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laparoscopic technique once the robot is undocked. It is not recommended to perform a robotic double purse-string (single stapled) technique until prociency with
the robotic system is gained [21, 26]. Each completed anastomosis is inspected with
a sigmoidoscope to watch for signs of intraluminal bleeding. An air-water leak test
is also performed.
Pitfalls andTroubleshooting
The da Vinci surgical robot system is a mechanical and highly sophisticated
computer system. As such, there is potential for malfunction or failure. Fortunately,
general system failures are rare, provided that proper maintenance and its software
updates have been carried out [10, 27].
The system has a user-friendly communication system to help with routine setup
and the docking process. The Xi system offers a self-optimizing robotic boom and
arm positioning, but it is important to note that strict reliance on that self- optimization
is not always benecial. The surgeon should know how to adjust the arms and the
boom, how to position the robotic cart, and how to distribute the arms in the most
ergonomic fashion. When setting up and docking the robotic cart, the assistant should
be provided with a comfortable place to stand or sit by the bedside, without assuming
any contorted positions or being placed near swinging robotic arms. Finally, it is
important that the console surgeon be actively engaged in port and instrument placement during the setup. This is to ensure full understanding of the limitations of reach
and instrument collisions, should they arise. Strict reliance on the assistant without
constructive feedback will not allow the team to evolve efciently.
Port setup is also crucial and can be a major factor for progress in the procedure. If
any restrictions or persistent collisions arise during instrument manipulation, the layout should be assessed and, if necessary, more ports be added in better locations.
Likewise, the robotic cart needs to be positioned correctly. If it is placed too close to
the eld, cramming of the arms and instruments will occur. If it is placed too far away,
the instruments will not have the full range of motion. The blue mark on the Si system
shows the optimal distance range between the robotic cart and the eld. This can be
adjusted, depending on the body habitus of the patient and the distance between ports.
Once the arms are docked with the ports, the elbows of the arms should be spread
sufciently to allow for clearance and avoidance of collisions. If the ports are placed
too far from the pelvis, the instruments may not reach the pelvic oor or may get
hung up on the pelvic brim, limiting the access to the posterior (presacral) aspect of
the mesorectal compartment. Similarly, if the instruments intended to dissect in the
deep pelvis are placed too far laterally (too close to the anterior superior iliac spine),
access to the ipsilateral pelvic sidewall will be limited as well. In case of insufcient
reach to the pelvic oor, advancing the robotic ports beyond the recommended
black mark on the robotic port cannula is suggested.
Procient camera operation is one of the primary determinants of uidity and
rhythm of the case. Proper visualization is not only important for the operator but
also helps to orient the assistant, whose instrument frequently retracts and protects
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
389
the operating eld outside of the active camera view. For this reason, frequent
zooming out and pan viewing of the eld must be performed. During TME in the
deep pelvis, there is a natural tendency to inadvertently “spiral” the camera (rotate
the horizon), especially during anterolateral dissection. This results in improper recognition of anatomical landmarks. It is true that experienced robotic surgeons are
known to perform up to four times more camera (and instrument) adjustments than
novice surgeons while still demonstrating the economy of movements [27]. What
should be avoided is dissection on the outskirts of the active view. Instead, the camera should have the working instruments in center view at all times.
Similar to constant camera adjustment is constant instrument adjustment with the
clutching mechanisms [27]. The surgeon’s hands should rest comfortably on the support and never be positioned “in the air.” This guarantees precision of movements
and control of the operating eld. Thus, by controlling three working instruments,
the camera, and “conducting” the position of the assistant’s instruments, the surgeon
is in full control of the entire case. It is imperative for the operator to subconsciously
know the spatial position of all instruments at any given time. Without this awareness, the instruments tend to clash internally and get damaged, but there is also an
increased risk of collateral tissue damage if the instruments are not seen.
The part of the instrument most susceptible to damage is the plastic wrist cover
of the monopolar cautery hook, which should always be checked when removed
from the patient body. The internal and external collisions can lead to loss of instrument wrist responsiveness. This requires resetting by simple removal and reinsertion. This malfunction can sometimes be observed during dissection around the
very distal rectum. Frequently, less experienced surgeons do not recognize the full
ability of the wrist articulation and use this sophisticated system in the traditional
laparoscopic-like fashion. The skill of procient utilization of the wrist articulation
is especially crucial during right pelvic sidewall dissection with the right-hand
instrument (hook or scissors) placed in the right lower quadrant. This often requires
cocking the wrist toward the right side (Fig.24.13). Additional unique articulation
Fig. 24.13 Cocking of the
right-hand dissecting
instrument during the
right-side pelvic dissection
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S. Marecik et al.
techniques are used for atraumatic retraction (L-shaping of the closed graspers),
including lifting of the mesorectum and resting it on the instrument shaft without
grabbing any tissue during posterior dissection (Fig. 24.6). Essentially, all techniques of robotic TME rely on two robotic instruments to provide micro- and macroretraction and one dissecting monopolar cautery instrument. While the most
lateral retracting instrument is typically used for macroretraction, one has to remember that switching roles of the retracting instruments can sometimes improve the
retraction. There is also a possibility, particularly during difcult and long cases, to
confuse the pedals of the monopolar and bipolar cautery, resulting in burning of the
specimen or, even worse, applying the heat to the grasper that is retracting the walls
of the mesorectal compartment.
The newest Xi system comes with a built-in electrocautery generator unit which
has different cautery settings than commonly used external units. As of now, the
former may have a slightly inferior performance than the latter. Some operative
adjustments may be necessary, and the settings increased to higher values than
expected from traditional units.
Multiple problems can arise from inadequate communication between the
console surgeon and the bedside assistant. Closed-loop communication in a
standardized fashion is mandatory to conrm receipt and implementation of
mutual instructions. Noise, insufcient microphone volume, or lack of team
concentration can set off intraoperative disasters. Unexperienced bedside
assistants may be unable to dock the robot efciently or may injure tissues (most
commonly small bowel) during instrument exchanges. In the newest Xi version,
protective visual mechanisms (hazard bars) allow one to visualize the path of the
inserted instruments, even when they are outside of the active visual eld. It is
recommended that instruments always be inserted under the camera’s vision.
Typically, the assistant’s instruments are 5 or 6mm in size, and occasionally they
will collide with the robotic instruments or arms, rendering them ineffective. If
such problems arise, a liberal new port insertion in the optimal location is
recommended. Additionally, because of the design of the robotic arms, the
instrument insertion or replacement requires more clearance over the sterile eld
toward the anesthesia stand. Therefore, the anesthesia screen and the poles must
be moved more cephalad in order to avoid instrument contamination.
It is important to remember that newer, integrated motion tables, designed for
use with the Xi system, will likely not have as extreme of a right-sided tilt when
combined with simultaneous extreme Trendelenburg positioning seen in most
traditional tables. Because of this, a more methodical small bowel positioning, or
even different approach (lateral to medial), might be required to gain access to
the base of the left colon mesentery. Finally, when the console operator leaves
the console and returns to resume the case, care must be taken to safely insert the
ngers in the manipulators before the surgeon’s head rests on the support with
the system activation sensors. This will help to avoid inadvertent movement of
the instruments which could be holding or retracting crucial anatomical
structures.
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
391
Common Errors andIntraoperative Difficulties
The most common errors specic to robotic cases result from inadequate retraction
and visualization of anatomic landmarks, failure to recognize visual cues of tissue
tension without a haptic interface, use of excessive or mistaken instrument energy
application, loss of visualization of the instruments, or unrecognized collision of the
instruments (Box 24.1).
Box 24.1 Most Common Errors Specic to Robotic Cases
• Improper retraction or clearance of small bowel and redundant sigmoid
from the pelvis
• Initial incision into the mesentery of the rectosigmoid (more common in
obese patients) or below the pHGNF, thus endangering the autonomic
nerves
• Traumatic macroretraction of the rectosigmoid with break of the peritoneum
or mesentery and bowel deserolization
• Dissection below the retroperitoneal fascia (very common), thus exposing
the ureter and gonadal vessels
• Too deep dissection through the layers of Toldt’s fascia (nuisance error
resulting in bleeding from the squiggly vessels of Toldt’s fascia)
• Inadequate clearance of the brotic trunk of IMA and not addressing vessel
calcication
• Inadequate lymphadenectomy at the IMA root
• Transection of IMV distal to splenic exure tributary (not close enough to
the origin at the inferior pancreatic border)
• Disruption of splenic exure vascular arcades (venous outow is more
common)
• Devascularization of omentum, with special emphasis to posterior omental
leaet attached to the cephalad surface of the transverse mesocolon
• Pulling on the omentum, resulting in splenic decapsulation, or rupture and
bleeding
• Stripping of the peritoneal or retroperitoneal layer of the sigmoid fossa
• Stripping the retroperitoneal areolar layer (fascia) of the left common iliac
vessels and psoas muscle (leading to a false pelvic dissection plane)
• Injury to the superior hypogastric plexus or the hypogastric nerves due to
unrecognized dissection below the pHGNF
• Presacral dissection below or through the sacral splanchnic nerve (SSN)
layer and too close to presacral vessels
• Lateral dissection below and outside of the SSN layer (exposing the
internal iliac vein and injuring the pelvic plexus, where the nerves converge)
• Lateral dissection beyond the lateral edge of Denonvilliers’ fascia
(exposing the anterior portion of the pelvic plexus) (Figs.24.8 and 24.11)
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S. Marecik et al.
• Unrecognized dissection in front of Denonvilliers’ fascia (safe and
intentional anterior dissection can be championed with experience)
• Lateral dissection into the mesorectum, leaving the mesorectum of the
lateral tethered surface remaining
• Breach of the mesorectal fascia
• Unintentional breach of Denonvilliers’ fascia during retraction or
dissection, with resulted sagging of seminal vesicles resulting in oozing
• Anterolateral dissection beyond the distal portion of Denonvilliers’ fascia,
resulting in bleeding from the neurovascular prostatic bundles
• Anterior and anterolateral dissection too close to sinuses of the posterior
vaginal wall
• Inadequate distal rectal mobilization
• Improper mesorectal transection (“spiral apple peel”) below the tumor,
resulting in too close distal margin or transection line (more common in
large specimens)
• Improper stapler application (green cartridges are likely more adequate for
thick rectal tissue) with insecure staple line after multiple stapler rings, ischemic dog ears, and large amount of loose foreign body (free oating staples)
• Devascularization of colonic conduit (indocyanine green angiography may
be helpful in suspected cases)
• Proximal purse-string application incorporating a diverticulum into the
circular staple line
• Tension on the anastomosis
• Insecure anastomosis with failed pressure-bubble test
• Not protecting the high-risk anastomosis with a proximal diversion
Management ofIntraoperative Complications andConversion
Most intraoperative complications during a robotic low anterior resection are similar
to those seen during traditional laparoscopic or open procedures. The lack of haptic
feedback is outweighed by the steady view, instrument articulation, and tireless
retraction. The ability to take visual cues of tissue or suture tension in lieu of haptic
feedback develops with experience.
In the simplest cases of non-life-threatening bleeding, compression of the
bleeding structure can be sufcient. The robotic platform allows the eld, including
the compressing instrument, to “freeze.” This allows for self-hemostasis or
preparation for the hemostatic maneuver (evacuation of blood and irrigation,
application of vessel sealer or suture-ligature). In cases of more severe and
potentially life-threatening bleeding, all robotic graspers should release any tissue,
the robot be undocked, and a rapid laparotomy be performed.
Suturing is easier with the robot and can be easily employed to repair a bowel
injury. The left ureter injury can be avoided if the retroperitoneal fascia is kept
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
intact, and the dissection is performed in the bloodless fashion. In all other cases, a
methodical, limited exposure of the ureter is required. Ureteral stents are helpful
during complicated redo surgeries, but routine stent placement is not recommended.
Lack of control of the powerful instruments in the pelvis can lead to violation of the
presacral Waldeyer’s fascia, with injury to the presacral venous plexus or, less likely,
sacral artery (median or lateral). Small injuries can be controlled with robotic arm
compression of the bleeding structure for 5–15minutes; however, more severe injuries may require conversion and specialized hemostatic techniques.
The most common reason for conversion during low anterior resection is the
inability to progress due to unclear anatomy as a result of extensive pelvic pathology. Unclear anatomy can even be encountered when preoperative imaging appears
to be clear. It helps in these situations to look for two features of a complete mesorectal compartment – roundness and symmetry – which are universally present.
They can be appreciated with appropriate exposure and deliberate slowing (or stopping) of the dissection to zoom out and in for reorientation.
Conversions have historically been associated with negative perioperative,
functional, and oncologic outcomes [28, 29]. It remains prudent to reevaluate the
various options and rather convert in a difcult situation than to proceed with
excessive case prolongation and suboptimal outcome [9, 30].
393
Prerequisite Skills andLearning Curves
Advanced laparoscopic skills and adequate case volumes are keys to performing
safe low anterior resection of the rectum [11]. The learning curve for robotic low
anterior resection is estimated to be approximately 30–40 cases to achieve primary
technical competence and around 70 cases to achieve prociency [31, 32]. Many of
the necessary robotic skills can be acquired with the help of virtual reality simulators and cadavers [16, 24, 33]. In order to keep operative times as short as possible,
a stepwise transition from hybrid to complete robotic procedures may be prudent.
Outcomes
Since the landmark paper by Pigazzi and colleagues in 2006, demonstrating the
feasibility of rLAR, many case series and several nonrandomized, retrospective, and
prospective comparative studies of robotic and laparoscopic technique followed [1,
2, 6, 7, 11]. Until now, only two randomized controlled trial were performed. The
ROLARR trial compared robotic and laparoscopic techniques, while the ACOSOG
study compared a robotic subgroup with laparoscopic and open cohorts [3, 4]. In
addition, several meta-analyses were conducted comparing robotic and laparoscopic techniques and others comparing all three techniques [34, 35].
Altogether, robotic surgery was shown to be safe and feasible but had longer
operative times when compared to the laparoscopic technique. Oncologic superiority of the robotic technique could not be demonstrated. Nonrandomized studies and
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meta-analyses frequently pointed toward lower conversion rates in the robotic technique [34, 35]. The pivotal ROLARR study (2017) suggested lower conversions and
lower positive circumferential resection margins with the robotic technique but
failed to reach statistical signicance [3]. Additionally, the study found no difference in operative and postoperative complication rates, or functional genitourinary
outcomes, in contrast to several nonrandomized studies that had suggested a potential respective advantage of the robotic technique [36–39].
Conclusions
Since its inception, the robotic technique for low anterior resection has continued to
undergo a constant evolution. Currently, it remains one of the many available tools
in the surgical armamentarium for surgeons treating rectal cancer. Further studies
are necessary to the optimal role of this technology.
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Part V
Emergencies and Troubleshooting