Robotic Use in Inflammatory Bowel Disease

Fig. 20.1

Robotic IPAA port placement diagram. 12 mm camera port can be placed supra- or infraumbilically. Right upper quadrant port can be placed either through the ileostomy opening for IPAA or next to the ileostomy for completion proctectomy

Initially we begin with laparoscopic approach using 10 mm 30° laparoscope.

Two 8 mm robotic cannulas are placed 8 cm caudally to the umbilical port site approximately along the mid-clavicular line.

Two 5 mm ports to be used by the assistants are placed in the left and right upper quadrants.

In case of the proctectomy for J-pouch procedure, we initially begin with the takedown of end ileostomy (almost all of our patients have previously undergone laparoscopic total abdominal colectomy). Through the stoma opening, we place a 12 mm balloon tipped port. The remainder of the ports are placed as indicated above.
In case of a completion proctectomy for Crohn’s disease, care must be taken to avoid injury to the ileostomy while placing the ports.

It is important not to place robotic cannulas too laterally as the range of motion of robotic instruments will be limited due to high likelihood of their collision with pelvic sidewall as rectal dissection advances into deep pelvis.

Occasionally, the positions of robotic cannulas have to be adjusted caudally or cephalad to assure that the instrument will reach into the deep pelvis. Prior to inserting the robotic cannula, the surgeon can place a robotic instrument over the patient’s abdomen to assess whether the ports are at an optimal distance from the final point of dissection within the deep pelvis.

20.4 Initial Laparoscopic Dissection

We begin by laparoscopic surveillance of the abdominal cavity and adhesiolysis if necessary.
In thin patients, left ureter can often be visualized through the peritoneum. If the left ureter is not clearly visible, the peritoneum over right pararectal sulcus is incised and the plane advancing from right to left is developed within the bloodless plane just posterior to the superior hemorrhoidal artery. The left ureter can be identified along the pelvic sidewall using this technique, which is similar to the medial-to-lateral approach used for initial dissection during low anterior resection.
Once the left ureter is identified and protected, the superior hemorrhoidal artery is ligated and divided with a bipolar energy device.
In case of J-pouch procedure, we would also elongate the mesentery of the distal ileum using a laparoscopic technique to assure sufficient reach of the J-pouch.
The uterus is retracted anteriorly by suspending it with sutures using a Keith needle placed through its fundus and brought through the anterior abdominal wall.
Following that, the robot can be docked.

20.4.1 Docking the Patient-Side Cart

The patient is placed in approximately 30° Trendelenburg position.
The robotic patient’s cart is docked between the legs.
- We begin with 30° down robotic scope placed through the umbilical port. The use of the 30° down robotic scope allows for better visualization of the pelvic structures located posteriorly within the pelvis, particularly superior hypogastric nerve trunks as we advance over sacral promontory. As dissection advances deeper into the pelvis, we switch to 0° scope.

20.4.1.1 Instrument Selection

For a right-hand instrument, we use a monopolar hook cautery.
For a left-hand instrument, we use a bipolar single fenestrated grasper.
- By limiting the number of instruments to only two, we aim to provide simplicity and avoid frequent swapping of the instruments. This also helps to contain the cost of the robotic segment of the operation.
- We prefer not to use the third robotic arm as retraction provided by an assistant is more dynamic and allows more active involvement of a trainee in the case. However, if no appropriate assistant is available, a fourth arm can be used with the double fenestrated bowel grasper placed through the left upper quadrant port.
- We routinely use normal scaling of robotic masters during the initial segments of the operation and occasionally switch to fine scaling for deep pelvic dissection in the rectovaginal and recto-prostatic plane.
The assistant grasps the rectum with the bowel grasper from the left upper quadrant port and retracted anteriorly and cephalad. Either the same assistant or a different assistant uses laparoscopic suction inserted through the right upper quadrant port to help with smoke evacuation and gentle retraction if needed.
We use heated CO₂ insufflation, which helps to decrease the scope fogging.

20.4.2 Posterior Dissection

Rectal dissection begins in posterior plane. We prefer the TME plane because it provides a relatively bloodless plane of dissection and creates an anatomical reference point from which lateral and interior dissection can proceed.
With an assistant retracting the rectum anteriorly and cephalad, the robotic single fenestrated grasper retracts the posterior aspect of the mesorectum anteriorly and slightly caudally. When performed correctly, the surgeon can visualize a “cotton candy”-like areolar tissue between the fascia propria of the rectum and presacral fascia. While applying continued traction with the grasper, the hook cautery is used to divide the tissue in a U-shaped fashion. The dissection is taken to the level of Waldeyer’s fascia. Care must be taken to follow the TME plane of dissection anteriorly as one advances deeper in the pelvis. Failure to do that may result in troublesome bleeding from the presacral veins.
Pigazzi [7] has proposed a variation of a posterior dissection technique as it applies to the robotic approach. In this technique, the dissection posteriorly proceeds in an oblique fashion including the division of the tissue along the right lateral stalk curving posteriorly and to the left. This approach allows excellent exposure of the pelvis since the surgeon is no longer “working in the hole” of straight posterior dissection. By carrying this dissection slightly to the left within the TME plane, it helps to provide an initial dissection of the left lateral aspect where anatomical relationships of the mesorectum and the left ureter could be more challenging.