Chapter 6
Robotic Low Anterior Resection of Rectal Cancer Se-Jin Baek and Seon-Hahn Kim
Introduction Similar to robotic prostatectomy, the advantage of robotic technology in the field of colorectal surgery is best represented during a low anterior resection, which is performed in a narrow and deep pelvis and is difficult to approach [1, 2]. As the procedure of low anterior resection is divided into two segments, the colonic and pelvic phases, two types of robotic procedures have been developed. The first procedure, a hybrid technique, utilizes the robot only in the pelvic phase, during which its advantage is maximized. Conventional laparoscopy is used during the colonic phase. In the second procedure, a totally robotic technique, the robotic system is used throughout both phases (Fig. 6.1). Totally robotic technique can be further characterized by a single or dual docking method. Each approach method requires optimized port placement, cart positioning, and appropriate docking. The surgical method of approach can be selected by operator’s preference and familiarity for the procedure.
Hybrid Technique Hybrid technique was adopted during the early stages of robotic rectal surgery and has been the most widely used procedure to date. One important reason that the utilization of a robot during rectal surgery was relatively delayed was that the range S.-J. Baek, M.D. Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Inchon-ro 73, Seongbuk-gu, Seoul 136-705, Korea e-mail:
[email protected] S.-H. Kim, M.D. (*) Colorectal Division, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Inchon-ro 73, Seongbuk-gu, Seoul 136-705, Korea e-mail:
[email protected] © Springer International Publishing Switzerland 2017 V. Obias (ed.), Robotic Colon and Rectal Surgery, DOI 10.1007/978-3-319-43256-4_6
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Fig. 6.1 Hybrid technique versus totally robotic technique
of the operation is wide over the pelvis to splenic flexure [3–7]. The up-and-down and left-to-right movements over a wide dissection field frequently resulted in the external collision of robotic arms during the surgery. Moreover, multiquadrant operations such as a low anterior resection require the relocation of the robotic cart, a time-consuming and difficult procedure as the robotic devices are heavy and bulky. Consequently, surgeons felt stressed and hesitated to apply a robot system toward rectal surgery. However, a hybrid technique, which concentrated solely on the pelvic dissection, otherwise known as total mesorectal excision (TME), was developed to facilitate the whole procedure more effectively and to reduce overall operation time by eliminating the need for repositioning of the robotic cart [4, 5, 7]. As a result, this technique lowered the barrier to entry for many surgeons and enabled the robotic system to be rapidly adopted in the field of rectal surgery. Port placement in the hybrid technique is designed not only to focus on robotic pelvic dissection but also to be available for laparoscopic colonic mobilization during the second phase of a low anterior resection. The current recommendations are as follows:
Patient Positioning and Preparation • This is the step common to all approach methods. • Patient is in 15°. Trendelenburg position with legs in adjustable stirrups (stirrups mounted at most distal point on operation room (OR) table rail) (Fig. 6.2). • Patient is tilted right-side down 10–15°. • Use pads for pressure points and bony prominences, and secure body position, especially on the right side, to avoid shifting.
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Fig. 6.2 Patient positioning ©2015 Intuitive Surgical, Inc. used with permission
Port Placement All port placement measurements must be made after insufflation is achieved. Make sure to position the remote center (thick black band) of the da Vinci cannula at the level of peritoneum, making the band invisible on either side of the abdominal wall. • da Vinci Camera Port, 12 mm (blue): Place port 3–4 cm to the right of and 2–3 cm above the umbilicus. Distance to symphysis pubis should be approximately 22–24 cm (Fig. 6.3). • da Vinci Instrument Arm ① Port, 8 or 13 mm (yellow): Place a minimum of 8 cm from the camera port, on the right midclavicular line (MCL), 2–3 cm above the right spinoumbilical line (SUL). If stapler access from this location is deemed necessary, dilate this port to a 13 mm da Vinci cannula. • da Vinci Instrument Arm ② Port, 8 mm (green): Place port at the level of the camera port on the left MCL. The distance to the other instrument ports and camera port should be at least 8–10 cm. • da Vinci Instrument Arm ③ Port, 8 mm (red): Place approximately 4 cm above the left anterior iliac spine. The distance to Instrument Arm ② Port should be at least 8 cm. • Assistant Port (A), 5 mm (black): Place port 8–10 cm superior to Instrument Arm ① on right MCL (a minimum of 8 cm from camera port). • Assistant Port (B), 5 mm (white): Place port 6–8 cm inferior to xiphoid process on the midline. The distance to the other instrument ports and camera port should be at least 8–10 cm. *Slight modifications to the port locations may be necessary due to patient’s anatomy.
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Fig. 6.3 Port placement for hybrid technique ©2015 Intuitive Surgical, Inc. used with permission
Patient Cart Positioning and Docking • After the colonic phase is finished using standard laparoscopy, the patient cart is positioned and docked with all instrument arms. • Position camera arm setup joint on the opposite side of the da Vinci Instrument Arm ③. • Lower OR table and raise all of the arms high enough to clear the patient’s abdomen. Push all overhead lights and equipment aside. • Align the center column and camera arm with the camera port along a straight line following over the left stirrup mounting clamp on the OR table (Fig. 6.4a). The sterile person directing the roll-up can use a straight laparoscopic instrument to line up the camera port and stirrup clamp as an aid in directing the person rolling up the patient cart. • Roll up the patient cart at approximately a 45° angle. The patient cart base should straddle the corner of the OR table (depending on OR table model). • Use port and arm clutch maneuvers to dock the camera and instrument arms (Fig. 6.4b). • Maximize spacing between all instrument arms. CAUTION: Once the patient cart is docked and connected to the cannulae, the operating room table cannot be moved.
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Fig. 6.4 Patient cart alignment (a) and docking (b) ©2015 Intuitive Surgical, Inc. used with permission
Procedure Steps In hybrid technique, standard laparoscopy is used in steps 1–4, and then robotic procedure is performed in steps 5–6: • Step 1: Initial exposure—Flip the greater omentum over the transverse colon toward the liver. Retract small bowel loops out of the pelvic area into the right upper quadrant. Suspend uterus in female patient. • Step 2: Primary vascular control—Primary vascular control is achieved by dividing the inferior mesentery artery (IMA) and the inferior mesenteric vein (IMV). • Step 3: Medial to lateral mobilization of sigmoid and descending colon—Extent of the dissection is superior to the inferior border of the pancreas, laterally following Gerota’s fascia and inferior to the psoas muscle where the ureter crosses the iliac vessels. • Step 4: Splenic flexure mobilization—To achieve a tension-free anastomosis, the splenic flexure is mobilized in a medial approach. • Step 5: Rectal dissection—The rectal dissection is performed using an elliptical dissection pattern of the posterior first, continuing laterally to the left side, then to the right, and finally to the anterior side of the rectum down to the levator ani muscle level. • Step 6: Rectal division and anastomosis—Performed in standard laparoscopy or alternatively with robotic assistance. Prep through minilaparotomy at left lower quadrant port location.
Operative Outcome Because the procedure was developed early and has been widely used, there are many reports for low anterior resection using the hybrid robotic technique. Most operative outcomes, such as blood loss, conversion rate, hospital stay, and
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complications, after robotic low anterior resection using hybrid technique were similar or better than results after laparoscopic or open low anterior resection with the exception of operative time (Table 6.1) [3–18]. Moreover, several articles have reported comparative operative time results between the robot and laparoscopic groups, which may reflect upon the merit of hybrid robotic technique in the matter of time saving [19–25]. Recently, long-term oncologic outcomes were reported to indicate comparable overall and disease-free survival between robot and laparoscopic procedures [26].
Totally Robotic Technique Single Docking Method The hybrid technique has contributed much toward the adoption of the robot system in rectal surgery. However, there are some limitations of forgiving the advantages of using a robot system during the colonic phase, which provides better visualization during lymphovascular dissection around the inferior mesenteric artery (IMA) and the convenience of splenic flexure mobilization [27–29]. Thus, other procedure was independently developed to utilize the robotic system throughout both phases of a low anterior resection. Initially, the totally robotic procedure was performed as a two-stage or a threestage technique, which necessitated multiple cart repositionings, a time-consuming process. Subsequently, a single docking totally robotic technique was developed and has been widely used to date. This method consists of stationing the robotic cart beside the left lower quadrant of the patient’s abdomen, allowing complete coverage of the wide operative field, from the stage of splenic flexure mobilization to pelvic dissection, without requiring cart repositioning [27–29]. As a result, the advantages of robotic system could be maximized both in colonic and pelvic phase, and operative time could be saved compared to a two- or a three-stage technique. Moreover, this approach allows for a transanal procedure such as colonoscopic examination, even in the situation that the robotic cart is docking [29]. In the hybrid technique, the robotic cart was initially located between the patient’s legs, but has recently been repositioned to the left lower quadrant of the patient’s abdomen because of the advantages described above. Port placement in single docking method was designed to cover the entire operation, including colonic mobilization and pelvic dissection (steps 1–6). The current recommendations are as follows below. Note that patient positioning, preparation, cart positioning, and docking are the same as in the other techniques. Port Placement Position the remote center (thick black band) of da Vinci cannula at the level of the peritoneum. Maintain at least 8 cm between robotic ports and Assistant Ports:
263 (R, 52; L, 123; O, 88)
82 (R, 36; L, 46)
Comparative analysis (robot vs. open)
deSouza et al. (2011) [13]
R, 0; L, 0; O, NA
–
–
R, 187.5 (98.1); L, 273.8 (165.4) (p = 0.036)
R, 0; L, 10.5 R, 5.7 (1.1); (p = 0.013) L, 7.6 (3.0) (p = 0.001)
–
113 (R, 56; L, 57)
R, 0; L, 11.1 R, 6.9 (1.3); (p = 0.486) L, 8.7 (1.3) (p
