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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 the 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 establish the docking to attach the robot and start surgery. Once we locate the target anatomy we 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 continue with the release of the left parietocolic. We perform the complete release of the colon taking care to avoid injury to retroperitoneal structures. We are able to easily change the approach, completing dissection from the left side connecting with the work done from the medial side.
At this point 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.
At this point we use the LigaSureTM through the assistant trocar to section the mesocolon in order to prepare the transection of the proximal colon. When the section area is prepared, we use indocyanine green to check the correct vascularization of the proximal colon and then carry out a safe anastomosis. An EndoGIA TriStapleTM is then inserted through the assistant port and is used to divide the colon. Subsequently, we proceed to section the distal area at the level of the rectum. In this case we use the ligasure to section it. Once sectioned we can extract the specimen through the rectum with no need to make any auxiliary incisions. We also take advantage of this moment to introduce through the rectum the anvil of the suture device to perform the anastomosis. Finally we section and close the rectum with an EndoGIA TriStapleTM that we introduced from the assistant’s port. Now we are going to prepare the proximal colon to perform the anastomosis. First we open the colon with the hook and introduce the anvil. The movements of the robotic instruments facilitate these precise actions. Then we make a pursestring to fix the anvil and create a side to end anastomosis. Finally, we introduce the suture device through the rectum and create the anastomosis with no complications and in an easy and safe manner, previously checking that the mesocolon is in a correct position and not rotated. To finish, we make two stitches at the corners of the anastomosis as reinforcement and check that there is no tension to end the surgery.
The surgery took 110 minutes. The patient started oral intake 6 hours after the surgery and left the hospital on the 3rd postoperative day. Pathological examination ruled out a colon adenocarcinoma pT1N0.
