Typically four trocars are placed through the single-incision access device (see Figs. 19.4 and 19.5). A 12-mm trocar for the robotic lens in the middle, two 8-mm trocars (arms 1 and 2) for each of the robotic arms to each side of the lens, and an additional 5-mm trocar for the robotic assistant. At the time of insertion, trocars should be placed aiming perpendicular to the skin level toward the center of the single-incision access device instead of in the direction of the target organ. This avoids excessive torsion on the incision during the procedure and also allows a greater range of motion for the instruments, which would otherwise lie close to the abdominal wall. If possible, have the thick black line at approximately the level of the peritoneum to reduce tension at the crossed arm areas. But, the thick black line can also be slightly above if more length is needed externally to separate the arms. We also use long bariatric trocars to keep arms 1 and 2 further away from each other. A 30 up positioned camera is then positioned underneath and between the two arms. This allows the surgeon to view the procedure between the two instruments, with the instruments coming from above into view. We then manually switch arm 1 from the left hand to the right hand, and manually switch arm 2 from the right hand, to the left hand. Since the arms are crossed, the right hand will be controlling what appears to be the robotic right hand intraperitoneally, even though it is really the left arm crossing over and vice versa.

We use the Applied Gel Point that is used for single-incision surgery (see Fig. 19.4). The robotic 8 mm trocars can all go through the applied trocars. At the start of the case, we place four of the applied trocars in a diamond configuration, with one of the points aiming at the right colon. At the top of the diamond closest to the right colon, the camera is placed. Arm 1 goes into the caudal port and arm 2 goes into the cephalad port. The port farthest from the right colon can be used as an assistant port. The assistant is mainly used for suction and retraction. This assistant is unique in SIRC as assistant ports are not generally used in SILS.

The robot is typically docked to the side where the intended anatomic site is located. For example, the robot will be docked perpendicularly from the patient’s right side for a right hemicolectomy and from the patient’s left side for a sigmoidectomy, with the robotic assistant standing to the opposite side.

For a right hemicolectomy, the robot is docked perpendicular to the patient, with the patient in slight trendelenburg position and airplaned to the left. This allows the omentum to be placed easily over the transverse colon, while the small bowel is left in the pelvis. This also allows the surgeon to see the root of the mesentery of the right colon and facilitates a medial-to-lateral dissection. A long grasping retractor is placed in arm 2 to assist in triangulation. A vessel sealer is placed in arm 1 for tissue manipulation, blunt dissection, and vessel ligation.

We start by grasping the cecum and tenting it up toward the right lower abdominal wall. With the cecum tented up, we are able to identify the ileocolic artery. We score underneath the artery and begin our blunt medial-to-lateral dissection. Once the duodenum is identified near the base of the ileocolic artery, we then use the vessel sealer to transect the artery. Care is taken to avoid injuring the duodenum. We can then carry our dissection in a cephalad direction until the right branch of the middle colic is encountered and transected. At this point, we have transected all the major arteries needed for our right colectomy.

We next bluntly separate the mesentery of the right and transverse colon from the retroperitoneum. This medial-to-lateral dissection is done under direct vision. Sometimes we can completely separate the right colon and proximal transverse colon and gain access into the lesser sac and dissect through the right white line of Toldt.

If this has not been the case, we will finish our medial-to-lateral dissection and separate the omentum from the transverse colon, gaining access into the lesser sac. We then enter our previous dissection plane to the right of the duodenum and fully mobilize the hepatic flexure. The right white line of Toldt is then mobilized in a top-down manner. Lastly, we mobilize the cecum and distal small bowel mesentery completely off the sacral promontory. It is very important to mobilize the ileal mesentery off the sacral promontory close to midline in order to facilitate subsequent exteriorization and extracorporeal anastomosis. Once all the mobilization is done we also use the vessel sealer to transect the mesentery of the ileum 10 cm from the ileocecal valve and transect the mesentery of the transverse colon at the appropriate distal margin. This helps reduce the risk of mesentery avulsion and bleeding that can occur with exteriorization and anastomosis.

At this point, the entire intra-abdominal portion is done. We then exteriorize the right colon through the gel point base which acts as a wound protector. The small bowel and transverse colon are transected with a GIA stapler . The specimen is opened in the back table to inspect margin. In order to determine appropriate perfusion of transected intestine ends, 3–4 cc (8–10 mg) of ICG is injected intravenously. Using the robotic camera with the Firefly view, the transected bowel ends are inspected and any area of hypoperfusion is transected if noted.

Once the perfusion of intestinal ends is deemed appropriate, an anatomic side-to-side functional end-to-end anastomosis with a 75 mm stapler and a 55 mm transverse stapler is fashioned. The anastomosis is then placed back into the abdomen and the fascia is closed with 0 PDS sutures in figure of eight fashion (see Fig. 19.6).