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approaches.DisColonRectum1998;41:832–8. KockerlingF,ReymondMA,SchneiderC,etal.Prospectivemulticenterstudyofthequalityof
oncologicresectionsinpatientsundergoinglaparoscopiccolorectalsurgeryforcancer.The
LaparoscopicColorectalSurgeryStudyGroup.DisColonRectum1998;41:963–70. KockerlingF,RoseJ,SchneiderC,etal.Laparoscopiccolorectalanastomosis:riskof
postoperativeleakage:resultsofamulticenterstudy.LaparoscopicColorectalSurgeryStudy
Group(LCSSG).SurgEndosc1999;13:639–44. KockerlingF,SchneiderC,ReymondMA,etal.Earlyresultsofaprospectivemulticenterstudyon
500consecutivecasesoflaparoscopiccolorectalsurgery.LaparoscopicColorectalSurgery
StudyGroup(LCSSG).SurgEndosc1998;12:37–41. LacyAM,Garcia-ValdecasasJC,DelgadoS,etal.Postoperativecomplicationsoflaparoscopic-
assistedcolectomy.SurgEndosc1997;11:119–22. LordSA,LarachSW,FerraraA,WilliamsonPR,LagoCP,LubeMW.Laparoscopicresectionsfor
colorectalcarcinoma:athreeyearexperience.DisColonRectum1996;39:148–54. MacRaeHM,McLeodRS.Handsewnvs.stapledanastomosesincolonandrectalsurgery:ameta-
analysis.DisColonRectum1998;41:180–9. MilsomJW,BohmB,DecaniniC,FazioVW.Laparoscopiconcologicproctosigmoidectomywith
lowcolorectalanastomosisinacadavermodel.SurgEndosc1994;8:1117–23. MonsonJRT,DarziA,CareyPD,GuillouPJ.Prospectiveevaluationoflaparoscopic-assisted
colectomyinanunselectedgroupofpatients.Lancet1992;340:831–3. PhillipsEH,FranklinM,CarrollBJ,FallasMJ,RamosR,RosenthalD.Laparoscopiccolectomy.
AnnSurg1992;216:703–7. PuenteI,SosaJL,SleemanD,DesaiU,TranakasN,HartmannR.Laparoscopicassistedcolorectal
surgery.JLaparoendoscSurg1994;4(1):1–7. SchlachtaCM,MamazzaJ,SeshadriPA,CadedduM,GregoireR,PoulinEC.Definingalearning
curveforlaparoscopiccolorectalresections.DisColonRectum2001;44:217–22. StocchiL,NelsonH.Laparoscopiccolectomyforcoloncancer:trialupdate.JSurgOnc
1998;68:255–67. WhelanRL.Laparotomy,laparoscopy,cancer,andbeyond.SurgEndosc2001;15:110–5. ZiprinP,RidgwayPF,PeckDH,DarziAW.Thetheoriesandrealitiesofport-sitemetastases:a
criticalappraisal.JAmCollSurg2002;195:395–408.
Chapter11
RoboticLeftColectomy
GarrettG.FriedmanandJoseG.Guillem
INDICATIONSANDCONTRAINDICATIONS
Leftcolectomymaybeindicatedforavarietyofbenignandmalignant conditions;however,themostcommonindicationsarecarcinoma,polyps notamenabletoendoscopicresection,andCrohn’sdisease.Otherless commonindicationsforresectionincludehemorrhageandischemia.The roboticapproachisgenerallyindicatedwheneverlaparoscopyis appropriate,whenthesurgeonisexperiencedandcomfortablewiththe roboticplatform.Thestandardcontraindicationsforlaparoscopy, includingpulmonarydiseaseprecludingpneumoperitoneum, uncontrolledcoagulopathy,andhemodynamicinstabilityremaintruefor roboticsurgeryaswell.Extensiveintra-abdominaladhesionsthatmay precludesafeminimallyinvasiveentryintotheabdominalcavityarea relativecontraindication.
PREOPERATIVEPLANNING
Patientsbeingconsideredforsurgicalmanagementofmalignancyshould havecarefulreviewofpreoperativeimaging,whichgenerallyincludes computedtomography(CT)scansofthechest,abdomen,andpelvis. Reviewofthepreoperativeimagingservesseveralimportantfunctions. First,itcanassistinthelocalizationofthetumorandconfirmthe locationofmalignancyintheleftcolon.Owingtotheredundancyofthe sigmoidcolon,endoscopiclengthmeasurementsandtheimpressionof theendoscopistmaynotprovideaccuratetumorlocalization.Second, carefulreviewoftheimagingcansometimesrevealsuspiciouslymph nodedisease,whichthesurgeonshouldplantoincludeinthesurgical specimen.Lastly,contrast-enhancedCTscansprovidecriticalanatomic informationthatmayaffectsurgicalplanningandcanassistwith dissection.Werecommendcarefulreviewofthemesentericvascular anatomyfoundonCTscanningbeforeembarkingondissection,because thisimagingprovidesaroadmapoftheoperationthatliesahead.
Allendoscopyreportsshouldbereviewedbeforesurgery;andifthere arequestionsregardingthelocationofthetumor,theoriginal endoscopistshouldbecontacted.Ifthelesionwasnottattooedinitially, westronglyadvisethatthepatientbereferredbacktotheoriginal endoscopistfortattooingofthelesion.
Theroleofmechanicalbowelpreparationremainscontroversial.Our currentpracticeisfullmechanicalbowelpreparationforallpatients, unlessacontraindicationexists.Oneimportantconsiderationregarding bowelpreparationforroboticsurgicalcasesbeingperformedfor malignancyisthatthetactilesensationofthesurgeons’fingerstopalpate thetumorisdiminished.Ifthereisaquestionastothelocationofthe tumor,itcanbeverydifficulttofeelthemassroboticallyifthecolonis filledwithstool.Forthisreason,theauthorsandeditorsstrongly recommendbowelpreparationforminimallyinvasiveoperations wheneverclinicallyfeasible.

SURGERY

Positioning
Thepatientisgenerallypositionedsupineforroboticleftcolectomy, althoughthelithotomypositioncanbeutilizedifthesurgeonisplanning toperformintraoperativecolonoscopy.Thepatientshouldbepositioned onananti-slipsurface,suchasagelpadoraneggcratefoam,for example.Werecommendanatraumaticcheststrapaswellaslegstrapto safelysecurethepatienttotheoperatingtable.Botharmsofthepatient aretuckedandallbonyprominencesarecarefullypadded.Thepatient shouldthenbeplacedinsteepTrendelenburgwithrightsidedownbefore drapingtoensurethatthesurgicaltableisfunctioningasexpectedand thatthepatientshouldideallynotslidewheninthisextremeposition.
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RoomSetup
Properorganizationandsetupoftheoperatingroomiscriticalforthe efficientperformanceofroboticsurgery.Forleftcolectomy,thepatient cartofthesurgicalrobotshouldbeontheleftsideofthepatient.We recommendthevisiontowertobelocatedontheleftsideofthepatient forthisoperation,becauseitprovidesadirectviewofthemonitorsfor thebedsideassistantlocatedonthepatient’srightside.Theavailabilityof appropriateinstrumentsshouldbeconfirmedbeforeincision,including theroboticvesselsealeraswellastheroboticstapler,ifintracorporeal divisionofthebowelisplanned.Theoperatingroomstaffshouldensure thattheTableMotionfeature,ifavailable,ispairedwiththerobotand correctlyfunctioning.
PortPlacementandInstruments
Thecameraportisgenerallyplacedineitherasupraumbilicalorslightly infraumbilicallocation,dependingonthepatient’sbodyhabitus.Ifmore workingroomandabroaderviewoftheabdomenaredesired,thecamera portcanbeplacedofftotherightside,atapproximatelythelevelofthe umbilicus.Theoperationistypicallyperformedusingallthreearmsof therobotandonelaparoscopicassistantport,althoughsomesurgeonsdo omittheuseofthethirdarmattheirownpreference.Ifanintracorporeal anastomosisisplanned,westronglyadviseutilizingthethirdarm.The
thirdarmisgenerallypositionedcephaladtothecameraport,justoffthe midline.Oneworkingarmisplacedbelowthecameraportandone above,spacedapproximately7cmapartformaximumclearance.If intracorporealdivisionofthebowelisplanned,itisoftenusefultoplace the12-mmstaplerportintheplaneoftheanticipatedPfannenstiel incision,tolimitthenumberoffascialclosuresnecessary.Severalport placementoptionsarepictured(Figs.11-1and11-2),including configurationsthatdonotutilizethethirdarm.Thelaparoscopic assistantportistypicallypositionedinthemid-rightabdomen,far enoughawayfromtherobotictrocarstopreventinterferenceofthearms withtheassistant’shand.
FIGURE11-1Portplacementforleft
colon/sigmoidresection.
FIGURE11-2Portplacementforonecartposition
lowanteriorresection(withpermission,HellanM, SteinH,PigazziA.Totallyroboticlowanterior resectionwithtotalmesorectalexcisionandsplenic flexuremobilization.SurgEndosc2009;23:447–51).
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Werecommendforthethirdarmalarge,atraumaticgraspingdevice suchasthetip-upfenestratedgrasperorthesmallgraspingforceps becausethisarmistypicallyretractingdelicatestructuressuchasthe colonoromentumtofacilitatedissection.ThePrograspcanalsobe utilizedforretraction,butshouldbeusedwithsignificantcautiononthe
bowel,becausethisisnotanatraumaticgrasper.Theinstrumentsutilized fordissectionontheothertwoarmsaretypicallyafenestratedbipolarin thelefthandandtheroboticmonopolarcurvedscissorsintherighthand. Ourpreferenceistoutilizethemonopolarcurvedscissorsfortheir precisionandabilitytolyseadhesionssharply.Therobotshouldthenbe dockedintheusualmanner;however,iftheXimodelisbeingutilized, targetingshouldbeperformedtowardthetumorlocation.
TechnicalDetails—InitialExplorationandExposure
Aninitialexplorationoftheabdomenshouldbeperformedtoruleout carcinomatosis.Afteraccomplishingthisstep,thetumorandtattoo shouldbeidentified.Ifthereisanyquestionastothelocationofthe lesion,thesurgeonshouldhavealowthresholdforutilizingCO
2
colonoscopyforconfirmationbeforeproceedingfurther.Afterlocalizing thetumor,appropriateexposureshouldbeobtained.Theomentum shouldbeflippedoverthetransversecolonandthesmallbowel positionedtowardtherightlowerquadrant.Weplacethepatientin approximately15degreesofrightsidedowntofacilitateexposure.Our preferenceistoinitiallyidentifytheinferiormesentericvein(IMV)asit exitsbelowtheinferiorborderofthepancreas,aswellastheleftcolic artery.TheIMVservesasareliableandconsistentanatomicmarkerand, assuch,representsasafelocationtobegindissection.
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Medial-to-LateralDissection
AnincisionismadeintheperitoneumunderlyingtheIMVanddissection iscontinuedinamedial-to-lateralmanner,usingacombinationof cauteryandbluntdissection,whichcontinuesuntiltheabdominalwallis reached.Thisdissectioniscontinuedinferiorlytotheleveloftheinferior mesentericartery.Althoughtempting,itisadvisabletorefrainfrom takingdownthewhitelineofToldtatthispoint,whichprovidesuseful lateralretractionofthecolon(Figs.11-3and11-4).
FIGURE11-3Initialexposureofinferior
mesentericvein(IMV).
FIGURE11-4Medial-to-lateralmobilization.Note
theupwardretractionofthemesocolonwiththeleft hand,exposingtheretroperitonealfoldontensionfor bluntdissection.
Mobilizationofthesplenicflexureisalmostalwaysrequiredforleft colectomyandcanbeperformedinmedial-to-lateralorlateral-to-medial manner,dependingonsurgeonpreference.Wetypicallyproceedusinga medial-to-lateralapproach.Thebodyofthepancreasshouldbe
identified,whichcanbedifficultintheobesepatient.Ausefulmaneuver istoobtainapanoramicviewandidentifytheduodenum,whichwilllead thesurgeontotheheadofthepancreas.Thethirdarmcanbeutilizedto placeupwardandslightlycephaladtractiononthemesocolontohelp exposethepancreas,whichcanoftenbeidentifiedasafattybulgeinthe retroperitoneum.Inmanyinstances,itispossibletoelucidateasubtle differenceinthecharacterofthepancreaticparenchymaversusthe mesentericandretroperitonealfat(Fig.11-5).
FIGURE11-5Initialexposureofpancreaticbody
duringthemedial-to-lateralapproach.
Anincisionisthenmadejustoverthesuperioredgeofthepancreas, andutilizingacombinationofcauteryandcarefulbluntdissection,the coloncanbefreedfromthepancreas.Atechnicalpitfallofthemedial-to­lateralapproachatthispointthatcannotbeoveremphasizedisthe correctidentificationofthepancreas.Theretropancreaticplanewill mobilizeinaclean,medial-to-lateralmanner,inadvertentlyleadingthe surgeondirectlytothesplenicvein.Theinabilitytocorrectlyand confidentlyidentifythepancreasduringthisportionofamedial-to­lateraldissectionrequiresconversiontoalateral-to-medialapproach. Anothertechnicalpitfallatthispointisinadvertentdamagetothe marginalarterybyupwardretraction.Thesurgeonmustalwaysbe cognizantofthestrengthoftheroboticinstrumentsandgaugeretraction appropriately.Oncethecolonhasbeenmobilizedawayfromthepancreas andthelessersacentered,thesplenocolicligamentsaredividedandthe omentumreleasedfromthetransversecolon.Thevesselsealerdevicecan behelpfulformaintaininghemostasisduringdivisionoftheomentum
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