Robotic right colectomy does not differ in any way from its laparoscopic counterpart. We routinely perform medial-to-lateral dissection with early division of the ileocolic pedicle close to its origin from the superior mesenteric vessels. Arm #3 provides traction to the cecum/terminal ileum to give tension and to lift the ileocolic vessels. The retroperitoneal space immediately below the vessels is entered and a retroperitoneal “cave” is developed, making maximum use of the pneumoperitoneum (Fig. 17.3). The duodenum is identified and displaced posteriorly and the ileocolic vessels are skeletonized and ligated/divided with clips, endovascular linear stapler, or energy source (Fig. 17.4). Arm #3 then grasps the divided ileocolic pedicle and retracts it toward the anterior abdominal wall. The retroperitoneal “cave” is further developed with identification of the right ureter. Gerota’s fascia is displaced posteriorly and the retroperitoneal dissection is completed out to the lateral parietal attachments and to the underside of the hepatic flexure.

The mesentery of the terminal ileum is divided up to the point of division of the small bowel. The assistant then divides the terminal ileum using a laparoscopic linear stapler. Division of the remaining peritoneal adhesions holding the inferior pole of the cecum and appendix is performed and extended up the right paracolic gutter, thus freeing the entire inferior and lateral part of the right colon. The dissection is completed with division of the hepatic flexure. This is best performed by retracting the right colon with the arm #3 grasper, retracting the transverse colon caudally by the assistant, and opening up the greater sac along the proximal transverse colon.

Once the hepatic flexure has been fully mobilized extending past the origin of the middle colic vessels, consideration is given to whether the middle colic vessels should be divided. This is a decision based upon the location of the tumor in the right colon. For proximal cancers it is usual to take the right branch of the middle colic artery. For hepatic flexure tumours the entire middle colic blood supply may be sacrificed. Division of the middle colic vessels may take either an infracolic or supracolic approach, depending on the ease of access. Vessel division and ligation is performed by the assistant using either clips or the laparoscopic linear stapler with a vascular cartridge. The right colon is now fully mobilized and resection is completed by division of remaining mesocolon up to the point of resection of the transverse colon.

The next decision is whether to perform an extracorporeal or intracorporeal anastomosis. For an extracorporeal anastomosis, the robot is undocked and a 5-cm umbilical incision is made to accommodate an Alexis wound retractor (Applied Medical). The right colon is delivered through the wound retractor and the resection and anastomosis completed in the usual fashion. For an intracorporeal anastomosis, the proximal transverse colon is divided by the assistant with a laparoscopic stapler and the mobilized right colon placed out of the way in the pelvis. Two sutures are used to approximate and orientate the divided ends of the terminal ileum and transverse colon. An enterotomy and colotomy are made at the distal proposed anastomotic site using diathermy scissors. A laparoscopic stapler is placed into the lumen of the bowel ends by the assistant with tension provided by a robotic grasper on the orientating sutures. The stapler is fired and carefully removed to prevent spillage of enteric contents (Fig. 17.5). The resulting entero-colotomy is closed by robotic suturing to complete the anastomosis (Fig. 17.6). The resected right colon is retrieved and extracted through a convenient site, but usually in the suprapubic region for best cosmesis. A final laparoscopic inspection is performed to ensure good hemostasis and the wounds closed taking care to prevent port-site herniation.

Postoperatively, patients are managed according to an enhanced recovery protocol [20]. Fluids are given as tolerated including dietary supplements and soft diet is commenced as tolerated from postoperative day #1. Patient controlled analgesia (PCA) is used until fluids and oral analgesia are tolerated. Early mobilization is encouraged with physiotherapy support. Thromboprohylaxis with fractionated subcutaneous heparin and antiembolism stockings is continued in the early postoperative period and continued for 1 month. Further antibiotics are avoided, unless there is a clinical indication. Patients are discharged when they are tolerating normal diet, mobile, and comfortable on oral analgesia.

The potential complications following robotic right colectomy include those related to any major abdominal operation with general anesthesia and those specific to a laparoscopic or robotic approach.