Obesity is associated with increased conversion rate, operating time, and postoperative morbidity of laparoscopic colorectal surgery but does not affect surgical safety or oncological security. Some authors expect that with the application of laparoscopic surgery in patients with cancer, the oncological results have improved outcomes. Balentine et al. [12] found fewer complications and rapid recovery in minimally invasive surgery than the open surgery in cancer patients and also more accurately lymph node resection and more technically demanding due to hindered exposure of the bowel, thickened mesentery with difficulty in dissection, mobilization, or ligation of the vessels. The total mesorectal excision (TME) , now the standard technique for surgical treatment of rectal cancer, has led to a reduction in local recurrence rates. The relative inaccessibility of the rectum within the bony pelvis and the proximity of other major anatomic structures place particular technical challenges to surgeons. High BMI increases the technical difficulty of TME and can compromise the possibility of complete resection, resulting in poorer oncologic outcomes [13] (Fig. 10.2).

The da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA^®) offers numerous advantages when compared to laparoscopy, including several degrees of motion, three-dimensional (3D) imaging, and superior ergonomics that enable easy and precise intracorporeal suturing. The improved visualization and tremor-less precision form the basis for the emergence of robotic techniques (Fig. 10.3).

Positioning: Positioning is a challenge in obese patients; they are at higher risk for pressure sores and neural injuries depending on the position used for surgery. Placement is always necessary in these patients by limitation of intra-abdominal space needing a table that can accommodate the specific weight of the patient with proper padding, beanbag, and appropriate retrains over the chest and also sometimes adequate arm boards (Figs. 10.4 and 10.5).

Gaining Intraperitoneal Access: Gaining safe intra-abdominal access remains the first step in minimally invasive surgery. This can be made difficult in the morbidly obese and in multiply operated abdomen. Sites of previous operative intervention will certainly influence the strategy to gain initial access. Individual surgeons will need to judge their laparoscopic capabilities realistically in offering laparoscopic colorectal procedures to their morbidly obese patients.

With proper preparation and careful consideration of surgical pitfalls of laparoscopy and robotics, the majority of the colorectal procedures that can be performed using a Veress needle or a trocar with direct laparoscopic visualization (Fig. 10.6) may be an easier approach, but traditional landmarks cannot be used in the morbidly obese patients. For extremely obese patients, longer trocars may be used, although these are rarely needed; for the robotic camera arm, the trocar should be 15 cm in length (Fig. 10.7). In these morbidly obese patients, the umbilicus is pulled downward. This means that some trocars need to be placed in the supraumbilical area. Leroy et al. analyzed 123 patients with laparoscopic left colectomy and reported that an increased number of ports were required in obese patients compared to non-obese patients.

Trocar Selection and Port Placement : Traditional landmarks cannot be used in the obese patient. For extremely obese patients, longer trocars may be used, although these are rarely needed. For the robotic camera arm, the trocar should be 15 cm in length. In these obese patients, the umbilicus is pulled downward. This means that some trocars are placed in the supraumbilical area (Fig. 10.8).

Incisions are placed 20–25 cm from the target, but in the obese, the distance should be confirmed and measured once the camera is inside the abdomen. Once the first port is placed under pneumoperitoneum, a minimum of 8–10 cm is measured between all trocars. Sometimes “cheating” on the trocar is necessary to be able to reach the target with minimal loss of the function of the robotic arm (Fig. 10.9).

If the patient is morbidly obese , the trocars are usually placed closer to the target anatomy. One example is the right colectomy where the ports tend to be closer to the umbilicus and midline in these obese patients, compared to their counterparts that are placed more laterally. This is because it is easier to go over the colonic flexures and able to see laterally straight down to the line of Toldt with the 30° down scopes.

In 1974 Palmer [14] described a technique of putting a small trocar below the left costal margin for an abdominal entry. This author prefers to use this technique because in the subcostal region in the mid-clavicular line, the abdominal wall is thinner by the ribs exerting traction (Fig. 10.6), but the surgeon should do the technique that he or she is comfortable with.

There is much controversy over the number of trocars and where to place them. But the most important thing is to place the necessary trocars to improve the performance.

Important steps to identification of anatomy will be: