LEFT COLECTOMY

Procedure Guide

Disclaimer The following material has been reviewed and approved by the following independent surgeon, who is not an Intuitive Surgical employee: Eduardo Parra-Davila, MD, FACS, FASCRS Director of Minimally Invasive and Colorectal Surgery Director of Hernia and Abdominal Wall Reconstruction Florida Hospital, Celebration Health 410 Celebration Place, Suite 401 Celebration, FL 34747

This procedure guide is provided for general information only and is not provided as formal medical training or certification. Intuitive Surgical trains only on the use of the da Vinci Surgical System. Intuitive Surgical does not provide clinical training nor does it provide or evaluate surgical credentialing or train in surgical procedures or techniques. This material presents the opinions of and techniques used by the above surgeon and not those of Intuitive Surgical. Before performing any clinical procedure utilizing the System, physicians are responsible for receiving sufficient training and proctoring to ensure that they have the requisite training, skill and experience necessary to protect the health and safety of the patient. For technical information, including full cautions and warnings on using the da Vinci System, please refer to the System User Manual. Read all instructions carefully. Failure to properly follow instructions, notes, cautions, warnings and danger messages associated with this equipment may lead to serious injury or complications for the patient. While clinical studies support the use of the da Vinci Surgical System as an effective tool for minimally invasive surgery, outcomes cannot be guaranteed, as surgery is patient and procedure specific. 2008 Intuitive Surgical. All rights reserved. Intuitive, Intuitive Surgical, da Vinci, da Vinci S, InSite, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their respective holders. PN 873523 Rev. A 5/10

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da Vinci Left Colectomy Procedure Guide

Table of Contents
1. INTRODUCTION 1a. Patient Benefits 1b. Surgeon Benefits 2. INSTRUMENTS AND ACCESSORIES 2a. Recommended EndoWrist Instrumentation 2b. Additional da Vinci Supplies 2c. Recommended Laparoscopic Instrumentation and Accessories 2d. Recommended Sutures/Clips 3. PATIENT SELECTION AND PREPARATION 3a. Patient Selection 3b. Patient Preparation 3c. Operating Room Configuration 4. POSITIONING, PORT PLACEMENT AND DOCKING 4a. Patient Positioning 4b. Port Placement 4c. Patient Cart Docking 5. PROCEDURE STEPS LEFT COLECTOMY 5a. Primary Vascular Control 5b. Medial to Lateral Mobilization of Descending Colon 5c. Splenic Flexure Mobilization (as necessary) 5d. Final Mobilization of Sigmoid and Superior Rectum, Colon Division 5e. Specimen Removal and Anastomosis 6. POST-OPERATIVE CARE APPENDIX A Cannula Remote Center Set-Up

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1. INTRODUCTION
1a. Patient Benefits da Vinci Left Colectomy offers patients numerous potential benefits: Safe and effective surgical treatment of colon disease.1,2 Quick return to bowel function.2 Low blood loss.3 Short length of stay.2

da Vinci Left Colectomy offers an effective surgical solution for the treatment of both benign and malignant colon disease with the potential benefits of a minimally invasive approach. 1b. Surgeon Benefits The unsurpassed visualization, precision, dexterity and control provided by the da Vinci Surgical System offers the following potential surgeon benefits: Greater ability to perform minimally invasive colon surgery safely, reproducibly and effectively.1,2 Superior exposure and meticulous dissection enable more precise and efficient colon mobilization.2 Better visualization of vessels, lymph nodes and the ureters.1 Easier, precise suturing for effective intracorporeal anastomosis.2 Accurate and comprehensive lymphadenectomy for malignant cases.1

Jayne, D. Robotics: Right Colon. Seminars in Colon and Rectal Surgery. Volume 20, Issue 4. December 2009, Pages 166-172. 2Spinoglio G, Summa M, Priora F, Quarati R, Testa S.Robotic colorectal surgery: first 50 cases experience. Dis Colon Rectum 2008;51:1627-32. 3Luca F, Cenciarelli S, Valvo M. Full Robotic Left Colon and Rectal Cancer Resection: Technique and Early Outcome. Annals of Surgical Oncology. May 2009, Vol. 16, No. 5: 1274-1278.

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2. INSTRUMENTS AND ACCESSORIES

2a. Recommended EndoWrist Instrumentation Hot Shears (Monopolar Curved Scissors): 400179/420179 (Requires Tip Cover: 400180) Small Graptor (Grasping Retractor): 420318 Hem-o-lok Clip Applier, Large: 400230/420230 Fenestrated Bipolar Forceps: 400205/420205 Harmonic Curved Shears: 400174/420147

Alternative EndoWrist Instrumentation Graptor: 400278/420278 Cadiere Forceps: 400049/420049 Double Fenestrated Grasper: 400189/420189 Permanent Cautery Hook: 400183/420183 Large Needle Driver: 400006/420006 SutureCut Needle Driver: 400209/420209 2b. Additional da Vinci Supplies Basic accessory kit and drapes Intuitive Surgical camera head Intuitive Surgical 0 and 30 endoscopes

2c. Recommended Laparoscopic Instrumentation and Accessories Laparoscopic Vision o Endoscopic video equipment with a 5 or 10 mm laparoscope (Olympus, Karl Storz, Stryker or similar) Sealing/Division o LigaSure V (http://www.ligasure.com/index2.htm) o LigaSure Atlas (http://www.ligasure.com/index2.htm) o EnSeal 5 mm (http://www.surgrx.com/product.html) Graspers/Forceps/Scissors o Olympus (http://www.olympus-europa.com/endoscopy/) Long Johann Forceps, 330 mm with Ergo handle (WA63130A) Maryland Forceps, 330 mm with Ergo handle (A63320A) Short Maryland Forceps, 330 mm with Ergo handle (A63340A) Metzenbaum Scissors, 330 mm with Ergo handle (A63810A) Grasping Forceps with Lumen, 330 mm with Ergo handle (A63040A) Atraumatic Grasping Forceps, 330 mm with Ergo handle (A63010A) HiQ+ Needle Holder or o Karl Storz (http://www.karlstorz.com) CLICKLINE Kelly Dissecting and Grasping Forceps 5 mm (33322ML) CLICKLINE Scissors 5 mm (34321MA) CLICKLINE Bowel Grasper fenestrated 5 mm (33431C) CLICKLINE Forceps atraumatic 5 mm (33431WTD) CLICKLINE Grasping Forceps 10 mm (33532 SG)

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Staplers o o o o Endo GIA Universal Roticulator with single use loading units (sizes 30, 45 and 60 mm lines, http://www.autosuture.com) DST Series EEA Stapler (http://www.autosuture.com) Endopath ETS-Flex Endoscopic Linear Cutter (http://www.jnjgateway.com) Proximate Intraluminal CDH Stapler (http://www.jnjgateway.com) 544965 Endo5 ML Hem-o-lok Clip Applier, 32.5 cm, 5 mm (http://www.teleflexmedical.com) 5 mm suction/irrigation device (HiQ+ suction/irrigation system from Olympus or Surgiwand II from Autosuture) Alexis Wound Retractor Ref. #C8301 (2.5-6 cm) S (Applied Medical)

Other o o o

2d. Recommended Sutures/Clips

Hem-o-lok Large Clips #544240 (violet) and Medium Large Clips #544230 (green) 2-0/3-0 Vicryl SH or SH-2 Plus needle (for mucosa/bowel repair or tag) 2-0 Prolene, CT or CT1 needle (for anvil purse-string suture)

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3. PATIENT SELECTION AND PREPARATION

3a. Patient Selection Ideal Patient Selection Criteria for Early Cases Good performance status Non-obese patients (BMI < 30) Healthy: few co-morbidities No previous intra-abdominal or pelvic surgery No prior chemotherapy or pelvic radiotherapy Low volume disease (non-bulky tumors) Avoid patients with moderate to severe cardiopulmonary compromise. Prolonged operative times and steep Trendelenburg positioning may be poorly tolerated by patients with cardiopulmonary disease. Recommended for patients with the following conditions Early T0 stage tumors (unresectable using colonoscopy) T1 stage tumors massively invasive to the submucosa Certain T2-T4 stages for colon cancer that are approachable by robotic technique Not recommended for patients with the following conditions Tumor (T3 and T4) invading into adjacent organs extensively or massive in size (greater than 8 cm in diameter) Patients with: 1. Intestinal obstruction requiring urgent decompression 2. Contraindication to general anesthesia under pneumoperitoneum Otherwise no specific non-recommendations for the robotic approach compared with open surgery 3b. Patient Preparation Pre-Operative Patient Preparation Bowel preparation is dependent on surgeons preference and is identical to that of open or laparoscopic left colectomy. Intra-Operative Patient Preparation Intra-operative preparation includes shaving the patient from the costal margin to the pubic bone. The abdomen, pelvis, perineum, upper thighs and peri-anal area are prepped and draped in the usual sterile fashion. A Foley catheter is inserted. A nasogastric or orogastric tube is inserted at the start of the procedure and removed at the end of the case if ileus not expected.

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Left Side Colectomy Approach

BLUE No splenic flexure mobilization RED Splenic flexure mobilization needed YELLOW End of case splenic flexure mobilization Place trocars for camera, arm and ~20 Trendelenburg Min. 15 rotated left
SUL MC MC

SUL

Place instrument arm port above pubis and assistant port in lateral RUQ. Dock over left shoulder with on MCL surgeons right the MCL

Mobilize SB to expose base of colon and assess colon

Place instrument arm port in LUQ and assistant port in lateral RUQ. Dock at 45 over left hip with on the surgeons left
MCL MCL

YES
A

Is splenic flexure mobilization needed?

NO
A

SUL

SUL

Medial or lateral mobilization above sacral promontory Identify ureter

SUL

SUL

Control IMA/IMV

Elevate colon off of Gerotas fascia

Dissect to the inferior border of the pancreas and enter the lesser sac, dissect laterally

Separate omentum from the transverse colon and dissect toward the splenic flexure

Mobilize proximal line of Toldt of descending colon

Place arm port in LUQ and assistant port in lateral RUQ. Dock at 45 over left hip Move to the left
MCL MCL

SUL

SUL

Pfannenstiel incision for specimen extraction and anastomosis

Mobilize mid to distal line of Toldt of descending colon

YES

Prepare superior rectum and staple across

Is enough colon mobilized for a tension-free anastomosis?

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NO

3c. Operating Room (OR) Configuration The following figure shows an overhead view of the recommended OR configuration for a da Vinci Left Colectomy. Patients left side is kept clear to allow for docking over the left upper quadrant (LUQ) or left lower quadrant (LLQ) [Figure 1].

LUQ docking

LLQ docking

Figure 1: Operating room set-up

Patient-side assistant is on patients right side. Scrub nurse is at the lower right side of the table. Main assistant monitor is located at the patients feet. Its useful to have a second monitor on the left side of the table across from the assistant. Sterile back tables (instruments) are located at the patients right knee.

NOTE: Configuration of the operating suite is dependent on the room dimensions as well as the preference and experience of the surgeon.

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4. POSITIONING, PORT PLACEMENT AND DOCKING

4a. Patient Positioning Patient is supine in modified lithotomy position with legs in adjustable stirrups (Yellowfin or SAM III stirrups, http://www.allenmedical.com). Legs are abducted and slightly flexed at the knees. Upper leg should be at or below the level of the torso. Patient's arms are alongside the body to lessen possibility of shoulder injury. Pad pressure points and bony prominences; secure body position with vacuum-mattress device, especially lateral on the right side. Carefully secure patient to the table to avoid any shifting with the Trendelenburg position. Patient is tilted right side down; adjust the angle during initial exposure step (see section 5a Initial Exposure). A nasogastric or orogastric tube and urinary catheter are placed. A body warmer to prevent patient hypothermia can be applied. Sequential compression devices can be applied to the legs for DVT prophylaxis. After positioning, padding, securing and preparing the patient in the supine position, the table is then placed in a Trendelenburg position, whereby the steepness should be adjusted per exposure needs during the initial exposure step (see section 5a Initial Exposure) [Figure 2].

NOTE: It is recommended to limit Trendelenburg to no more than 15-20, especially if it is planned to mobilize the splenic flexure. Small bowel management can be facilitated by rolling the patient fully to the right.

Figure 2: Patient positioning

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4b. Port Placement Preparing for Port Placement Insufflation up to 15 mmHg is achieved through a Veress needle at the subcostal area. Perform initial assessment of entire anatomy once the endoscope port is inserted in the location described below (focus on liver for malignancy and check Veress needle for any possible injuries.) Check for optimal port sites and adhesions, then place ports for the camera and instrument arms and . First Stage Port Locations Splenic flexure line

Figure 3: da Vinci left-side approach preliminary port placement

da Vinci Camera Port, 12 mm (Blllue): Place port 3-4 cm right and 2-3 cm above umbilicus. B ue B ue Distance to symphysis pubis should be ~21-23 cm. da Vinci Instrument Arm Port, 13 mm stapler cannula (Yellllllow): When a line is drawn Ye ow Ye ow between the camera port and approximate location of the splenic flexure (splenic flexure line), should be approximately 2 cm inferior to the line and on the patients right the instrument arm MCL. da Vinci Instrument Arm Port, 8 mm (Grreen): Place just right of midline. Distance to Green G een xiphoid process should be ~2-3 cm and the port should be approximated over the transverse colon. NOTE: Be cautious at the lower quadrant cannula sites to avoid injuring the inferior epigastric artery and vein. Camera port, port and port should be placed first and the anatomy evaluated laparoscopically prior to selecting the following procedure paths.

Instrumentation: 0da Vinci endoscope or 30 laparoscopic endoscope, two laparoscopic bowel graspers through the da Vinci ports. A 5 mm laparoscopic suction instrument can also be used as necessary. Free any adhesions as necessary Flip the greater omentum cephalad over the transverse colon using the laparoscopic instrumentation. Retract small bowel loops out of the pelvic area into the right upper quadrant. The Trendelenburg position of the OR table with the right side down will allow to maintain

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exposure and help shift the small intestine into the right upper quadrant NOTE: It is recommended to limit Trendelenburg to no more than 15-20, especially if it is planned to mobilize the splenic flexure. Small bowel management can be facilitated by rolling the patient fully to the right. Evaluate the colon to determine level of redundancy in the sigmoid and estimated amount of resection following standard oncologic principles as needed. Decide whether the mobilization of the splenic flexure is likely to be needed or not.

Mobilization needed:
da Vinci Instrument Arm Port, 8 mm. (Red): Place on the midline. Distance to Red Red symphysis pubis should be ~3-4 cm.

Mobilization not needed:

da Vinci Instrument Arm Port, 8 mm. (Red): Place on the left MCL midway between Red Red the camera port and instrument arm port. Distance to other instrument ports and the endoscope port should be at least 8-10 cm.

Arm

is placed on the RIGHT

MCL MCL

Arm

is placed on the LEFT

MCL MCL

SUL

SUL

SUL

SUL

Figure 4: da Vinci left side approach port placement, splenic flexure mobilization

Figure 6: da Vinci left side approach port placement, no splenic flexure mobilization

Docking: Dock the system over the left shoulder at approximately 15to perpendicular to the patient.

Docking: Dock the system over the left hip at approximately 45to perpendicular to the patient.

Figure 5: LUQ docking approach

Figure 7: LLQ docking approach

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Assistant Port: Assistant Port (A1), 5 mm ( the camera and instrument arm retraction.

): Place port lateral to the right MCL between the level of port. This port is used for suction/irrigation, ligation and

NOTE: Following port placement, the patient is then placed in the Trendelenburg position, rotated to the right and the patient-side cart is docked. 4c. Patient Cart Docking NOTE: The patient cart will be docked after port placement, exposure and procedure mapping (see step 4b) has been achieved. Nevertheless, adjusting and aligning the camera arm and sweet spot can be performed prior to the docking. Step 1: Adjust Camera Arm Set-Up Joint When using all three da Vinci instrument arms, position the camera arm set-up joint toward the side of the patient that has just one instrument arm. If doing a procedure that requires a second docking of the patient-side cart, this joint should be moved when the 3rd arm is moved. Step 2: Determining "Sweet Spot The sweet spot maximizes the range of motion for the instrument arms. Confirm sweet spot prior to docking. da Vinci S System - The blue arrow should align within the blue marker on the 2nd joint [Figure 7a] or assure a ~90angle between the 1st and 3rd joint on the camera arm [Figure 7b].

90

Figures 7a-b: Sweet Spot on da Vinci S

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Step 3: Align Camera Arm

Align the camera arm, camera arm set-up joint, column and target anatomy. A straight line should be achieved by aligning the clutch button, the 3rd joint of the camera arm and the gray dot in da Vinci on the center column [Figure 8].

Figure 8: Align camera

Step 4: Roll in Patient Cart Patient is placed in the Trendelenburg position and tilted to the right before rolling in the patient cart. Depending on procedure plan, the cart will be brought in using the LUQ approach or the LLQ approach. The left stirrup might need to be adjusted and moved slightly medial or downward to allow space for the patient cart column and arm or . Once the correct location of the camera arm within its sweet spot is reached, the patient cart can be locked. The base of the cart will usually straddle the base of the operating table corner for the LLQ docking position [Figure 9].

Figure 9: Patient cart base straddles the operating room table base for LLQ docking

Push aside overhead lights and equipment to maintain sterility of the patient cart. The arms of the patient cart should be positioned high enough to clear the patient's legs.

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Step 5: Dock Arms [Figure 10] Ensure endoscope port, target anatomy and patient cart center column are aligned Position camera cannula mount over the endoscope port and dock Use port and arm clutch maneuvers to dock remaining instrument arms Keep instruments in the center of their range of motion

Figure 10a: LUQ docking

Figure 10b: LLQ docking

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5. PROCEDURE STEPS Left Colectomy

Figure 11 shows an overview of the anatomy involved in the left colectomy procedure. Depending on the extent of the specimen to be removed (green) the minimum mobilization is the dark grey area and mobilization can extend through light grey area as required, based on the approach used.

Figure 11: Overview of surgical anatomy

As noted above, the key steps for left colectomy are as follows: Step 1 - Primary Vascular Control Step 2 - Medial to Lateral Mobilization of Descending Colon Step 3 - Splenic Flexure Mobilization (as necessary) Step 4 - Final Mobilization Sigmoid and Superior Rectum, Colon Division Step 5 - Specimen Removal and Anastomosis The procedure is performed in a medial to lateral approach [Figure 12] as it: Provides a more natural view of the anatomy. Helps to avoid ureteral injuries through optimal representation of the sympathetic nerve plexus trunks, left ureter and gonadal vessels. Preserves the lateral abdominal wall attachments of the colon for a longer time during the dissection which increases workspace and exposure. Permits a safe primary dissection by avoiding unnecessary manipulation of the colon. Enhances complete lymphadenectomy following the vascular anatomy.

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NOTE: This port placement and docking also support the lateral approach if anatomical variations make the medial to lateral approach difficult.

Figure 12: Medial to lateral approach to dissection in an avascular plane between the sigmoid mesentery and Toldts fascia

TIP: To avoid intraoperative complications: Create adequate exposure Use proper traction and countertraction Develop the correct planes Standardize the assistants role Beware of the variations of vasculature and anatomy

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5a. Step 1 - Primary Vascular Control NOTE: Step 1 can be completed from either the LUQ or LLQ docking positions. Primary vascular control is achieved by dividing the inferior mesentery artery (IMA) first, then the inferior mesenteric vein (IMV), or vice versa based on surgeons preference. The left colic branch of IMA may be saved as necessary. Anatomical overview below [Figure 13].

Figure 13: Anatomy overview for vascular dissection

IMA Dissection Instrumentation: 0 endoscope, Fenestrated Bipolar Forceps (left ; alternatively Fenestrated Maryland Bipolar), Hot Shears (right ; alternatively Harmonic Curved Shears), Small Graptor (in arm ; alternatively Cadiere Forceps) The monopolar cautery is set to 25W fulgurate; bipolar cautery is set to 40W on the Valleylab Force FX generator (for settings on other electrosurgical generators see the Instructions for Use for EndoWrist energy instruments). Expose base of the sigmoid mesocolon by retracting it anteriorly with the Graptor in arm and incise the peritoneum at level of the sacral promontory with the Hot Shears [Figure 14].

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Figure 14: Initial dissection starts with incision of the peritoneum around the base of the sigmoid mesentery

Look for pulsations and identify IMA. Under continuous traction (IMA pulled ventrally), continue peritoneal dissection superiorly along the right anterior border of the aorta up to the root of the IMA [Figure 15].

Figure 15: Identification and exposure of the IMA root

Combine blunt and electrosurgical/ultrasonic dissection to safely divide small visceral branches of the nerves, preserving the pre-aortic sympathetic neural plexus. Skeletonize 1-2 cm up from the root of the IMA for adequate lymphadenectomy and safe clipping/division. This also helps to avoid injury to the left sympathetic trunk (on the left border of the IMA) and minimizes the risk of ureteral injury during the transection of the IMA. Place two clips with the Hem-o-lok Large Clip Applier on the exposed IMA in sufficient distance and transect in between with the Hot Shears [Figure 16 and 17].

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Figure 16: IMA transected after pervious placement of Hem-o-lok clips

Figure 17: Anatomy overview of IMA and IMV transection

Alternatively, a linear stapler (vascular 2.5 or 2.0 mm cartridges) or the LigaSure Atlas or EnSeal can be used.

TIP: Identify the ureter and gonadal vessels one more time before dividing any tissues. IMV dissection Identify the IMV cephalad to the IMA and retract the pedicle. Incise the peritoneum with the Hot Shears and dissect superiorly toward ligament of Treitz where the IMV can usually be identified [Figure 18].

Figure 18: Identification and exposure of the IMV

Transect the IMV close to the inferior border of the pancreas with the Hot Shears after ligation with two Hem-o-lok clips [Figure 19].

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Figure 19: IMV is clipped and ready for division close to the pancreas

Alternatively, a linear stapler (vascular 2.5 or 2.0 mm cartridges) or the LigaSure Atlas or EnSeal can be used.

TIP: Identify the ureter and gonadal vessels one more time before dividing any tissues. TIP: Leave 1.0-1.5 cm on either side of the transected IMA and IMV so that if any bleeding occurs grasping of the vessel is still possible to allow application of hemostatic technique (clips, LigaSure, EnSeal or suture).

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5b. Step 2 - Medial to Lateral Mobilization of Sigmoid and Left Colon NOTE: Step 2 can be completed from either the LUQ or LLQ docking positions. Mobilization will be achievable at least to the level of the camera port if docked in the LLQ position. Extent of the dissection is superiorly for the inferior border of the pancreas, laterally following Gerotas fascia and inferiorly for the psoas muscle where the ureter crosses the iliac vessels. Anatomical overview and arm set-up shown below [Figures 20].

Figure 20: Anatomy overview for procedure step 2

Instrumentation: 0 endoscope, Fenestrated Bipolar Forceps (left ), Hot Shears (right ), Small Grasping Retractor (arm ) - if visualization is compromised, switch to a 30 down endoscope for a more topographical view. Elevate the rectosigmoid mesentery superiorly and anteriorly following the IMA. Identify and bluntly dissect on the avascular plane between the Toldts fascia and the left colonic mesentery. Identify the hypogastric nerve plexus, gonadal vessels and ureter beneath the Toldt's fascia [Figure 21].

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Retraction

gonadal vein

ureter Figure 21: Avascular dissection plane beneath Toldts fascia with ureter and gonadal vessels identified

TIP: Countertraction on the retroperitoneal tissues by the assistant greatly facilitates safe and easy dissection along the avascular plane. Avoid injury to the gonadal vessels and the ureter by maintaining exposure and the anterior avascular dissection plane above Toldt's fascia during the dissection. Continue dissection laterally toward Toldt's line.

NOTE: Should repeated outside collisions occur between arms and , which potentially compromises exposure, it is advisable to undock arm and park it close to the patient cart column. 5c. Step 3 - Splenic Flexure Mobilization (as necessary) If splenic flexure mobilization is not necessary, move to Step 4 (section 5d) to finish mobilization. NOTE: Splenic flexure mobilization is performed with the da Vinci System docked in the LUQ docking position. If the system is not in the following position, it must be repositioned prior to starting.

Figure 22: Splenic flexure set-up

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Instrumentation: 0 endoscope, Fenestrated Maryland Bipolar (left ), Hot Shears (right , alternatively Harmonic Curved Shears) - if visualization is compromised, switch to a 30endoscope up/down for a different viewing angle. To achieve a tension-free anastomosis, the splenic flexure is mobilized in a medial approach. From the supra-umbilical endoscope port the surgeon has optimal view of the anterior surface of the pancreas and the base of the left transverse mesocolon, especially in obese patients. Anatomical overview and arm set up shown below [Figure 23].

Figure 23: Anatomy overview of procedure step 3

Continue to follow the dissection plane cephalad and anterior to Toldt's fascia [Figure 24].

Pancreas

Figure 24: Cephalad dissection towards the transverse mesocolon

The 3rd Arm retracts the transverse colon anteriorly to expose the inferior border of the pancreas. The assistant retracts the small bowel for exposure.

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Open the transverse mesocolon just above the body of the pancreas and lateral to the IMV origin to enter the lesser sac [Figure 25].

Figure 25: Opening the lesser sac

Continue dissection posteriorly toward the base of the descending colon and distal transverse colon. Dissect the omentum in the avascular plane towards the transverse colon, starting from the middle third of the transverse colon. Transverse colon can be rolled caudally (as posterior dissection has already been performed) to help with tissue tension on the omentum [Figure 26].

Figure 26: The assistant rolls the transverse colon caudally to expose the avascular dissection plane at the omentum

The lateral attachments are divided and the splenic flexure is fully mobilized [Figure 27].

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Figure 27: Division of the last lateral attachments to fully mobilize the splenic flexure

Continue caudally, freeing the lateral attachments of the descending colon to the proximal sigmoid.

5d. Step 4 - Final mobilization sigmoid and superior rectum, colon division NOTE: If the system was docked over the left shoulder for steps 1-3, it should now be repositioned over the left hip as shown below. Refer to the flow chart on page 8 for further details.
MCL MCL

SUL

SUL

Figure 28: Lower Left Quadrant docking

Reposition the system as necessary Next, detach adhesions at the sigmoid-descending colon junction. Retract the free sigmoid loop toward the right upper quadrant (laparoscopic retraction by the assistant) to apply tension on the white line of Toldt. Incise "white line" and dissect (sharp and blunt) lateral attachments of descending colon just anterior to Toldt's fascia [Figure 29 and 30].

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Figure 29: Dissection of lateral colon attachments

Figure 30: Anatomy overview of lateral dissection

Once dissection joins the previously performed medial dissection, the sigmoid colon is completely mobilized. Dissect medially to mobilize the upper rectum as necessary. Select proximal and distal staple locations. Skeletonize area of the colon or superior rectum in preparation for stapling.

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Colon Division Undock the da Vinci patient cart and perform remaining procedure steps in standard laparoscopy

NOTE: Alternatively, the rectal division can be performed with robotic assistance leaving the patient cart docked (performed by advanced surgical teams after initial learning curve). The right lower quadrant robotic 8 mm cannula is switched to a 12 mm port and the stapler is introduced here. Align the rectum cephalad with the robotic instrumentation (in arms and ) within the open stapler jaw. Clear communication with the patient-side assistant during this step is essential. As a second alternative, the suprapubic port can be used to introduce a staple if a 13 mm da Vinci cannula or other stapler cannula is placed in the suprapubic location rather than instrument arm . Anatomical overview shown below [Figure 31].

Figure 31: Anatomy overview of rectal division

Remove 8 mm reducer from the lower right quadrant port and introduce stapler (Endopath or roticulating Endo GIA). Align stapler at a right angle to the long axis of the colon as much as possible. Align the colon cephalad within the open stapler jaw.

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Figure 32: Endoscopic stapler placed across the colon for transection

If one cartridge of the stapler does not completely transect the colon, fire a second cartridge and overlap the initial staple line.

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5e. Step 5 - Specimen removal and anastomosis If not undocked already, remove the patient cart and perform remaining procedure steps in standard laparoscopy Create a small (4 cm) supra-pubic incision (Pfannenstiel) and cover with a plastic wound protector (Alexis Wound Retractor from Applied Medical or similar) to minimize the risk of tumor cell spreading and avoid CO2 leak during the intracorporeal colorectal anastomosis [Figure 33].

Figure 33: Wound retractor covering mini-Pfannenstiel incision

Deliver specimen out of the abdominal cavity. Divide the colon proximally in a healthy and well-vascularized zone using conventional techniques, and remove the specimen for pathology screening. Introduce anvil head of circular stapler (CDH Ethicon or similar) into bowel lumen and secure with a 2-0 Prolene purse-string suture [Figure 34].

Figure 34: Bowel prepped with circular stapler head for distal anastomosis

Return the colon into the cavity and close the wound retractor with a large clamp to make abdomen airtight again (suture incision closed at the end of the procedure). Restore pneumoperitoneum up to 15 mmHg prior to colorectal anastomosis.

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Gently dilate the anus and pass the circular stapler into the rectum. Ensure visually that the stapler spike protrudes from immediately below or above the center of the previous stapling division line [Figure 35].

Figure 35: Stapler spike introduced through staple line

Align the anvil center rod and the distal part of the stapler. Click stapler parts together and check for any twisting of colon and mesentery. Ensure that surrounding tissues and neighboring organs are away from the stapling line. Fire the stapler to complete the coloanal anastomosis. Visually inspect the staple line after the firing to verify completeness. Check for complete donut-shaped tissue rings removed from circular stapler. To perform leak test, fill pelvis with saline and insufflate rectum with air. Colon proximal of the anastomosis should be occluded during this test. If necessary, place suction drain into the pelvis next to the anastomosis (through left lower quadrant port). Check cannula sites under endoscopic view for hemorrhage. Close incisions with absorbable suture: o Suprapubic incision size 0 or 1 suture in layers o All cannula sites 8 mm or greater with size 0 suture at the fascia level Skin closed with subcuticular absorbable suture [Figure 36].

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Figure 36: Closed ports

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6. POST-OPERATIVE CARE
Post-operative care should be equivalent to the individual hospital protocol for a laparoscopic colectomy. Inpatient hospital follow-up and discharge should be based on surgeons experience and preference.

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APPENDIX A
Cannula Remote Center Set-Up To correctly place the remote center, the thick black line on the da Vinci cannula (which indicates the remote center) should be inserted within the boundaries of the patients body wall. Correct placement will allow the robotic instrumentation to pivot through the incision with the least friction and highest precision, which will minimize tissue trauma (Figure a, below). Correct placement of the cannula should be verified by looking at the cannula tip with the endoscopic camera (cannulae should always be placed under endoscopic camera view). Only the first thin line at the distal cannula tip should be visible. This indicates that the remote center is placed correctly within the boundaries of the patients body wall (Figure b, below). If the thick black line on the cannula is seen in the endoscopic view, this means that the remote center is set incorrectly (inserted too deeply). Setting the remote center incorrectly will increase friction, reduce precision and increase tissue trauma at the port site (Figure c, below).

c
Figure A1: Proper placement of the instruments cannula remote center

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