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SURGERY

ThedaVinciSurgicalSystem(IntuitiveSurgicalInc.,Sunnyvale,CA, USA),firstintroducedin1999,isthesoleroboticsurgicalsystem currentlycommerciallyavailableintheUnitedStates.Itwasfirst approvedbytheFoodandDrugAdministrationforuseintheUnited Statesin2001.Theinitialprototypehadthreearms;in2003,the companyintroducedanewerversionwithafourtharm.Sincethenthere hasbeenthreegenerationalupgrades:thedaVinciSin2006,theda VinciSiin2009,andthelatestgeneration,thedaVinciXi,whichwas introducedin2014(Fig.17-1).
FIGURE17-1EvolutionoftheroboticdaVinci
SurgicalSystem.©2016IntuitiveSurgical,Inc.Used withpermission.
Thesystemiscomprisedofthreemaincomponents(Fig.17-2):
FIGURE17-2Operatingroomsetupforrobotic
rectalsurgery.
Surgeon’sconsole Apatient-sideroboticcartwithfourroboticarms(oneforthecamera
andthreeforsurgicalinstruments)thataremanipulatedbythesurgeon attheconsole
High-definitionthree-dimensionalvisionsystem,controlledbythe operatingsurgeon
Roboticsystemswereoriginallydesignedtoallowdissectionin confinedspacesandhavebeenwidelyusedforprostaticsurgerywith goodoutcomes.Thus,theroboticapproachbecameattractivein colorectalpelvicsurgeryexplicitlyinthemanagementofrectalcancer surgery.Becauserestorativeproctectomyrequiresatension-free anastomosis,splenicflexuremobilizationisgenerallyrequired.Theneed forcolonicmobilizationseparatesroboticrectalsurgeryfrom prostatectomy,whereextensionoftheoperativefieldisrequiredoutside theconfinedpelvicspace.However,limitedrangeofmotionofthe roboticarmsandsurgicalfieldcompromisingmultiplequadrants challengeadeptnessandefficiencyofroboticrectalsurgery,especially whenusingthepreviousroboticplatformssuchasthedaVinciSandda VinciSisystems.Toovercometheselimitations,severaltechniqueshave beendescribedforroboticrestorativeproctectomy:hybrid(with laparoscopicsplenicflexuremobilization),fullyroboticwithsingle docking([daVinciSi:generallyexchangingthesecondandthirdrobotic armsfordifferentpartsofthesurgery]or[daVinciXi]),orfullyrobotic withdoubledocking(firstdockingfromtheleftupperquadrantfor
splenicflexuremobilizationandthendockingtotheleftlowerquadrant fortherestoftheprocedure)(Fig.17-3AandB).
FIGURE17-3Operatingroomsetupfor(A)rectal
surgeryand(B)splenicflexuremobilization.
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OperatingRoomSetup
UsingbothdaVinciSiandXiSurgicalSystemsfortheroboticrestorative proctectomy,thepatientisplacedinamodifiedlithotomypositionusing adjustablelithotomystirrups.Theassistantsurgeonremainsontheright sideofthepatienttoassisttheconsolesurgeonthroughoneortwo additionallaparoscopicassistantports.Theoperatingroomdesign duringroboticsplenicflexuremobilizationisshowninFigure17-3B.For proceduresrequiringpelvicdissection,therobotistypicallydockedata 45degreeanglefromthepatient’sleftside.
PatientPositioning
Thepatientshouldbecorrectlypositionedonthemodifiedlithotomy position,whichallowsaccesstotheanusforthenumerouspurposes includingintraoperativeCO2colonoscopyand/orusingcircularstapling
device.IntraoperativeflexiblesigmoidoscopywithCO2hasbeenusedin ourpracticeforbothtumorlocationandanastomoticevaluation.The
lithotomypositionprovidesadditionalspaceforthesurgicalteam, especiallywhenoperatingintheupperquadrantsoftheabdomen,by standingbetweenthepatient’slegs(Fig.17-4).Paddedstirrupsoryellow finsareusedandattentionisgiventopreventingperonealnerveinjury. Botharmsaretuckedatthepatient’ssides.Agelpadontheoperating tablecanprovideadditionaldecubitussupportandstabilityagainst extremesoftabletilting.Changesinoperationtablepositionand subsequentpatientslidingcanleadtothestirrupapplyingpressuretothe
posterioraspectofthelowerextremityandconstitutesriskfornerve injury.Thus,weprefertosecurepatientsontheoperatingtablewitha strongtapeanteriorlysurroundingthechesttopreventthemfromsliding duringsteeptablepositions.
FIGURE17-4Demonstrationofthemodified
lithotomypositioninroboticrectalsurgery.
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PortPlacementandDocking
Toperformroboticrestorativeproctectomy,fivetosixportsarerequired, includingcameraandassistantports.Figure17-5showstheport placementforthreeroboticarms,camera,andassistantports.When usingtheSorSigenerations,a12-mmcameraportisplacedinthe supraumbilicalareawithanopentechnique.An8-mmportisplacedin theleftlowerquadrantlateraltotheumbilicus10cmapart;two additional8-mmportsareplaced,oneintherightupperandoneinthe rightlowerquadrant.Oneassistantportisinsertedontherightlateralto theroboticportsandinequaldistancefromtherightupperandlower quadranttrocars.Arightupperquadrantroboticport(port3)isusedfor thesplenicflexuremobilizationandleftcolectomy.Anadditionalrobotic port(port3P)isplacedintheleft-midabdomen,lateraltotheedgeofthe rectusmuscle.Thisport,3P,isusedforpelvicdissection(anterior resection,lowanteriorresection,abdominoperinealresection procedures).Theassistantportcanbeusedforsmallbowel/colon
retractionandsuctionirrigation.AfterthedaVincipatientcartisdocked asdescribed,thearmsarearrangedaccordingtoFigure17-2.Forthe purposeofthesplenicflexuremobilization,monopolarcurvedscissors (daVinciSurgicalSystem,IntuitiveSurgical,Sunnyvale,CA)isinserted throughrightlowerquadrantport(port1).Abipolargrasper(daVinci SurgicalSystem,IntuitiveSurgical,Sunnyvale,CA)isinsertedfromthe rightupperquadrantport(port3).ACadieregrasper(daVinciSurgical System,IntuitiveSurgical,Sunnyvale,CA)isplacedatport2lefttothe cameraport.Typically,theassistantinstrumentisentailedofa laparoscopicbowelgrasperorsuction.
FIGURE17-5Demonstrationofthetrocar
placementinroboticrectalsurgery.
Technique
Followingpneumoperitoneum,thecameraisinsertedandadditional trocarsareplacedunderdirectvision.Therobotisdockedusingthetwo right-sidedrobotictrocars(8mmand8mm)andtwoleft-sidedrobotic trocars.Thepatientthenispositionedintherightsidedownandslight
Trendelenburgtofacilitatedisplacementofthesmallbowelandthe cecumoutofthepelvis.Atfirstusingtherobot,amedial-to-lateral mobilizationoftheleftcolonisaccomplishedandthisisourpreferred approach.However,dependingonthecomfortlevelofthesurgeon,a lateralapproachcanalsobeutilized.
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ImportantStepsforMobilizationoftheSplenicFlexure andtheLeftColon(AppliestoBothHybridandTotal RoboticApproaches)
Weperformmedial-to-lateraldissectionandmobilizationusing embryologicplanesbetweenthemesocolonandtheretroperitoneum (Video17-1).Thenextstepsinournovelsplenicflexuretakedown techniqueareasfollows:
00:00/00:00
Video17-1:Medial-to-LateralTotal RoboticSplenicFlexureMobilization Technique
fromtheaorta
Aftertheparaaorticperitoneumisincised,theIMAisexposed;local tissueisclearedfromaroundthearteryatitsoriginfromtheaorta withoutinjuringthehypogastricplexus.Fortheligation,weuse endoscopicHem-o-lockclips(Fig.17-6).Theoperationisstartedunder theoriginoftheIMA,asoriginallydescribedbyFazioetal.Highligation oftheIMAallowsforadditionallymphnodestoberetrievedduring colorectalcancersurgery.
FIGURE17-6Demonstrationofthehighligation
oftheinferiormesentericarterywithendoscopic Hem-o-lockclips.(Hem-o-lok(r)MLXpolymericclips, NC,USA)
inferiorborderofthepancreas
ThehighligationoftheIMVwithendoscopicHem-o-lockclips facilitatesfurthermobilizationthroughthemesocolon(Fig.17-7). Usually,theIMVisneartheligamentofTreitzandpassesbelowthe borderofthepancreastojointothesplenicvein.
FIGURE17-7Demonstrationofthehighligation
oftheinferiormesentericveinattheinferiorborderof thepancreas.
betweenthemesocolonandGerota’sfasciaalongtheToldtline
anteriorborderofthepancreas
Thisisthemostimportantstepinoursurgicaltechnique.Tofacilitate thisentry,westartthedissection1cmlateralandanteriortotheligated IMVstump.Theposteriorwallofthestomach,pancreaticbody,andtail areclearlyvisualizedinFigure17-8.
FIGURE17-8Demonstrationoftheentranceto
thelessersacbydissectingthroughanteriorborderof thepancreas.
descendingcolon
Thefinalstepiscarryingthisdissectionacrossthesplenicflexureand towardthedistaltransversecolon.Atthispoint,themobilizationofthe splenicflexureiscompletedbydissectingthesplenocolicligamentand lateralattachmentsofthedescendingcolon.Enteringthelessersac earliermakesthisstepmucheasier.Ultimately,afullymobilizeddistal transverseandsplenicflexureisachieved.
Oncethemedial-to-lateraldissectioniscompletedandadequateleft colonicmobilizationachieved,therightupperquadrantroboticarmis flippedfromtherighttotheleftsideandthepelvicdissectionisstarted. Atthispoint,mesorectalexcisionbeginsatthesacralpromontorybelow theplaneofthesuperiorhemorrhoidalartery,intheavascularplanethat existsbetweenmesorectalenvelopeandendopelvicparietalfascia. Dissectioniscarrieddownallthewaytothelevatormusclewithcareful preservationofboththehypogastricnerveplexusesincludingtheerigent pillarandentiretyofthemesorectalenvelope.Classically,wedividethe rectumusingreticulatingroboticstaplingdevices,oftenwithoneor, occasionally,twofiresofroboticstaplers.Atthispoint,thereisalsoan unconventionaltechniquedescribed,whichincludestransectingthe rectumunderdirectvisionusingacauteryhookandthenpursestring sutureoftherectalcufffollowedbycircularstapler(EEA)(CovidienEEA Stapler,Medtronic,Inc,Minneapolis,MN,USA).Thespecimenisthen
exteriorizedfromtherightlowerquadrantincisionwherethepotential ileostomyisgoingtotakeplaceusingawoundprotector(Fig.17-9).As definedinthelaparoscopicsurgicalapproach,naturalorificespecimen extraction(NOSE)throughtheanushasalsobeenreportedinpatients undergoingtotalmesorectalexcision(TME).
FIGURE17-9Demonstrationofthespecimen
extractionthroughtheileostomysite.
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TheHybridRoboticTechnique
Thehybridtechniqueisalaparoscopic-assistedrobotictechnique.This eliminatesrepeatedmovementstorepositiontheroboticsystemandthus decreasesoveralloperativetime.Also,itiseasiertomobilizethesplenic flexurelaparoscopicallyandthenshifttoroboticsduringthepelvic dissectionforTME.Twomonitorsonbothsidesofthetableshouldbe routineinlaparoscopicsurgeryandrobotichigh-definitionvisionsystem ispositionedsidebysidethelaparoscopicmonitorforthebedside assistant.Thissetupisalsohelpfulinhybridprocedureswherepartofthe operationisperformedusingthelaparoscopicapproach(Fig.17-10).
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