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266
M.H. Whiteford
and sympathetic nerves innervating the urogenital regions.
Despite its wide acceptance, TME does have its technical
challenges related to exposure and dissection of the proper
planes in the confi nes of the deep bony pelvis. The pelvic
curvature makes visualization of the anterior structures diffi cult, particularly in the obese or in males with an enlarged
prostate. Long lighted retractors and/or headlights are
required to gain visualization in the deep pelvis. Identifi cation
of the distal oncologic margin is estimated by techniques of
external palpation, digital rectal examination, or visualization of a diffused tattoo—and this critical step is relegated to
the end of the procedure. Even following successful pelvic
dissection, current laparoscopic stapling devices utilized for
rectal division have limited angulations, making a perpendicular rectal division and seal with a single cartridge application the exception rather than the rule. Hence, distal rectal
division often necessitates several overlapping staple lines
to complete the distal rectal transection, which may lead to
increased risk of anastomotic leak [
While NOTES surgery is being performed in very select
cases in specialized centers, in reality, it is proceeding
through three overlapping phases of clinical development.
The fi rst (and still ongoing) phase involves preclinical work
identifying safety and effi cacy, appropriate procedures, technical factors, and instrument development. A second phase
will be early adoption of hybridized procedures that are a
combination of established laparoscopic and transanal procedures. This phase is also starting to gain traction, though
still remains somewhat of a niche. With increasing experience and new instrument development, the laparoscopic
components can be phased out, and the third phase of fully
transanal NOTES procedures will transcend.
14 , 15 ].
Phase 1: Preclinical NOTES Developments
Based on the tenets laid fourth by the NOTES White Paper
2 ] calling for preclinical laboratory investigations prior to
[
clinical introduction, several investigators began laying the
groundwork for transanal NOTES procedures. Radical transanal sigmoid colectomy with intracorporeal anastomosis was
initially performed in the cadaver model using off the shelf
transanal endoscopic surgery instrumentation, demonstrating the feasibility and fundamental steps of this procedure
[
16 ]. This and other studies confi rmed the reproducibility of
this technique for pelvic rectal dissection [ 17 – 19 ]. From
these experiences, it seems that the primary technical limitation of a pure NOTES rectosigmoid resection was not the
pelvic dissection, but rather the sacral curvature and sacral
promontory that limited current rigid and fl exible instruments access and safe dissection higher in the abdomen. Key
portions of the rectosigmoid resection such as high ligation
of the inferior mesenteric artery and vein and left colon
and splenic fl exure mobilization could not reliably be
accomplished with either currently available rigid or fl exible
instruments [
hybrid transanal proctectomy with laparoscopic assistance for
the abdominal portions of the procedure was the initial
transanal NOTES procedure to break into the human clinical
realm.
The potential benefi t of a hybrid transanal TME realized
during these studies was that it allowed surgeons to overcome some of the challenges of operating in the deep pelvis
by performing the deep pelvic dissection from the bottom
up. This includes better visualization of the mesorectal
envelope with easier retraction and dissection, as well as a
more precise determination of the oncologic distal margin.
The potential disadvantages include the learning curve in
adopting this new point of view, the remaining underlying
technical diffi culty of the procedure, and the potential risk of
bacterial or tumoral peritoneal contamination.
Due to these limitations and obvious concerns over patient
safety, the initial foray into transanal total mesorectal excision was performed in a hybrid fashion whereby the deep
pelvic portion of the surgery was performed transanally, and
the left colon mobilization, vascular ligation, upper pelvic
dissection, and air leak test were all performed via standard
laparoscopic techniques. What seems apparent is that for the
foreseeable future, laparoscopic assistance will be required
until technological advancements in surgical instrumentation
permit reproducible facile performance of the abdominal
steps of the operation in a safe, reliable, and cost-effective
fashion.
17 , 19 , 20 ]. To overcome these obstacles, a
Phase 2: Initial Clinical NOTES Developments,
Hybrid Laparoscopic and Transanal
Rectosigmoid Resection (Transanal Total
Mesorectal Excision (
The fi rst hybrid transanal total mesorectal excision was
performed by the team of Sylla and Lacy in 2009 [
patient was a 76-year-old woman with node-positive rectal
cancer treated with preoperative chemoradiotherapy. They
performed a combined transanal, transvaginal, and laparoscopic total mesorectal excision. Since then, the number of
case reports detailing various modifi cations of taTME is
approaching 100 patients [ 3 , 21 ]. The collective early experi-
ence for transanal total mesorectal excision in cancer patients
has shown feasibility by demonstrating intact mesorectal
specimens, negative circumferential radial margins, adequate
lymph node harvest rate, and acceptable complication rates
in properly selected patients [
long-term oncologic results have yet to be reported, and
future implementation of this method depends largely on
these outcomes.
taTME))
20 ]. This
21 ]. Unfortunately, to date, the
23 Natural Orifi ce Surgery (NOTES)
267
Patient selection : Most clinical studies included patients preop-
eratively staged at T1-3, N0-1, M0, and with a negative predicted circumferential margin based on preoperative clinical
examination and imaging. One study varied from this theme
and included particularly high-risk patients with T4 tumors,
recurrent cancers, and cancers with less than 1 mm circumferential radial margin [ 22 ]. Not surprisingly, they report an
increased positive circumferential margin rate of 13 % and
higher cancer recurrence rates. At present, these high-risk
patients should be excluded from early investigations.
Transanal TME (taTME) Procedural Steps
(Table
The patient receives a mechanical bowel preparation, perioperative antibiotics, and pharmacologic thromboembolic prophylaxis. Preferred positioning in the operating room is
lithotomy prepped for synchronous abdominal laparoscopy
and transanal endoscopic surgery (Fig.
commences with placement of an anoscope to visualize the
rectal lumen and the tumor. A suture purse string is then
secured 1–2 cm distal to the tumor to mechanically occlude
the proximal bowel from stool spillage during the case
(Fig. 23.2 ). A circumferential, full-thickness, hemostatic
incision is then created to transect the rectum just distal to
the purse string. This step can be performed via traditional
anoscope or via a transanal endoscopic surgery (TES) platform. Several platforms have been described including TEM
(transanal endoscopic microsurgery, Richard Wolf GmbH,
Knittlingen, Germany), TEO (transanal endoscopic operations, Karl Storz GmbH, Tuttlingen, Germany), or TAMIS
(transanal endoscopic minimally invasive surgery) disposable platforms: SILS™ Port, (Covidien, Mansfi eld, MA) or
GelPOINT Path (Applied Medical, Rancho Santa Margarita,
CA) (Fig. 23.3 ). The remaining of the pelvic dissection is
performed via the TES platform of choice.
23.3 )
23.1 ). The operation
Dissection is initiated in a cephalad direction along the
TME plane around the fascia propria of the mesorectum and
along the levator muscles. The carbon dioxide pneumodistention aids in identifying the proper planes. Dissection is
initially established posterolaterally followed by following
the plane around anteriorly. Digital vaginal examination can
also facilitate anterior dissection in women. A dry dissection
plane is maintained through the use of both monopolar and
bipolar cautery devices and small gauze swabs. The parasympathetic nerve roots at S3–5 are swept laterally during
the mid-pelvic dissection. The curvature of the sacrum is
followed posteriorly along the TME plane. Anteriorly, dissection continues between the rectum and Denonvilliers
fascia. As pneumodistention is instrumental in maintaining
adequate visualization and retraction during transanal endoscopic surgery, intraperitoneal entry, typically accomplished
anteriorly, should be avoided until the majority of the pelvic
dissection is completed (Fig. 23.4 ). Once connection to the
peritoneum occurs, pneumodistention of the TME plane collapses and visibility is markedly hampered.
Several potential challenges exist during the transanal
TME dissection. Particular care is required at the start of the
pelvic dissection to correctly identify the TME plane on the
surface of the mesorectal envelope. A plane too lateral or
radial will risk injury to the pelvic nerves, sidewall structures, presacral vessels, urethra, prostate, or vagina. A plane
too medial or central will risk violating the rectal wall and
mesorectum. However, once the correct mesorectal plane is
established, it has the same appearance of the plane when
dissected from above in the standard fashion.
The abdominal portion of the procedure can be performed
laparoscopically by a simultaneous team working from
above (Fig. 23.5 ). Left colon and splenic fl exure mobilization,
Table 23.3 Procedural steps of transanal total mesorectal excision
1. Transanal identifi cation of the distal margin and purse-string
occlusion of the lumen
2. Use of a rigid reusable transanal endoscopic surgical or disposable
TAMIS platforms to perform transanal mesorectal excision
3. Monopolar and bipolar energy utilized for transanal pelvic
dissection
4. Identifi cation and avoidance of the pelvic nerves
5. Laparoscopic left colon, high vascular ligation, and (when needed)
splenic fl exure mobilization. Usually performed synchronously
with the transanal portion
6. Transanal specimen extraction
7. Coloanal hand-sewn or circular-stapled anastomosis
8. Diverting-loop ileostomy (performed in majority of cases)
Fig. 23.1 Transanal total mesorectal excision (taTME) positioning in
modifi ed lithotomy allowing perineal and abdominal access simultaneously. Courtesy of Mark Whiteford, MD and Antonio Lacy, MD
268
M.H. Whiteford
Fig. 23.2 taTME setup and initial dissection. Courtesy of Patricia Sylla, MD, with permission
just below the peritoneal refl ection. Working together, they
circumferentially complete the remaining TME mobilization.
The mesentery proximal to the resection margin is then
divided with a laparoscopic vessel-sealing device.
The specimen is properly oriented then delivered and
divided transanally. If the specimen is too bulky, then an
abdominal extraction should be performed to avoid anorectal
damage and tumor exfoliation. The specimen is then
inspected for mesorectal grading and confi rmation of adequate margins. The anastomosis can either be created as a
hand-sewn coloanal or with a circular stapler. The latter
involves securing the stapler anvil in the proximal bowel segment, placing a purse string on the open distal rectum, and
completing the double purse-string circular-stapled anastomosis. Leak test can then be performed followed by proxi-
Fig. 23.3 taTME perineal setup. Courtesy of Mark Whiteford, MD and
Antonio Lacy, MD
mal fecal diversion in most cases.
Outcomes : A review of the fi rst 72 cases of taTME has
mesenteric vascular ligation, ureteric identifi cation, and the
proximal mesorectal dissection are all completed in the conventional fashion. The laparoscopic and transanal surgeons
typically join up anteriorly under direct vision, usually at or
demonstrated encouraging results [ 21 ]. What stands out is
that the average BMI was less than or equal to 26 in all series.
Most tumors were located in the mid and low rectum.
Most patients underwent stage-appropriate neoadjuvant
23 Natural Orifi ce Surgery (NOTES)
269
Fig. 23.4 taTME anterior dissection with peritoneal entry and specimen extraction. Courtesy of Patricia Sylla, MD, with permission
operative urinary retention, thought to be secondary to transient parasympathetic nerve injury [ 22 ]. Short-term oncologic
outcomes were also adequate. The quality of the mesorectal
specimen was complete in all patients, and resection margins
were negative in all patients preoperatively staged as having
T3 or less disease. Lymph node harvest rates were likewise
comparable to historical TME patients. As expected, longterm oncologic data have yet to be reported.
Phase 3: Initial Clinical Pure NOTES Transanal Resection
At present, two cases of transanal total mesorectal excision
without the assistance of laparoscopy have been reported in
Fig. 23.5 Aerial view of port placement for taTME. Courtesy of Mark
Whiteford, MD and Antonio Lacy, MD
c hemoradiotherapy. Overall, operative times ranged from
125 to 460 min, with most cases lasting 4–5 h. Nearly all of
the intraoperative complications occurred in patients with
locally advanced or recurrent tumors. These included two
urethral injuries and two patients converted to open surgery.
One study reported that two of fi ve patients experienced post-
the literature [ 23 – 25 ]. Both were performed using either a
rigid or fl exible transanal platform, and primary anastomoses
were performed in each case. Mesorectal excisions were
graded as complete and lymph node harvest was adequate.
Neither patient was diverted and the short-term outcomes
were good. One patient had a postoperative hematoma
requiring drainage. These cases did not require splenic fl exure mobilization. Obviously, further experience is needed to
determine the ultimate role of this approach in the surgeon’s
armamentarium.
270
M.H. Whiteford
Pearls and Pitfalls
• While NOSE and NOTES offer certain theoretical advantages, they should be performed by experienced teams or
special monitored circumstances.
• Patients deemed high risk for increased recurrence or
inability to gain margins should be avoided until further
experience is gained.
• Although the NOTES approach is unique and technically
demanding, the principles of oncologic surgery and operating in the pelvis remain the same as open or standard
laparoscopy.
Summary
A considerable foundation of benchtop research and clinical
progress has occurred since the NOTES White Paper was
published in 2006 and called for a safe and rational introduction of this new surgical paradigm. It is likely that
NOTES progress will continue in a gradual, stepwise fashion, as did laparoscopic surgery, which had its humble
beginnings near the start of the twentieth century, yet did not
attain widespread use as a therapeutic modality until the
1980s. The tipping point for laparoscopy was when the
enabling technological advancement (the video chip) liberated the procedure from that of a one-handed, solo operator
tied to monocular scope to the multiport, multimember surgical team now capable of working in a coordinated fashion
to accomplish complex integrated tasks [ 26 ].
Colorectal NOTES procedures are becoming a reality.
Natural orifi ce specimen extraction of large colonic specimens following laparoscopic resection can be performed
safely in experienced hands. Early investigation and clinical
experience of transanal total mesorectal excision has been
met with excitement as a potentially easier method to perform the deep pelvic dissection during TME. With time and
further experience, these techniques will become refi ned and
applicable to more surgeons and situations.
Until that the elusive enabling technology declares itself,
it is likely that colorectal NOTES procedures will gradually
progress as modifi cations of hybrid laparoscopic, transanal,
and natural orifi ce specimen extraction procedures for the
foreseeable future. In the meantime, though, the dream of
NOTES has inspired some secondary gains in the general surgical realm. These include single-port surgery, the increased
use of transanal minimally invasive surgery, and advanced
endoscopic surgical procedures such as the per- oral endoscopic myotomy (POEM) as a scarless and fully endoscopic
treatment for achalasia.
References
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13. Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK. Rectal
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14. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito
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resection. Int J Colorectal Dis. 2008;23(7):703–7.
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Robotic Surgery
Mehraneh Dorna Jafari , David E. Rivadeneira ,
and Alessio Pigazzi
24
K e y P o i n t s
• The specifi c indications for the utilization of a robotic
approach continue to evolve.
• Advantages of robotic surgery include better visualization, surgeon-controlled camera, improved ergonomics,
and overall dexterity.
• At present, pelvic, more than colonic, operations allow
for a more wide application of the robotic advantages.
• A robotic approach allows an intracorporeal anastomosis
during a right colectomy to be much more feasible.
• Left colectomy and pelvic operations can be performed
via a hybrid or totally robotic approach using a one or two
docking method.
• Robotic surgeons should be profi cient in advanced laparoscopic surgery.
Introduction
Robotic surgery has been evolving since its fi rst introduction
in 1994. The FDA approved the use of the da Vinci ® robotic
system (Intuitive Surgical Inc., Sunnyvale, CA, USA) as the
fi rst telerobotic manipulation system for intra-abdominal
Electronic supplementary material: Supplementary material is
available in the online version of this chapter at
1581-1_24
com/videos/978-1-4939-1580-4
M. D. Jafari , M.D. (*)
Department of Surgery , University of California, Irvine School of
Medicine , 333 City Blvd. West Ste 850 , Orange , CA 92868 , USA
e-mail:
A. Pigazzi , M.D., Ph.D.
Colorectal Surgery, University of California ,
Irvine Medical Center , 333 City Blvd. West Ste 850 ,
Orange , CA 92868 , USA
e-mail:
D. E. Rivadeneira , M.D., M.B.A., F.A.C.S., F.A.S.C.R.S.
North Shore-LIJ Health System , Huntington Hospital, Hofstra
University School of Medicine , Huntington , NY , USA
e-mail:
. Videos can also be accessed at http://www.springerimages.
.
jafarim@uci.edu; apigazzi@uci.edu
jafarim@uci.edu; apigazzi@uci.edu
drivadeneira@nshs.edu
10.1007/978-1-4939-
surgery in 2000. An explosion of robotic surgery utilization
has occurred mostly in the last decade with more than
350,000 procedures done worldwide by 2011 (Fig.
24.1 ).
This increase in robotic procedures has been mostly brought
about from our other pelvic subspecialist colleagues, namely,
urology and gynecology (Fig.
24.2 ). Robotic colorectal
surgery was fi rst reported in 2001 [ 1 ], and the fi rst of total
mesorectal excision was reported in 2006 [ 2 ]. Although mul-
tiple case series and at least one randomized prospective
study have demonstrated the feasibility and safety of robotic
surgery in colorectal resections [ 3 – 12 ], its adoption in the
colorectal surgical community has been increasing slowly.
A recent study of national trends of robotic surgery in the
United States showed that it is utilized in only 2.8 % of minimal invasive colorectal surgery [ 13 ].
This slow adoption is despite the many purported advantages of robotic surgery including better visualization,
improved ergonomics, and overall dexterity. The robot provides a steady camera with highly magnifi ed stereoscopic
optics, which provides 3-D visualization and improved
depth perception of the operative fi eld. Furthermore, the
surgeon at the console has complete control of the camera,
removing any potential distraction of an assistant that normally used in traditional laparoscopic surgery. The superior
surgical dexterity provided by the robotic approach is due
to the instruments having seven degrees of freedom, 180°
articulation, and 540° rotation—all allowing for easier
manipulation within small spaces. The robot also allows for
motion scaling and tremor fi ltering, which again facilitate
technically challenging laparoscopic procedures. Moorthy
et al. reported that the robot was associated with an
enhanced dexterity by 65 %, reduction in skill-based errors
by 93 %, and reduction in time needed to complete a task
by 40 % [ 14 ]. The robot also allows for superior ergonom-
ics [ 15 ], as the enhanced dexterity and superior visualiza-
tion are especially helpful in the narrow confi nes of the
pelvis, and is very appealing for surgical subspecialties that
deal with pelvic pathology such as urologists, gynecologists,
and colorectal surgeons.
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_24, © Springer Science+Business Media New York 2015
273
274
Fig. 24.1 Total robotic
procedures performed worldwide
(2005–2011). With permission
from Intuitive Medical
M.D. Jafari et al.
Fig. 24.2 Robotic cases by specifi c procedure. With permission from Intuitive Medical
The disadvantages of robotic-assisted surgery can be
attributed to lack of haptic feedback, longer operative time,
and cost. The time-consuming aspect of robotic surgery is
docking, especially in certain totally robotic colorectal
approaches which can require multiple docking and/or reengaging of instruments. However, it has been shown in rectal
surgery that as experience is gained, operative time will
improve [
16 ]. Recent meta-analyses have suggested that
operating time for robotic rectal procedures is similar to
that for a conventional laparoscopic approach [ 12 , 17 ]. The
authors agree that with continued experience of an assembled robotic surgical team, the operative times of robotic
colorectal procedures will approach the times of similar laparoscopic procedures. While there continues to be a debate
regarding the cost-effectiveness of the robot, especially given
the current lack of clinical evidence demonstrating its
24 Robotic Surgery
275
superiority compared to the laparoscopic approach, there is
no doubt it has an expanding role for colorectal surgeons. In
this chapter, we will review the technical aspects of robotic
use for colorectal surgery and share several tips and tricks we
have found useful in our experience with robotic approaches
to colorectal disease.
Indications
The specifi c indications for the utilization of the robot when
compared to laparoscopy continue to evolve. To date, there
are no large randomized controlled studies that demonstrate
the benefi ts of the robotic approach with regard to colorectal
surgery. In fact, the majority of data detailing robotic use
comes from single institution cases series. Therefore, the specifi c indications for colorectal surgery are evolving as new
evidence comes to light. The clinical outcomes of robotic and
laparoscopic colorectal procedures have overall been similar.
The utilization of robotics for colorectal resection is at
the discretion of the surgeon. As mentioned above, the use of
robotics can increase operative time, but once the learning
curve is overcome, this is not a hindrance to the use of the
robot. During segmental resections, the robot will allow for
easier intracorporeal suturing, given the EndoWrist ® technology. However, intracorporeal suturing has not translated
into superior outcomes [ 18 ]. In short, despite the technologi-
cal advantages afforded by the robot, and proven feasibility,
there have been no tangible clinical improvements reported
with the use of the robot for colon resections [ 13 , 19 , 20 ].
Rather, laparoscopic colon resection has the same clinical
outcomes as robotic colon resection with a lower cost and
shorter operative time.
Currently, however, there may be stronger indications for
robotic rectal surgery given that studies have shown lower rate
of conversion when robotic technology is used to facilitate
total mesorectal excision (TME) [ 12 , 13 , 21 ]. The anatomical
confi nes of the pelvis render rectal surgery more diffi cult
compared to colon surgery, especially using a minimally invasive approach. Total mesorectal excision demands a high
degree of precision, since anatomic dissection of the mesorectal envelope allows for the best oncological outcomes for
rectal cancer. Moreover, the degree of diffi culty for TME is
directly proportional to the size of the pelvis [ 22 ]. Laparoscopic
TME can be very challenging, especially in males and in
those with very low tumors and obese patients [ 23 ]. Using the
nonarticulating laparoscopic instrumentation and obtaining
an optimal surgical view can become very challenging and
lead to higher rates of conversion [ 24 , 25 ]. The abovemen-
tioned advantages of the robot can overcome these challenges
and, in fact, lead to lower conversion rates [ 12 , 13 ].
We should point out that there are no absolute
contraindications to the utilization of a robot in colorectal
surgery—only the experience and expertise of the surgeon.
Similar to laparoscopy, the robot is a tool or approach used to
complete the same operation as in an open case. The robot
can be used for diverticular disease, infl ammatory bowel disease, and malignancy. The loss of haptic feedback may be
more diffi cult in certain infl ammatory conditions, and extra
care must be taken when handling infl amed tissue. However,
the indication should rely mostly on the underlying disease
process; then consideration should be given to whether or
not the patient can tolerate a pneumoperitoneum, steep
Trendelenburg for pelvic cases, and perhaps longer operative
times that occur with a robotic approach.
Equipment
The equipment needed for a laparoscopic case, as described
by Dr. Bafford in Chap.
cases, especially when using the hybrid approach. Therefore,
additional towers for insuffl ator, electrosurgical units, and
extra monitors in rooms that are used for laparoscopic
and robotic cases are necessary. The operating room setup
should provide adequate space for staff and large equipment
and allow the surgeon to have a direct view of the patient
from the surgeon’s console. The room should also allow
docking of the robot from several angles (Fig.
1 , should be available for all robotic
24.3 ).
Robotic System
The da Vinci ® exists in fi ve models: standard, streamline
(S), S-high defi nition (HD), and S-integrated (i) HD. At the
time of this writing, the new da Vinci Xi has just been introduced into the market. This system features improved
robotic arm movements and the ability to introduce the
camera in any of the arms. The standard system originally
was a three-arm robot. In 2006, the S-system offered numerous improvements including motorized patient cart, colorcoded optic connection, easier instrument exchange,
improved trocars, and increased range of motion and reach
of instruments. The da Vinci ® surgical system consists of
three components: the surgeon’s console, the cart with the
four robotic arms, and the electronic/vision tower
(Fig. 24.3 ). The HD camera was an addition for the S-HD
model, while the most recent version includes the enhanced
HD vision at 1080i, upgrades to surgeon console and ability
for dual console.
The surgeon operates at the console (Fig. 24.4 ); a three-
dimensional image is obtained through the stereoviewer,
which can be adjusted via the pod controls. The instruments
are controlled using the master controllers and foot pedals.
The surgeon’s instruments and console are only active when
the surgeon’s head is at the stereoviewer. This allows for
immediate deactivation of the surgical arms when the
surgeon looks away from the surgical fi eld.
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Fig. 24.3 Operating room setup should include ample room for robotic cart and laparoscopic and robotic towers. The system includes a robotic
cart, console, and tower. With permission from Intuitive Medical
The surgeon controls the instruments via the master
controllers using the index fi nger and thumb. The robotic
technology (without delay) scales, fi lters, and relays the
information to the instruments. The surgeon should keep in
mind the ergonomics while using the controllers and should
be able to sit comfortably without overreaching. The robot is
dual energy capable, and both monopolar and bipolar instruments can be used simultaneously.
The patient cart has 3–4 arms, one of which is the camera.
Each arm has multiple clutch buttons for gross and fi ne
movements (Fig. 24.5 ).
Camera
The endoscope is available as a 0° and 30° lens. Our preference for robotic colectomy is to use a 30° lens, while
we normally use a 0° scope for robotic TME. The camera
system has digital zoom and allows for magnifi cations by
pressing the left and right arrow keys on the left-side pod
Fig. 24.4 The da Vinci Si™ console, which includes master controls
and pedals. With permission from Intuitive Medical
controls or depressing the camera pedal and moving the masters together or apart.