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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1369_Библиотеки_им_академика_М_И_Перельмана.pdf
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H.J. Lujan et al.
percentage of laparoscopic colectomies performed in the USA range from 40 to
45 % and for laparoscopic rectal resection range from 10 to 15 % [10, 11].
Initially, laparoscopic colectomy took longer and was more expensive than conventional open colectomy. However, with time, it proved to offer significant advantages to the patient, including quicker return of bowel function, less post operative
pain, shorter hospital stay, and lower postoperative morbidity and mortality [5].
Robotic surgery purportedly offers advantages to overcome the limitations of laparoscopic surgery [2]. Some surgeons believe this could lead to wider use of minimally invasive surgery techniques for colorectal resections [12].
Robotics for colorectal surgery has been shown to be safe and feasible, and perioperative and pathologic outcomes appear to be equivalent to laparoscopic surgery.
However, most authors believe that the robot will have the greatest impact on rectal
resection [2, 12]. It seems ideally suited for pelvic dissection, where the superior visualization and articulating instruments facilitate exposure, retraction, and difficult dissection. It is hypothesized that these advantages will result in lower conversion rates
and higher rates of adoption. Furthermore, possible advantages of better mesorectal
excision, better preservation of nerves, and easier operation in the obese are all areas
of ongoing investigation. But, for partial colectomy, the benefits are more difficult to
foresee. In the literature, modest advantages in visualization and possibly decreased
blood loss seem to be offset by longer operative times and higher costs thus far [4, 13].
If nothing else, robotic right colectomy is an ideal case for a surgeon’s initial
experience with robotic techniques [3]. It is a familiar procedure to general and
colorectal surgeons alike. It is technically easier than other colon procedures with
relatively short operative times. It is commonly used as learning and/or teaching
tool. It is a procedure that is easily converted to either laparoscopic or open colectomy with relatively little clinical consequence.
The indications and setting for right colectomy are well described and include
benign and malignant conditions, elective, urgent, and emergent operations. Benign
conditions include: inflammatory bowel disease, volvulus, diverticular disease, arteriovenous malformations, ischemic colitis, and polyps not amenable to endoscopic
removal. Adenocarcinoma, carcinoid tumor, and appendiceal tumors account for
most malignant diseases. Surgery for the right colon is usually elective. However,
urgent indications include nearly obstructing lesions, ischemic colitis, and hemorrhage. There are only a few emergent indications, with perforation, complete
obstruction, and refractory hemorrhage the most common [14].
Technique
1. Room setup and patient positioning
Our three-arm technique for robotic right colectomy with intracorporeal anastomosis has been previously described [15]. We modified this technique from the
description by Crawford et al. [8]. The patient is under general anesthesia in the
supine position. Room setup is shown in Fig. 4.1. Pneumoperitoneum can be
4 Robotic Right Hemicolectomy
Fig. 4.1 Room setup
25
achieved with a Veress needle. As an alternative, open laparoscopic entry (Hasson
technique) or visual entry systems (Optiview/Visiport) can be used per surgeon’s
preference. Patient positioning is performed just prior to docking the robot. The
table is positioned in 10–20° of reverse Trendelenburg and 15–30° of right side up
to allow the small intestine to fall away from the midline (Fig. 4.2a–c).
Some authors prefer 10–15° of Trendelenburg so that the terminal ileum is better
exposed for dissection of the pelvic brim. This is an important point that is best
addressed at the time of initial evaluation by laparoscopy. If the terminal ileum is
fixed in the right lower quadrant, it may be difficult to free the bowel in a fixed table
position with the patient in Trendelenburg. We recommend early evaluation in order
to be able to complete this portion of the operation with the robot. Alternatively, the
terminal ileum can be freed laparoscopically. Occasionally, it may be necessary to
undock the robot in order to change the table position so that lysis of adhesions can
be completed by either laparoscopic or robotic means.
Localization of the pathology is mandatory during the initial laparoscopic evaluation. Our preference is to have the lesion tattooed preoperatively. Therefore, for
most right colectomies, the patient is supine and access to the perineum is not necessary. In select cases, the lithotomy position may be advantageous. For example, if
intraoperative colonoscopy is necessary to check the anastomosis or confirm
adequate removal of the pathology, access to the perineum is needed. Lithotomy
position is preferred when transrectal or transvaginal extraction of the specimen will
be performed. Finally, when the possibility of avoiding a resection exists, as in
26
H.J. Lujan et al.
Fig. 4.2 (a) Table position. (b) Si picture robot docked. (c) Xi picture robot docked
colotomy and polypectomy, laparoscopic-guided polypectomy, or wedge resection
of a benign lesion, the lithotomy position is used.
2. Port placement
The port placement for Si and Xi systems differ and diagrams are shown for the different configurations (Figs. 4.3, 4.4, and 4.5). Our preferred port placement for a threearm Si system technique is shown in Fig. 4.3a. It is specific for cases when the EndoWrist®
Stapler 45 System (Intuitive Surgical, Inc., Sunnyvale, CA) is not available. When the
EndoWrist® Stapler 45 System is available for use, we replace the left upper quadrant
8 mm port with the 13 mm stapler port. In this case, the assistant 12 mm port can be
downsized to a 5 mm port as shown in Fig. 4.4a and b. Some authors prefer a four-arm
Si technique and the common port configurations are shown in Fig. 4.5a and b.
Si Port Placement
An extra long 12 or 8.5 mm periumbilical port for the camera is placed, usually 2 cm
below and 2 cm lateral to the umbilicus (depending on the patient’s body habitus). A
left upper quadrant and suprapubic 8 mm robotic trochars are placed for arms 1 (R1)
4 Robotic Right Hemicolectomy
Fig. 4.3 (a) Si ports three arm. (b) Si Veress. (c) Xi Veress
27
Fig. 4.4 (a) Si ports. (b) Si picture ports
and 2 (R2). Five mm robotic trochars and arms can be used, but this limits the instrument options and degrees of articulation with today’s available instrumentation, and,
therefore, we prefer 8 mm ports at this time. In cases of polyps or tumors, the lesion
is localized prior to docking the robot using a 5 mm laparoscope, which is always
available. The table is then positioned in 10–20° of reverse Trendelenburg and
20–30° of right side up to allow the small intestine to fall away from the midline. The
robot is docked from the patient’s right side or over the right shoulder. Although this
chapter describes a three-arm technique below, a fourth arm can be added intraoperatively if needed. An additional port (R3) can be added to the right lower quadrant or
the subxiphoid area (see Fig. 4.5a and b). In select cases, particularly in the obese
patient, it may be advantageous to start with a four-arm technique to facilitate the
procedure.
28
Fig. 4.5 (a) Si ports four arm. (b) Si ports four arm
Xi Port Placement
H.J. Lujan et al.
There are two port placement options that can be utilized with the Xi system depending on whether extracorporeal or intracorporeal anastomosis is performed. The port
placement guidelines as published by Intuitive Surgical, Inc. for the da Vinci Xi is
shown in Fig. 4.6. This is ideal for extracorporeal anastomosis. With this port configuration, any port site (typically the umbilical trochar site) can be extended and
utilized as an extraction site. Incorporating trochar sites has cosmetic advantages.
For intracorporeal anastomosis, we recommend a modification as shown in
Figs. 4.7 and 4.8. This diagonal orientation extends from a port placed midline and
4–6 cm above the pubis. The diagonal now proceeds to the splenic flexure at 6–8 cm
intervals. The fourth port is the 13 mm stapler port. As will be shown, this port can
later be used as the extraction site if cosmesis is not important. An assistant 5 mm
port can be placed equidistant from ports 3 and 4 or 2 and 3 depending on the patient’s
®
body habitus. For situations where the robotic EndoWrist
Stapler 45 System is not
available, only four 8 mm robotic ports and a 12 mm assistant port are used as shown
in Fig. 4.8. In this case, a 12 mm assistant port is necessary for bowel transection and
creation of the intracorporeal anastomosis utilizing standard endoscopic staplers.
With the Xi system, the port configurations when placed in a line allow the most
consistent performance of the entire operation [16]. The line should extend from
4 cm above the pubis in the midline toward the splenic flexure with ports placed
4 Robotic Right Hemicolectomy
Fig. 4.6 Xi ports midline
29
6–10 cm apart (see Fig. 4.7). Slight angulation away from the hepatic flexure provides in-line viewing of and access to a greater length of the proximal transverse
colon. Further, moving the line of ports off the midline to the patient’s left facilitates
dissection of the ileocolic pedicle. For complete mesocolic excision with central
vessel ligation moving the entire line of ports further toward the patient’s left will
enable access to the middle colic vessels along with more length of the transverse
colon. Midline ports (placed along the linea alba) would lie directly above the ileocolic origin and might make its dissection more challenging. The assistant port is
placed in the left lateral mid-abdomen.
®
Since the robotic EndoWrist
Stapler 45 System was not yet available for the Xi
at the time of this publication, it is recommended to add a 12 mm assistant port in
the left lateral mid-abdomen for an intracorporeal anastomosis with a laparoscopic
stapler. For an extracorporeal anastomosis, the port placement line can be through
the umbilicus and linea alba (Fig. 4.6) with the port for arm 2 being placed at the
umbilicus (which can be extended later for bowel exteriorization/specimen extraction). When the robotic stapler is available, a 13 mm port for arm 4 placed in the left
®
upper abdomen is needed for the insertion of the robotic EndoWrist
stapler for
intracorporeal anastomosis creation.
30
Fig. 4.7 Xi ports diagonal
H.J. Lujan et al.
Fig. 4.8 (a) Xi ports diagonal. (b) Xi picture ports
Xi instrumentation for robotic right colectomy includes EndoWrist® Stapler 45
System, EndoWrist® One™ Vessel Sealer, bipolar fenestrated grasper, Tip-Up
fenestrated grasper, and needle drivers. With regard to instrumentation, we recommend the use of the fenestrated bipolar in arm 1; 30° down da Vinci endoscope in
4 Robotic Right Hemicolectomy
Table 4.1 A summary of the critical steps of robotic right colectomy with intracorporeal
anastomosis (ICA) using a medial-to-lateral (MtL) dissection and preferred instruments
Instruments
1. Identification of ileocecal junction (IJ) HS, BF, TUp
2. Traction on IJ to expose the ileocolic vessels at their origin HS, BF, TUp
3. Identify duodenum HS, BF, TUp
4. Transect ileocolic vessels at their origin HS, BF, TUp
5. Medial-to-lateral dissection VS, BF, TUp
6. Transect terminal ileum EW-S, BF, TUp
7. Mobilize hepatic flexure (identify MtL dissection plane) VS, BF, TUp
8. Identify and divide right colic and right branch of middle colic VS, BF, TUp
9. Isolate and transect transverse colon EW-S, BF, TUp
10. Intracorporeal, side-to-side, isoperistaltic anastomosis EW-S, ND
11. Detach specimen, complete lateral dissection if needed HS, BF, TUp
12. Specimen extraction (wound protector) Alexis™
HS hot shears, BF bipolar fenestrated grasper, TUp Tip-Up grasper, VS EndoWrist
Sealer, EW-S EndoWrist
Medical, Rancho Santa Margarita, CA)
®
Stapler 45 System, ND needle driver. Alexis™ wound retractor (Applied
®
One™ Vessel
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arm 2; Monopolar Scissors (hot shears), Permanent Cautery Hook, or EndoWrist®
One™ Vessel Sealer device in arm 3; and a Tip-Up fenestrated grasper or Small
Graptor in arm 4 (see Table 4.1). The Xi has to a great extent eliminated issues with
arm collisions. So, although we advocate a three-arm technique with the Si system,
we have adapted our technique to include all four arms with Xi.
3. Technique/procedure
The robotic camera is inserted through the 8.5 mm periumbilical port. The assistant surgeon uses a lateral 12 mm port to introduce laparoscopic instruments, energy
devices, endoscopic staplers, and suction as needed. Using the bipolar fenestrated
grasper (R2) and the hot shears (R1), a medial-to-lateral (MtL) dissection is realized. The port placement is as shown in Fig. 4.3. First, the assistant surgeon grasps
the ileocecal junction (IJ) to place the ileocolic vascular pedicle on tension. It is
critical to identify the cecum and ileocecal junction; this step cannot be over emphasized (Fig. 4.9a). A small window is created posteriorly near the origin of the ileocolic vessels. The dissection is continued for 2–3 cm to reveal the duodenum
(Fig. 4.9b). Typically, the duodenum identifies the origin of the ileocolic artery. A
second window is created to isolate the base of the vascular pedicle. It is divided at
the level of the duodenum with a vascular stapler load on the endoscopic stapler,
clips, or energy device, which are brought in through the left lateral 12 mm assistant
port or the EndoWrist
®
One™ Vessel Sealer may be used.
The medial-to-lateral dissection is continued. The right mesocolon is mobilized
off the retroperitoneum. This dissection is mostly blunt and accomplished by pushing the mesocolon anteriorly and the retroperitoneum posteriorly. This can be
advanced to the lateral attachments, to the liver and hepatic attachments, and to the
32
Fig. 4.9 (a) Picture IC vessels. (b) Picture duodenum
H.J. Lujan et al.
duodenal sweep as needed. The ileal mesentery is divided with an energy source or
cautery to a point 8–10 cm from the ileocecal valve. Typically, two small vessels or
branches will be encountered and can be divided with an energy device or
®
EndoWrist
One™ Vessel Sealer. The mesocolic mobilization is then carried up to
the duodenum and the transverse mesocolon. The terminal ileum is transected with
an endoscopic stapler or EndoWrist® Stapler 45 System. Next the right branch of
the middle colic is identified and transected with the energy device or stapler. The
ascending colon can be left attached to the right paracolic gutter to keep it from falling medially or completely detached and the specimen placed above the liver for
later retrieval (if the resection is for cancer, the specimen is placed in a bag). Lateral
mobilization begins at the ileocecal junction along the right paracolic gutter and
advanced to the hepatic flexure and along the right transverse colon. Sometimes
omentum is removed with the specimen. Usually, the omentum is partially detached
from the colon by dividing the gastrocolic ligament. The transverse colon is isolated
by creating a mesenteric window and then divided with the endoscopic stapler or
®
EndoWrist
Stapler 45 System.
Next, attention is turned to construction of an isoperistaltic, side-to-side ileocolic anastomosis. For this purpose, the terminal ileum and the transverse colon
stump are brought together side by side as shown in Fig. 4.10. A 20 cm nonabsorbable suture on a Keith needle is used to put a stay suture approximating the transverse colon and terminal ileum up to the abdominal wall to provide tension and
elevate the site of the anastomosis. Prior to creating the enterotomies, an endoscopic intestinal clamp (bulldog) can be placed on the terminal ileum to prevent
spillage (not the author’s routine). Using an energy device or hot shears (author’s
preference), a colotomy and ileotomy are created through which the jaws of the
®
endoscopic linear stapler or EndoWrist
Stapler 45 System are introduced to construct the common channel (Figs. 4.11 and 4.12). The remaining common enterotomy is then closed with 2-0 vicryl in two running layers using robotic suturing
techniques (Fig. 4.13).
Once complete, the stay suture is cut and then attention is directed again to the
specimen. As an alternative, a complete robotic sewn anastomosis can be fashioned.
If necessary, the remaining lateral and hepatic attachments are freed. A grasper with
teeth or endoloop is introduced through the 12 mm left lateral port to hold the speci-
4 Robotic Right Hemicolectomy
Fig. 4.10 Iso ICA
33
Fig. 4.11 Picture stapler 45