1. PORT PLACEMENT
IDENTIFY THE SURGICAL WORKSPACE
Identify where the instrument tips must reach in order to complete the procedure. If the surgical workspace of any procedure requires access to more than two quadrants, consider Dual Docking.
DETERMINE THE TARGET ANATOMY
The target anatomy is not the pathology. It is the area where the midline of the surgical workspace intersects with the far edge of the surgical workspace boundary.
PLACE THE INITIAL ENDOSCOPE PORT
Place the initial endoscope port 10–20 cm from the target anatomy, on the opposite edge of the surgical workspace boundary.
DECIDE ON THE HAND CONTROLS
Decide whether to control two instruments with the left hand or with the right hand. This determines port placement. Two da Vinci instrument ports will go to one side of the initial endoscope port, and one da Vinci instrument port will go to the other.
PLACE THE DA VINCI PORTS
Place the remaining da Vinci ports 8 cm apart, along a line perpendicular to the target anatomy.
- Port distance should range between 6 and 10 cm and be adapted according to the patient’s body habitus.
- Place the ports at least 2 cm away from any bony structures.
- Do not place ports between other ports and the target anatomy.
PLACE THE ASSISTANT PORTS
Place the assistant ports as needed, as far away as possible from the da Vinci ports (at least 7 cm).
- Ensure port location enables you to reach the desired anatomy.
- Ensure port location gives you physical access to the port.
- Consider placing the ports lateral to the da Vinci ports or triangulated between the da Vinci ports.
- Use bariatric-length laparoscopic instruments with assistant ports.
- Do not place any assistant ports between the da Vinci ports and the target anatomy.
2. DEPLOY FOR DOCKING
SELECT THE ANATOMY
Select the anatomic region of the desired surgical workspace on the Patient Cart helm.
SELECT CART LOCATION
Select how the Patient Cart will approach the patient: from the Patient’s Right, the Patient’s Left, or the Patient’s Legs.
PRESS AND HOLD ‘DEPLOY FOR DOCKING’
Deploy for Docking adjusts the da Vinci to an appropriate starting position automatically.
- It automatically rotates and pivots the boom to optimize access to the patient.
- It readies the da Vinci to be driven to the patient.
3. DRIVE THE LASER LINES TO THE ENDOSCOPE PORT
DRIVE THE CART
Grasp the handlebars and the cart drive enable switches and slowly drive the Patient Cart to the operating table, monitoring patient clearance.
DRIVE THE LASER LINES TO THE SCOPE PORT
Drive the laser lines within 5 cm of the initial endoscope port. This positions the center of the da Vinci boom over the initial endoscope port.
DOCK THE INITIAL ENDOSCOPE ARM
Dock the initial endoscope arm to the initial endoscope port. Insert the endoscope and ensure it is rotated to a ‘neutral’ horizon position before targeting.
POINT THE ENDOSCOPE AT THE TARGET ANATOMY
The target anatomy is not the pathology. It is the area where the midline of the surgical workspace intersects with the far edge of the surgical workspace.
Hold the cannula with one hand to support it while it moves.
Press and hold the targeting button on the endoscope.
The boom will automatically rotate and orient itself toward the target anatomy. Hold the targeting button until the audible countdown completes and motion stops.
Performing targeting simultaneously adjusts column height, boom extension, and boom rotation, and achieves the following:
- It centers the boom over the initial endoscope port.
- It rotates the boom to point toward the target anatomy.
- It adjusts column height to maximize sterility and ensure arms reach to all ports for docking.
5. PERFORM MANUAL ARM ADJUSTMENTS
ALIGN THE ENDOSCOPE ARM
Adjust the flex on the initial endoscope arm, using the laser lines as a positioning guide. Make the back of the arm parallel to the laser line. This aligns the arm with the target anatomy.
DOCK THE REMAINING ARMS
Dock the remaining arms to the corresponding ports.
ADJUST THE SIDE WITH ONE (1) ARM
Adjust the flex on the arm to maintain a minimum distance of one fist to the initial endoscope arm.
ADJUST THE SIDE WITH TWO (2) ARMS
Flex the outer arm away from the inner arm (the arm nearest to the endoscope) to get it out of the way for initial adjustment.
Adjust the flex on the inner arm to maintain a minimum distance of one fist to the initial endoscope arm.
Go back to the outer arm and adjust the flex back toward the inner arm to maintain a minimum distance of one fist.
SPECIFIC CONFIGURATIONS BASED ON THE SURGICAL PROCEDURE
Left colectomy, sigmoidectomy and high anterior resection
Left colectomy, sigmoidectomy, and robotic high anterior resection are used for colon tumors located in the left colon, sigmoid, and rectum.
Position: The robot cart is placed to the left of the patient, who is in the supine position with open legs, in the Trendelenburg position (> 10º), lateralized to the right (> 10º). Before connecting the robotic system, the patient’s position must be adjusted to ensure sufficient exposure of the surgical field. Subsequently, the operating table cannot be mobilized.
Trocar placement: for trocar placement, a line can be drawn from the right femoral head (lateral edge of the inguinal triangle) to the left mid-clavicular line, crossing the left subcostal border. Port 2 should be placed at the junction of this line with the middle line, this port being the initial one. Then we place 1, 3 and 4 at a distance of 8 cm between them. Finally, the assistant’s port must be positioned as far as possible from the da Vinci ports and lateral to the right of the mid clavicular line.
Mobilization of the splenic flexure: in order to mobilize the splenic flexure, it is necessary to mobilize the orientation of the robotic arms toward the upper left quadrant of the patient, beginning by adjusting arm 1 to the maximum possible flexion. The goal is to open up space between the arms to increase reach and avoid interference.
Low anterior resection, tumors located in the pelvis
Low resection is used for colon tumors located in the mid and lower rectum.
Position: The robot car is placed to the left of the patient, who is in the supine position with open legs, in the Trendelenburg position (> 15º), with no lateralization and with the surgical table at the lowest possible height to avoid conflicts with the robot. Before connecting the robotic system, the patient’s position must be adjusted to ensure sufficient exposure of the surgical field. Subsequently, the operating table cannot be mobilized.
Trocar placement: in this case the initial port where the camera will go should be placed at the umbilical level. Port 1 on the left side, 8 cm from port 2 and 3, 4 on the right side to port 2, 8 cm from each other. The auxiliary port must be placed triangulating, as far as possible from the da Vinci ports between 3 and 4.
Right colectomy and Extended right colectomy (intracorporeal anastomosis)
Right colectomy and Extended right colectomy are used for colon tumors located in the right colon and proximal transverse.
Position: The robot car is placed to the right of the patient, who is in the supine position, in the Trendelenburg position (> 10º), lateralized to the left (> 10º) and with the surgical table at the lowest possible height to avoid conflicts with the robot. Before connecting the robotic system, the patient’s position must be adjusted to ensure sufficient exposure of the surgical field. Subsequently, the operating table cannot be mobilized.
Trocar placement: the first trocar should be placed 4-5 cm above the pubic symphysis. A line can then be drawn from port 1 to where the left clavicular midline crosses the left subcostal margin, placing ports 2, 3 and 4 at a distance of 8 cm from each other on the line. The auxiliary port should be placed triangulating, as far as possible from the da Vinci ports and lateral to the midline clavicular left.
Another option would be chosen for localized tumors either in the hepatic flexure or in the transverse colon. In this case we can draw a transversal line 3 cm higher than the pubic symphysis. Place ports 2 and 3 on the transverse line, equidistant to 6 cm around the middle line. Port 1 is positioned 6 cm right side to port 2; port 4, 6 cm left side to port 3 and auxiliary port 5 cm directly top and side to 4.
Segmental colon resections
Segmental colon resections can be used for tumors located in the transverse colon or at the splenic flexure.
Both robot position and trocar placement depend on the location of the tumor, being able to use a pelvic location or right, following the principles previously described depending on where the target anatomy is located.
Double docking is used when the surgical field is too large to be reached with single docking. After working toward the first target anatomy, the user undocks the da Vinci Xi, rotates its boom 180°, and docks again to the same ports. This enables reach towards the second target anatomy.
It is used mainly when:
- The surgical field extends beyond two quadrants.
- The initial port of the endoscope is within the planned surgical field and is surrounded by most of it.
Local invasion and distant metastasis are common in patients with colorectal cancer and, therefore, multiple organ resection is an important measure for radical resection of colorectal cancer. Robotic surgery is also applicable in combined resection, although it should only be performed by experienced surgeons after consultation with a multidisciplinary team. For locally advanced colorectal cancer with invasion of adjacent organs (mainly tumors that invade the urinary bladder, ovary, and uterus), robotic surgery can be performed safely. This type of surgery can also be applied in the synchronous resection of colorectal cancer with distant metastases, such as liver metastases.
In addition, during resections of different lesions, the same ports can be used to minimize trauma. Currently, hepatic robotic resection has been shown to be safe and effective, but the long-term effects of synchronous resection of colorectal cancer and hepatic metastasis lesions are yet to be assessed.
TAKE HOME MESSAGES
- Robotic surgery is growing rapidly in the world, and will possible become a standard tool in the future.
- A good learning curve with a sufficient number of cases is very important.
- The robot is a particularly useful tool in the dissection of the rectum, especially in male patients, obese patients, and patients with large tumors.
- It should be reserved for experienced centers and surgeons with a high volume of cases.
- The use of robotic surgery is promising but still limited, and still requires randomized studies.
- Large volume tumors and the involvement of neighboring or distant organs do not represent a contraindication to perform robotic surgery.