of our learning curve, initially to simplify the setup and decrease arm collisions.

By only utilizing three robotic arms when using the Si system, port placement is easier because there is less concern with arm collisions. This is especially useful during the initial experience when the surgeon is challenged with multiple nuances of a new technique. As experience is gained, a fourth arm can be used selectively. We have found it advantageous to use the fourth robotic arm in right colectomies in the obese patient and when the dissection is challenging.

We believe the technique as we described above can be used in most cases and decreases time-consuming exchanges of instruments to the robotic arms. A 12 mm left lateral port allows the assistant to quickly do the necessary exchanges of graspers, suction, harmonic scalpel, suture transfer, and laparoscopic staplers. The assistant is kept actively involved in the procedure and robotic arm exchanges are minimized. This is also useful when the assistant is teaching the procedure to the console surgeon. It may also make the operation more efficient.

More recently, our outcomes with 52 robotic right colectomies were published [18]. We have updated the demographics, outcomes, and complications for 100 robotic right colectomies for this chapter and summarized them in Tables 4.2 and 4.3.