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6 Robotic Low Anterior Resection of Rectal Cancer
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S.-J. Baek and S.-H. Kim
Chapter 7
Robotic Total Colectomy
Cesar Santiago and Sean Satey
Introduction
Before the introduction of multi-quadrant access robotic platforms, performing
robotic colorectal surgical procedures that required access to multiple quadrants
was a challenge. Older robotic platforms, such as the standard, S, and Si, were
designed to work in only one quadrant. Most robotic platforms utilized in the United
States and other countries are designed as single-quadrant access platforms. This
chapter addresses how to perform a multi-quadrant operation, such as a subtotal or
total colectomy, with a platform designed to work in a single quadrant. We will
describe the optimal locations for the robotic platform and ideal use for the robotic
arms via multiple dockings or “port hopping” for each step of the procedure.
Technical pearls of each procedural step will be highlighted for the benefit of the
reading surgeon.
Background
In 2000, the da Vinci® system was approved by the FDA as the first robotic system
to be used in general laparoscopic surgery. Among its first reported uses were
esophageal and pancreatic surgery at Ohio State University and robot-assisted cardiac surgery at the Cleveland Clinic in Florida [1]. The use of the robot was later
extended to prostatic and urologic procedures as the platform allowed operating in
C. Santiago, M.D. (*)
Department of Colon and Rectal Surgery, St. Joseph’s Hospital, Tampa, FL, USA
e-mail: cesar_santiago22@hotmail.com
S. Satey, M.D.
Department of General Surgery, Riverside University Health System—Medical Center,
University of California Riverside, Riverside, CA, USA
V. Obias (ed.), Robotic Colon and Rectal Surgery,
DOI 10.1007/978-3-319-43256-4_7
79© Springer International Publishing Switzerland 2017
80
C. Santiago and S. Satey
narrow and confined spaces. Initial attempts to perform robotic colorectal procedures were unsuccessful since the procedures required multi-quadrant access. The
first robotic colorectal surgery was performed in 2001. Weber et al. reported three
®
robotic right and sigmoid colectomies for benign disease using the da Vinci
robotic
system [2]. Simple procedures, such as a sigmoidectomy, were difficult to perform;
the short instruments and single-quadrant access made mobilization of the proximal
descending colon and splenic flexure arduous. The introduction of the S platform in
2008 advanced the role of the robot in colorectal surgical procedures. The release of
the Si platform further enhanced the ease at which multi-quadrant procedures could
be performed and the use of robotic technology was extended to the realm of
colorectal surgery.
Subtotal or total colectomies are common multi-quadrant procedures that may
be efficiently performed with the assistance of a robot designed for use in a single quadrant. Subtotal colectomy resects part of the colon, whereas a total colectomy resects the entire colon with sparing of the rectum. The most common
indications for subtotal colectomies include polyposis syndromes with rectal
sparing, Lynch syndrome, synchronous colonic lesions or tumors, and inflammatory bowel disease [3, 4]. Less common indications include colonic inertia and
Hirschsprung’s disease [5, 6].
We believe that robotic subtotal or total colectomies should be performed after
the operating surgeon is proficient with less complex robotic cases and toward the
end of the operating surgeon’s learning curve. Recent literature reports that the
learning curve for robotic colorectal procedures would be achieved after approximately 15–25 cases [7].
Operating Room Setup and Preparation
Utilization of a dedicated robotic operating room (OR) has become the norm when
performing advanced robotic procedures, such as subtotal and total colectomies.
The room must be large enough to house both the robotic platform and console
while accommodating platform movement to other quadrants, if needed. The possibility of a dual robotic console and the need for a colonoscopy cart should also be
entertained. In addition, a dedicated robotic OR ensures a consistent team that facilitates efficiency, decreases OR time, and decreases cost [8]. Fully integrated robotic
ORs now enable the surgeon to record the procedure for educational and/or research
purposes and offer the ability to perform tele-surgery.
The operating surgeon should be mindful of the room configuration, including
entryways, doors, and anesthesia equipment to ensure the most ergonomic setup.
A subtotal colectomy performed with an Si platform, for instance, requires more
than one docking and requires all of the above considerations.
We prefer to start our subtotal colectomies with dissection of the right colon first;
thus, the robot is initially docked over the patient’s right shoulder. This setup places
7 Robotic Total Colectomy
Fig. 7.1 OR setup and patient preparation—right and proximal transverse colon. Patient is placed
in lithotomy position with right side tilt in mild reverse Trendelenburg. The robotic second arm is
placed ipsilateral to the fourth arm and extended over the patient’s head
81
the robot’s second arm ipsilateral to the fourth arm and extended over the patient’s
head, as illustrated in Fig. 7.1.
The anesthesia cart is positioned at the head of the patient’s bed. The anesthesiologist must utilize tubing long enough to allow rotation of the patient in any direction necessary to accommodate the robotic platform. We advise the operating
surgeon to sit on the right side of the patient, positioned toward the feet, to ensure
direct view of the robotic arms and assistant at all times; thus, we advise against
surgeon positioning behind the platform.
The first assistant should sit on the left side of the patient to avoid injury from the
moving camera. We also recommend the use of a two-way radio between the surgeon and first assistant to prevent breach of communication. The surgical technician
is positioned on the left side of the first assistant to pass instruments as needed. The
tower and robotic power source is located at the foot of the table. Two monitor
slaves are required and may be relocated depending on the surgical quadrant.
When performing procedures that require multiple positions, it is imperative to
secure the patient to the operating table to prevent sliding. Surgical beanbag positioners may be used to prevent movement. If used, care must be taken to ensure that
the lateral sides of the beanbags do not interfere with the third robotic arm.
82
Fig. 7.2 OR setup and patient preparation—splenic flexure and distal transverse colon. Patient
remains in lithotomy position with left side tilt up and in mild reverse Trendelenburg. The robot is
re-docked over the patient’s left shoulder
C. Santiago and S. Satey
Prior to docking of the robot, the ileocolic vessel and duodenum are identified
laparoscopically. The initial portion of the robotic procedure—right colon mobilization
and hepatic flexure mobilization—requires a few degrees of reverse Trendelenburg
and tilt to the right. The same position is maintained until the mid to distal transverse colon is reached. Once reached, the robot is re-docked over the patient’s left
shoulder, as illustrated in Fig. 7.2. The patient remains in mild reverse Trendelenburg.
The distal transverse colon, splenic flexure, and a significant amount of proximal
and descending colon are subsequently dissected.
The final stages of the procedure—accessing the distal descending colon to the
rectosigmoid junction—require turning the patient on an axis and brining the platform over the left hip at a 45° angle, as illustrated in Fig. 7.3. The patient is then
placed in a Trendelenburg position with the patient’s left side up. This facilitates
movement of the small bowel out of the pelvis and to the right of the right iliac vessel
until the inferior mesenteric vessels are identified.
We caution against prolonged steep (25–45°) Trendelenburg position to prevent
significant physiologic consequences, such as pulmonary edema, exacerbation of
ventilation/perfusion mismatch, and upper airway and brain edema [9]. The wristed
arms of the robot allow for precision which make the dangerous practice of steep
Trendelenburg virtually unnecessary.
7 Robotic Total Colectomy
Fig. 7.3 OR setup and patient preparation—left and sigmoid colon. Patient remains in lithotomy
position with left side tilt up and in mild reverse Trendelenburg. The patient is turned on an axis,
and the platform is moved over the left hip at a 45° angle
83
Trocar Placements
Multiple quadrant access is required for this procedure. The operating surgeon must
be cognizant of the procedural steps to minimize trocar placement despite multiple
dockings. We suggest port addition as the surgery progresses to accomplish this
goal. The initial trocar configuration mimics that of a right hemicolectomy. The
configuration will then emulate that of an isolated splenic flexure lesion and finally
a sigmoidectomy. The camera port will remain in the midline in order ensure equal
access to all quadrants.
The camera port is placed in the midpoint between the xyphoid process and the
pubis. The surgeon must avoid placing the camera port too low to ensure visualization of the hepatic and splenic flexures over the transverse colon and, at the
same time, avoid placing the camera too high to circumvent the falciform ligament and prevent obscure visualization of the operative field. The camera port
may be moved laterally, in either direction; however, that practice may place the
camera too close to the target in subsequent steps of the operation and should be
avoided.
The first arm trocar is placed to the left of the midclavicular line, as illustrated in
yellow in Fig. 7.4. The second arm trocar is placed at the midpoint between the
84
Fig. 7.4 Port placement—right and proximal transverse colon. Target anatomy is referenced in
orange. Camera port is referenced in blue and is placed at the midpoint between xyphoid process
and pubis. Instrument arm 1 is referenced in yellow and is placed to the left of the patient’s midclavicular line. Instrument arm 2 is referenced in green and is placed at the midpoint between the
camera port and the pubis. Instrument arm 3 is referenced in red and is placed to the left of the
falciform ligament. The 12-mm assistant port is referenced in black and is placed at the midpoint
between the first and second instrument arms
C. Santiago and S. Satey
camera port and the pubis. We prefer to make this incision horizontally in preparation
for our extraction site. The third arm trocar is placed to the left of the falciform ligament. The surgeon must take care to allow adequate distance for access to the gastrocolic ligament. The assistant port is placed at the midpoint between the first and
second arms after making sure that the robotic camera will not interfere with the
assistant’s hand. This trocar configuration will allow the operating surgeon to reach
the level of the proximal to mid-transverse colon.
The second stage of the operation involves the dissection of the mid-transverse
colon, splenic flexure, and proximal descending colon. Once again, the robotic platform is re-docked over the patient’s left shoulder. A 12-mm assistant port is added
in the right lower quadrant at the midpoint between the camera port and the iliac
spine. During the second stage, this port will serve as the assistant port; during the
final stage of the procedure, it will become the first arm. An 8-mm port is added to
the right upper quadrant, as illustrated in red in Fig. 7.5, which will now serve as the
second arm.
7 Robotic Total Colectomy
Fig. 7.5 Port placement—splenic flexure and distal transverse colon. Target anatomy is referenced in orange. Camera port remains the same as Fig. 7.4. Instrument arm 1 is referenced in
yellow and is re-docked at the previous left lower quadrant assistant port site. Instrument arm 2
is referenced in red and is placed to right of the patient’s midclavicular line. Instrument arm 3 is
referenced in clear and is re-docked at the previous site of instrument arm 2 in Fig. 7.4. The
12-mm assistant port is referenced in white and is placed at the midpoint between the second and
third instrument arms
85
At this point, the first arm is docked on the previous left lower quadrant assistant
port site. The third arm is docked in the suprapubic area where the second arm was
docked previously.
For the final stage of the procedure, the patient is turned on an axis with the
platform over the patient’s left hip at a 45° angle. The distal descending colon,
sigmoid colon, and rectosigmoid junction are accessed with the following trocar
configuration, as illustrated in Fig. 7.6.
The first arm is re-docked at the site of the right lower quadrant assistant port.
The second arm may be placed in two possible areas: remain docked on the right
upper quadrant where it was previously or re-dock at the left lower quadrant where
it was previously the first arm with the robotic platform over the right shoulder.
The third arm is re-docked close to the left anterior axillary line. This is where
the first arm was docked at the beginning of the case. Alternatively, an additional
8-mm trocar may be added if the previously placed port is not in an optimal position
to be used as the third arm.