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15 Robotic Right-Sided Colon Resection: Unique Considerations andOptimal Setup
223
(Chap. 13) indications in this textbook. There is a consensus in the literature that the
medial to lateral approach is the preferred approach during laparoscopic and robotic
surgery. Robotic right colectomy is compared to the laparoscopic approach based on
quality metrics such as operative time, rate of conversion to open surgery, blood loss,
procedural complications, early and long-term morbidity rates, incidence of incisional
hernia, and short and long-term oncologic outcomes (R0 resection, lymph node yield,
local and distant recurrence rates, and long-term survival).
Preoperative Planning, Patient Workup, andOptimization
Specic preoperative planning for robotic right colectomy should include detailed
review of computer tomographic (CT) imaging, particularly the relationship of the
tumor to surrounding structures such as the liver, gallbladder, duodenum, right kidney/ureter, and adrenal gland. Preoperative planning should also consider points for
potential transection of the colon and ileum as well as planning for the extraction
site and type of anastomosis (intracorporeal vs. extracorporeal) to be performed. If
the tumor is not visible on imaging and has not been tattooed at the time of initial
colonoscopy, a preoperative colonoscopy should be performed to identify and mark
the lesion. Alternatively, intraoperative colonoscopy could be performed prior to
commencing the procedure, but even with the CO
bowel can become distended, obscuring the operative eld.
insufation, the colon and small
2
Operative Setup
The patient is placed in a supine or lithotomy position. The patient is secured to the
operating table with the help of a Pink Pad® (Xodus Medical, New Kensington, PA,
USA) or similar anti-sliding device, with both arms tucked at bedside. The patient
is placed in slight Trendelenburg position, and tilted right side is up. Upon initial
exploration of the abdomen, unless the da Vinci Xi® system (Intuitive Surgical,
Sunnyvale, CA, USA) is used in combination with the OR table equipped with an
integrated table motion functionality, the small bowel is retracted to the left upper
quadrant laparoscopically prior to docking the robot. Table motion functionality
allows changes in OR table position with the robot being fully docked. The robotic
arms will automatically adjust their position as table position changes [12]. If a da
Vinci Si® or X® system (Intuitive Surgical, Sunnyvale, CA, USA) is used or if the
integrated table motion is not available with Xi robot, there can be no changes in
table position or the robot’s position without rst undocking the robotic arms.
General Considerations forPort Placement andDocking
In the early stages of adoption of the robotic approach for right colectomy, surgeons may consider replicating the steps of laparoscopic procedure using similar
224
K. Umanskiy
port conguration and steps of the procedure. This allows the surgeon to begin the
procedure laparoscopically, dock the robot, but have the option of converting back
to laparoscopy at any time during the case. Familiar port placement may reduce
surgeon’s anxiety, decrease operative time and make adoption of robotic technology easier. As the surgeon’s prociency increases, ports can be placed to accommodate a potential extraction site, optimize intracorporeal anastomosis, and
cluster near the pubic region where it is more cosmetically favorable [13]. Because
of the mechanical differences between da Vinci Si, da Vinci X, and da Vinci Xi
robots, port placement varies. There are no strict rules for robotic port placement,
and many surgeons arrive to their own preferred conguration. When considering
port placement, one must ensure an optimal camera view, trocar spacing to minimize external collisions, and adequate reach of the operating instruments to the
targeted eld.
da Vinci Si® andX® Setup (Intuitive Surgical, Sunnyvale, CA, USA)
The da Vinci Si and newer X models use the similar general mechanical architecture; however, the da Vinci X features upgraded arms and instruments of the Xi
model.
After pneumoperitoneum is established, a 12mm camera port is placed either
supraumbilically or 2–3cm to the left of the midline to decrease the incidence of
incisional hernias related to the a midline location [14]. The larger (stapler) port
could be placed at the proposed extraction site. Location and position of the hepatic
exure should be noted. Ports placed too far laterally on the left side may not have
sufcient reach and excursion for dissection and retraction of colon at hepatic exure. While some surgeons use robotic camera from the beginning of the case, others
nd da Vinci Si camera to be too cumbersome and heavy to be used as a laparoscope. The da Vinci X camera, on the other hand, is 8mm in diameter and signicantly smaller and lighter than Si’s, making it easier to be used as a laparoscope.
The da Vinci X camera can be inserted into any of the robotic cannulas and connected to any of the robotic arms.
Instrument cannulas are placed under direct laparoscopic or robotic camera
vision. These additional ports should be triangulated in relation to the target anatomy with instrument ports approximately 10–20 cm from the target anatomy
(Figs.15.1 and 15.2). Five mm assistant ports (non-robotic instrument cannulas)
should be placed as needed. Most surgeons who use the Si system for right colectomies dock the robot over the right side (over right shoulder). General principles of
docking are the same between Si and X machines. When docking the patient’s cart,
the distance of the robot from the OR table is determined by the camera arm’s
“sweet spot.” The camera port, target anatomy, and patient cart should be in a
straight line to maximize range of motion of the robotic arms, though side docking
is also a widely used option.
xtraction site
15 Robotic Right-Sided Colon Resection: Unique Considerations andOptimal Setup
8
12
12 Camera
8
Potential
specimen
e
8
225
Fig. 15.1 Port placement for da Vinci Si® or da Vinci X® (Intuitive Surgical, Sunnyvale, CA,
USA) right colectomy
da Vinci Xi® Setup (Intuitive Surgical, Sunnyvale, CA, USA)
The da Vinci Xi has sleeker arms with an extra joint for movement, which allows for
closer arm positioning without concern for external collisions. The Xi instruments
are longer than Si, and the camera is the same as the one used for da Vinci X (8mm).
Port placement for robotic right colectomy with the Xi system is in a diagonal line
from a point to the left of the costal margin cephalad to the suprapubic region caudally (Fig. 15.3). Alternatively Xi ports can be clustered within the suprapubic
region to improve cosmetic outcomes (Fig.15.4). Most surgeons dock the Xi robot
directly over the right side of the operating table.
226
xtraction site
Fig. 15.2 Operative photograph
demonstrating port placement for
da Vinci Si® or da Vinci X®
(Intuitive Surgical, Sunnyvale,
CA, USA) right colectomy.
(Photo courtesy of Dr. Craig
Johnson, Tulsa, Oklahoma)
K. Umanskiy
8 or 13
8
8
8
5
Potential
specimen
e
Fig. 15.3 Port placement for da Vinci Xi® (Intuitive Surgical, Sunnyvale, CA, USA) right
colectomy
15 Robotic Right-Sided Colon Resection: Unique Considerations andOptimal Setup
Fig. 15.4 Alternative
port placement for da
Vinci Xi® (Intuitive
Surgical, Sunnyvale, CA,
USA) robotic right
colectomy. (Courtesy of
Dr. Craig Johnson, Tulsa,
Oklahoma)
227
Operative Technique: Surgical Steps
The abdomen is inspected laparoscopically to determine the feasibility of minimally
invasive resection and to identify the extent of disease. The patient is placed in slight
Trendelenburg position with the right side tilted up. This allows for the small bowel
to be displaced to the left upper quadrant, exposing the cecum, terminal ileum, and
right colon mesentery. The omentum is retracted over the liver. We prefer to use a
robotic hook cautery on the left robotic arm, while other surgeons prefer to use
robotic shears and a bipolar fenestrated grasper on the right robotic arm. Other surgeons will use either two instruments for the left hand or two for the right hand and
swap them as needed. For example, two left-hand instruments could be a tip up/
stapler and a fenestrated bipolar and one right-hand scissors/vessel sealer/needle
driver. Depending on the surgeon’s comfort, training, and experience, an additional
robotic port can be used for the swappable instrument. We typically proceed with a
medial to lateral approach. If medial to lateral approach is not feasible because of
anatomic variant or inability to expose the ileocolic pedicle, a lateral to medial
approach can be used.
The cecum is grasped and retracted laterally, caudally, and anteriorly exposing
the ileocolic pedicle. In most individuals, the second portion of duodenum can be
visualized through a thin layer of parietal peritoneum. In the setting of visceral obesity, however, these anatomic landmarks may be more difcult to identify
228
Fig. 15.5 (a, b) The
ileocolic pedicle is
retracted and placed under
tension (a). The plane
between the right colon
mesentery and the
retroperitoneum is
dissected bluntly, and the
second portion of the
duodenum is identied (b).
(Courtesy of Daniel
Popowich, MD)
K. Umanskiy
a
b
(Fig.15.5a). The peritoneum inferior and posterior to the ileocecal pedicle is opened
sharply, and blunt dissection is carried out along the retroperitoneal plane
(Fig.15.5b). Next, the ileocolic pedicle is controlled. The ileocolic artery is carefully dissected close to its origin (Fig.15.6a). While visualizing the duodenum, the
artery is ligated and divided using a suitable device (Fig.15.6b). Available methods
include vascular endostapling, clips, bipolar energy, or suture ligation with the
robotic system. The robotic technique has been successfully applied to complete
mesocolic excision (CME) for right-sided colon cancers. In this approach, the ileocolic vessels are dissected and ligated near their origin. Dissection continues cephalad along the ventral aspect of the superior mesenteric vein (SMV). While following
embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels and middle
colic vessels. Depending on the location of the mass, one or both of the above vessels are divided at their origin. After transection of the terminal ileum, the remainder
of the operation proceeds in the conventional fashion with mobilization of the colon
from the gastrocolic ligament and from its lateral attachments.
The table is tilted to reverse Trendelenburg position to mobilize the hepatic exure, although this is not mandatory, and often single docking is usually suitable. The
omentum and transverse colon are retracted caudally thereby exposing the hepatocolic ligament. For this step, unless da Vinci Xi with table motion is used, the instruments may need to be removed and the robotic arms temporarily undocked from the
ports before changing the OR table position. The transverse colon is retracted caudally and the hepatocolic ligament is divided with energy device to control the
15 Robotic Right-Sided Colon Resection: Unique Considerations andOptimal Setup
Fig. 15.6 (a, b) The
ileocolic artery and vein
are dissected (a). The
ileocolic artery is divided
using the robotic vessel
sealer (b). (Courtesy of
Daniel Popowich, MD)
a
229
b
Fig. 15.7 Division of the
hepatocolic ligament. The
mentum is dissected off
the proximal transverse
colon. (Courtesy of
Daniel Popowich, MD)
blood vessels within the ligament (Fig.15.7). The dissection is continued toward the
hepatic exure, and the nal attachments of the colon to the retroperitoneum are
divided. The rst and second portions of the duodenum should be visualized and
protected. If necessary, the gastrocolic ligament is divided to achieve additional
mobilization of transverse colon.
Depending on the surgeon’s skill and complexity of the procedure, the terminal
ileum and its mesentery and transverse colon with its mesocolon are divided with
230
ab
ab
Fig. 15.8 (a, b) Following complete mesocolic excision, bowel perfusion is assessed using ICG
perfusion and FireFly uorescence imaging (a). After conrming the level of vascular demarcation,
the proximal colon is divided with the robotic stapler (b). (Courtesy of Daniel Popowich, MD)
K. Umanskiy
Fig. 15.9 (a, b) Following mobilization of the terminal ileum mesentery, ICG perfusion conrms
the level of vascular demarcation along the small bowel (a) which is divided with the robotic stapler at that level (b). (Courtesy of Daniel Popowich, MD)
Fig. 15.10 An
enterotomy is made along
the terminal ileum and the
transverse colon, and the
robotic stapler is inserted
to complete stapled
side-side isoperistaltic
anastomosis. (Courtesy of
Daniel Popowich, MD)
the robotic bipolar energy device and/or stapler (Figs.15.8a, b and 15.9a, b). An
intracorporeal anastomosis can be constructed robotically with removal of the specimen through either a Pfannenstiel incision or by extending left upper quadrant
12mm stapler trocar (Figs.15.10 and 15.11). For more details on how to perform
laparoscopic intracorporeal anastomosis, please refer to Chap. 14 on option for ileocolonic reconstruction.
15 Robotic Right-Sided Colon Resection: Unique Considerations andOptimal Setup
Fig. 15.11 The common
enterotomy is closed
using intracorporeal
robotic suturing to
complete the ileocolonic
anastomosis. (Courtesy of
Daniel Popowich, MD)
231
Alternatively, the remainder of the operation can be performed via an open
approach. After the robot is undocked, the incision for a camera port is extended
superiorly to create a small midline mini-laparotomy. The mobilized right colon is
then exteriorized through this incision and resected. A standard extracorporeal sideto- side ileocolic anastomosis is created.
Pitfalls andTroubleshooting
1. Incorrect port placement. This could result in external collisions, limited reach, or
instrument excursion. An attempt at repositioning the arms or adjusting the Flex joints
on Xi should be made. If the setup remains suboptimal, the surgeon should consider
placing another robotic cannula in a more favorable location on the abdomen.
2. Motion scaling. Most da Vinci machines have their default scaling set to “ne.”
For right colectomy, ne scaling may result in excessive need for clutching;
therefore, we prefer to use “normal” scaling.
Common Errors andIntraoperative Difficulties (Anatomic
Landmarks)
1. Failure to identify the correct plane during medial to lateral dissection. Initial
incision posterior to ileocolic pedicle does not always lead to a correct bloodless
retroperitoneal plane. If the plane of dissection appears bloody, it is recom-
mended to enter the plane in a different location distal or proximal along the
ileocolic pedicle.
2. Division of the ileocolic artery using energy device without clear identication of
the duodenum. In the event of bleeding from the ileocolic artery following divi-
sion, attempt at controlling the artery could result in injury to the duodenum.
3. Failure to fully mobilize terminal ileal attachments could result in limited mobil-
ity of the transected terminal ileum and tension on the anastomosis.
4. Excessive traction on the transverse colon during exteriorization of the specimen
could result in avulsion of middle colic vein at its conuence with the SMV.
232
K. Umanskiy
Management ofIntraoperative Complications: Tips andTricks,
Salvage, andWhen toConvert
1. Rapid control of intraoperative hemorrhage is one of the essential skills in robotic
surgery. Unless a major vascular injury has occurred, an attempt at robotic con-
trol of hemorrhage should be made. It is imperative to communicate with the OR
team and especially bedside assistant in a calm and clear fashion. An assistant
can operate the suction, apply pressure on a vessel, and introduce a mini-
laparotomy pad. A bipolar energy device should be used in controlled and pre-
cise fashion since careless bites can result in injury to nearby organs, such as
duodenum, or worsen the hemorrhage. Suture ligature, ties, clips, or stapler can
be considered as alternatives. Most importantly, the surgeon must exercise judg-
ment and consider converting to laparoscopy, hand-assist laparoscopy, or open
approach if several attempts at control of the hemorrhage have been made with-
out success. It is ill-advised to struggle robotically to control intraoperative hem-
orrhage, especially in the early phases of learning of robotic technique.
2. Organ injury may occur during dissection in the vicinity of the duodenum, liver,
and gallbladder. Injury to the right ureter and gonadal vessels is rare during right
colectomy. If the correct retroperitoneal plane is developed during medial to
lateral dissection, identication of right ureter and gonadal vessels is not required.
However, if the psoas muscle is exposed, the plane of dissection is likely too
posterior. In this circumstance right ureter needs to be positively identied to
assure that it has not been lifted with ascending mesocolon. If injury to the organ
is identied, a skilled colleague should be asked to assist with repair. The repair
should be carried out robotically only if the surgeon is absolutely condent in
their skill to complete the task. An example of repair suitable for robotic approach
is a small defect in the second portion of the duodenum that can be repaired with
suture closure.
3. If the decision to convert has been made, it does not necessarily mean that a
surgeon should convert right away. For example, in the cases of severe terminal
ileal of Crohn’s disease where dense phlegmon is deemed not amenable to
robotic mobilization, the surgeon may still consider taking down hepatic exure
and mobilize ascending colon robotically. This way the incision may be created
in the lower midline or in the right lower quadrant to specically address termi-
nal ileal disease and eliminate the need for cephalad extension of the incision.
For more details, refer to the chapter on advanced laparoscopic right colectomy
techniques in Crohn’s disease and preoperative ileocolonic resection.
Outcomes
The comparison of outcomes between laparoscopy and robotic right colectomy is
summarized in Table15.1. In a recent meta-analysis by Solaini and colleagues [15],
operative time was found to be signicantly longer for robotic colectomy procedures in the pooled analysis (standard mean difference (SMD)−0.99; 95% CI−1.4