Robotic Total Colectomy

Fig. 7.1

OR setup and patient preparation—right and proximal transverse colon . Patient is placed in lithotomy position with right side tilt in mild reverse Trendelenburg. The robotic second arm is placed ipsilateral to the fourth arm and extended over the patient’s head

The anesthesia cart is positioned at the head of the patient’s bed. The anesthesiologist must utilize tubing long enough to allow rotation of the patient in any direction necessary to accommodate the robotic platform. We advise the operating surgeon to sit on the right side of the patient, positioned toward the feet, to ensure direct view of the robotic arms and assistant at all times; thus, we advise against surgeon positioning behind the platform.

The first assistant should sit on the left side of the patient to avoid injury from the moving camera. We also recommend the use of a two-way radio between the surgeon and first assistant to prevent breach of communication. The surgical technician is positioned on the left side of the first assistant to pass instruments as needed. The tower and robotic power source is located at the foot of the table. Two monitor slaves are required and may be relocated depending on the surgical quadrant.

When performing procedures that require multiple positions, it is imperative to secure the patient to the operating table to prevent sliding. Surgical beanbag positioners may be used to prevent movement. If used, care must be taken to ensure that the lateral sides of the beanbags do not interfere with the third robotic arm.

Prior to docking of the robot, the ileocolic vessel and duodenum are identified laparoscopically. The initial portion of the robotic procedure—right colon mobilization and hepatic flexure mobilization—requires a few degrees of reverse Trendelenburg and tilt to the right. The same position is maintained until the mid to distal transverse colon is reached. Once reached, the robot is re-docked over the patient’s left shoulder, as illustrated in Fig. 7.2. The patient remains in mild reverse Trendelenburg. The distal transverse colon, splenic flexure, and a significant amount of proximal and descending colon are subsequently dissected.

Fig. 7.2

OR setup and patient preparation —splenic flexure and distal transverse colon. Patient remains in lithotomy position with left side tilt up and in mild reverse Trendelenburg. The robot is re-docked over the patient’s left shoulder

The final stages of the procedure—accessing the distal descending colon to the rectosigmoid junction—require turning the patient on an axis and brining the platform over the left hip at a 45° angle, as illustrated in Fig. 7.3. The patient is then placed in a Trendelenburg position with the patient’s left side up. This facilitates movement of the small bowel out of the pelvis and to the right of the right iliac vessel until the inferior mesenteric vessels are identified.

Fig. 7.3

OR setup and patient preparation —left and sigmoid colon. Patient remains in lithotomy position with left side tilt up and in mild reverse Trendelenburg. The patient is turned on an axis, and the platform is moved over the left hip at a 45° angle

We caution against prolonged steep (25–45°) Trendelenburg position to prevent significant physiologic consequences, such as pulmonary edema, exacerbation of ventilation/perfusion mismatch, and upper airway and brain edema [9]. The wristed arms of the robot allow for precision which make the dangerous practice of steep Trendelenburg virtually unnecessary.

Trocar Placements

Multiple quadrant access is required for this procedure. The operating surgeon must be cognizant of the procedural steps to minimize trocar placement despite multiple dockings. We suggest port addition as the surgery progresses to accomplish this goal. The initial trocar configuration mimics that of a right hemicolectomy. The configuration will then emulate that of an isolated splenic flexure lesion and finally a sigmoidectomy. The camera port will remain in the midline in order ensure equal access to all quadrants.

The camera port is placed in the midpoint between the xyphoid process and the pubis. The surgeon must avoid placing the camera port too low to ensure visualization of the hepatic and splenic flexures over the transverse colon and, at the same time, avoid placing the camera too high to circumvent the falciform ligament and prevent obscure visualization of the operative field. The camera port may be moved laterally, in either direction; however, that practice may place the camera too close to the target in subsequent steps of the operation and should be avoided.

The first arm trocar is placed to the left of the midclavicular line, as illustrated in yellow in Fig. 7.4. The second arm trocar is placed at the midpoint between the camera port and the pubis. We prefer to make this incision horizontally in preparation for our extraction site. The third arm trocar is placed to the left of the falciform ligament. The surgeon must take care to allow adequate distance for access to the gastrocolic ligament. The assistant port is placed at the midpoint between the first and second arms after making sure that the robotic camera will not interfere with the assistant’s hand. This trocar configuration will allow the operating surgeon to reach the level of the proximal to mid-transverse colon.

Fig. 7.4

Port placement—right and proximal transverse colon . Target anatomy is referenced in orange. Camera port is referenced in blue and is placed at the midpoint between xyphoid process and pubis. Instrument arm 1 is referenced in yellow and is placed to the left of the patient’s midclavicular line. Instrument arm 2 is referenced in green and is placed at the midpoint between the camera port and the pubis. Instrument arm 3 is referenced in red and is placed to the left of the falciform ligament. The 12-mm assistant port is referenced in black and is placed at the midpoint between the first and second instrument arms

The second stage of the operation involves the dissection of the mid-transverse colon, splenic flexure, and proximal descending colon. Once again, the robotic platform is re-docked over the patient’s left shoulder. A 12-mm assistant port is added in the right lower quadrant at the midpoint between the camera port and the iliac spine. During the second stage, this port will serve as the assistant port; during the final stage of the procedure, it will become the first arm. An 8-mm port is added to the right upper quadrant, as illustrated in red in Fig. 7.5, which will now serve as the second arm.

Fig. 7.5

Port placement—splenic flexure and distal transverse colon . Target anatomy is referenced in orange. Camera port remains the same as Fig. 7.4. Instrument arm 1 is referenced in yellow and is re-docked at the previous left lower quadrant assistant port site. Instrument arm 2 is referenced in red and is placed to right of the patient’s midclavicular line. Instrument arm 3 is referenced in clear and is re-docked at the previous site of instrument arm 2 in Fig. 7.4. The 12-mm assistant port is referenced in white and is placed at the midpoint between the second and third instrument arms

At this point, the first arm is docked on the previous left lower quadrant assistant port site. The third arm is docked in the suprapubic area where the second arm was docked previously.

For the final stage of the procedure, the patient is turned on an axis with the platform over the patient’s left hip at a 45° angle. The distal descending colon, sigmoid colon, and rectosigmoid junction are accessed with the following trocar configuration, as illustrated in Fig. 7.6.

Fig. 7.6

Port placement—left and sigmoid colon . Target anatomy is referenced in orange. Camera port remains the same as Figs. 7.4 and 7.5. Instrument arm 1 is referenced in yellow and is re-docked at the previous right lower quadrant assistant port site. Instrument arm 2 is referenced in green and may remain docked as placed in Fig. 7.5 or may be re-docked to the left lower quadrant port site. Instrument arm 3 is referenced in red and is re-docked at the previous site of instrument arm 1 in Fig. 7.4. The 12-mm assistant port is referenced in black and is re-docked at the previous site of instrument arm 3 in Fig. 7.5

The first arm is re-docked at the site of the right lower quadrant assistant port. The second arm may be placed in two possible areas: remain docked on the right upper quadrant where it was previously or re-dock at the left lower quadrant where it was previously the first arm with the robotic platform over the right shoulder.

The third arm is re-docked close to the left anterior axillary line. This is where the first arm was docked at the beginning of the case . Alternatively, an additional 8-mm trocar may be added if the previously placed port is not in an optimal position to be used as the third arm.

Docking

The surgeon must make sure that the bed is in the correct orientation, that proper safety belt or beanbag is employed, and that the patient is positioned in a modified lithotomy position for access to the peritoneum, as needed, prior to docking. Platform location is dictated by the quadrant in which the surgeon is operating.

In the case of a subtotal colectomy, we prefer to start with the right colon. Thus, the platform is placed at the patient’s right shoulder and toward the patient’s head to ensure that the third arm can clear the patient’s head. When docking the robot, the surgeon must align the robotic spine, camera arm, and camera shoulder while ensuring that the robot is neither docked too far nor too close to the patient.

Care should be taken to ensure that the blue arrow is in the middle of the marked areas, especially if single docking procedures are to be attempted. Prior to docking, a brief laparoscopic inspection should be performed in order to expose the anatomy; this is especially important if organs are to be retracted toward the opposite quadrant to where the platform will be docked. The operating surgeon must understand that the S and Si platforms are designed to work in one quadrant. For this reason, exposures such as mobilizing the small bowel out of the pelvis and/or to the right upper quadrant must be achieved prior to docking the platform, especially if the platform is to be docked over the left hip.

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