Robotic sigmoidectomy: Step by step

The patient is supine in a modified lithotomy position with legs in adjustable stirrups and tilted right side down in a Trendelenburg position; angles should be adjusted prior to docking the robot. If the splenic flexure will be taken down, less Trendelenburg is preferred.

You must keep at least 8 cm between robotic ports and 5 cm between the assistant port and other robotic ports. In this case we placed 4 ports, where 1, 3 and 4 are work ports and port number 2 is for the scope. In addition, a 12 mm trocar is used as an assistant in the right flank.

All port placement measurements must be taken after insufflation is performed. Then we proceed  to make the docking to attach the robot and  start surgery. The first step is to do the targeting for sigmoidectomy and complete the docking. Once the patient cart is docked and connected to the cannulae, the operating room table cannot be moved.

Once we locate the target anatomy we proceed to release the left parietocolic. We can see how instrument mobility allows us at all times a wide range of movements that simulate the human wrist.

We continue with the release of the left colon. We can see how the main surgeon handles the scope himself to show the workplace where he is dissecting. We perform the complete release of the colon with care to avoid injury to retroperitoneal structures such as the ureter, as we can see during this stage of surgery.

We also dissect the descending colon to assess whether it is necessary to release the splenic flexure and thus avoid further anastomotic tension.

We now proceed to the exposure of the mesenteric vessels for proper section, as in laparoscopic surgery from medial to lateral. The dissection starts with an incision of the peritoneum in the mesentery.  A cautery is used to open the peritoneum along this line, opening the plane cranially up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.

We continue the medial to lateral dissection, taking care not to injure the iliac vessels or the left ureter. Blunt dissection is used to lift the vessels away from the retroperitoneum. Then the dissection of the inferior mesenteric artery ends. The 3D HD visualization provided by the da Vinci System and the dexterity of the EndoWrist® instruments are crucial for an autonomic nerve-preserving dissection at the root of the IMA.

The vessels are transected by LigaSureTM from the assistant trocar.  We place a gauze to help and continue the dissection. At this time we release the posterior side of the colon from medial to lateral up to the promontory.  The 3 robot arms at all times allow us to have good traction and counter-traction for good exposure of the surgical field.

We are able to easily change the approach, completing dissection from the left side connecting with the work done from the medial side. We can take the gauze placed on the other side as a reference point. The rectal resection is then performed using an elliptical dissection pattern from right lateral, to posterior and now left lateral to anterior.

For proper exposure and countertraction we grasp the colon above the rectosigmoid junction and retract to the opposite direction of the dissection plane. The EndoWrist instrument in arm provides traction by pushing the lateral pelvic walls, lifting up the rectum or lifting anterior structures.

At this point we also used the LigaSureTM through the assistant trocar for sectioning the mesocolon. Once the tattoo area is exceeded (in this case) and the rectum is properly dissected, we prepare the sectioning area. An EndoGI TriStapleTM is then inserted through the assistant port and is used to divide the rectum with two  firings.

We can finally see the rectal stump sectioned, ready to create the anastomosis. After this, the specimen is exteriorized through a Pfannenstiel incision in the hypogastrium. We cut the proximal colon, completing the sigmoidectomy. At this point we remove the robot and proceed to create the anastomosis by laparoscopy.

We make an end to end colorectal anastomosis using an EEA stapler, completing the surgery. The anastomosis is reinforced with 3 stitches. Finally a drain is placed and the surgery is over.

In conclusion, our experience to date is positive. Robotic colorectal operations provide favorable results, with acceptable operative times and low conversion rates and morbidity. Surgical robots may provide additional benefits treating challenging pathologies, such as colorectal cancer. Further clinical studies and long-term follow-up are required to better evaluate the outcomes of robotic colorectal surgery.