Robotic left hemicolectomy and low-anterior resection

Indications

A left hemicolectomy is commonly indicated for colonic polyps, neoplasms, and diverticular disease. By employing robotic technology, we can offer a truly minimally invasive operation for varied pathologies. Robotic technology provides stable 3D visualization, more manual dexterity, and an additional arm for self-retraction or maintenance of exposure. These features are paramount when operating in tight spaces, such as the pelvis. Moreover, an intracorporeal anastomosis, which is technically challenging with conventional laparoscopy, is less cumbersome when facilitated by wristed robotic instrumentation. An intracorporeal anastomosis provides the benefits of accelerated gastrointestinal recovery and a lower surgical site infection rate and minimizes the postoperative incisional hernia risk.

Relative contraindications to the robotic approach are few, including the need for challenging multivisceral resections and, rarely, the multiply re-operated abdomen, where adhesions may be prohibitive to a safe, minimally invasive operation. In this chapter, I will describe my routine surgical approach to the sigmoid colon and upper rectum.

Patient preparation

Surgical setup and patient positioning setup

After the induction of general anesthesia, the patient is positioned in lithotomy using Allen Yellofins (Allen Medical, Acton, MA), after taking off the foot piece of the operating table. The arms are preferably tucked, and pressure points must be padded. It is important to secure the patient to the operating table with a safety strap or nonslip padding. Port positions and trocar sizes are depicted in Figs 25.1 and 25.2 and Fig. 25.3 for the Xi and Si systems, respectively. With that schema in mind, we commence the operation in the right lower quadrant, with a transverse 3–4-cm skin incision. A muscle-splitting approach is used. Once access to the abdomen is accomplished, an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA) with its cap cover is placed in this incision. A 12-mm robotic trocar is inserted directly through the Alexis cap and the pneumoperitoneum is insufflated. This initial surgical access is multifunctional as the initial camera port, the ultimate stapler port, the anvil introduction site, the specimen extraction site, and potentially a diverting loop ileostomy site, if necessary. At this point, I tend to use a roughly 25–30-degree Trendelenburg position, with 35-degree right tilt. Three additional 8-mm robotic trocars are placed, creating a gentle half-moon line. The concavity of the imaginary line points to the sigmoid colon and upper rectum. An (optional) 5-mm assistant port is usually placed laterally in the right abdomen, behind the 12-mm trocar site. My personal preference is to use an Airseal (Conmed Corporation, Utica, NY) 5-mm trocar as my assistant port. This allows continuous smoke evacuation and prevents the loss of pneumoperitoneum during suctioning and, later, anvil introduction. The Xi robot can be docked from either side, but the Si must be docked over the left hip. Xi robotic instruments are inserted under laparoscopic visualization as follows: Arm #1 holds a tip-up grasper, and Arm #2 holds a fenestrated bipolar grasper; Arm #3 sequentially holds the 30-degree camera, which is then replaced by a robotic 45-mm stapler; and Arm #4 holds monopolar scissors, which are later exchanged with a vessel sealer. At this point, the surgeon retreats to the robotic console. The assistant remains at bedside, typically on the right side of the patient.

Key operative steps