robot-assisted laparoscopic rectal...

11
Journal of Visceral Surgery (2014) 151, 377—387 Available online at ScienceDirect www.sciencedirect.com SURGICAL TECHNIQUE Robot-assisted laparoscopic rectal resection A. Valverde , N. Goasguen , O. Oberlin Service de chirurgie viscérale, groupe hospitalier Diaconesses Croix Saint-Simon, 125, rue d’Avron, 75020 Paris, France Available online 20 August 2014 KEYWORDS Robot; Laparoscopy; Telemanipulation; Gastrointestinal surgery The prognosis of rectal cancer is directly related to the quality of the mesorectal excision. While the laparoscopic approach has been validated for rectal cancer, it poses real tech- nical difficulties, particularly for certain unfavorable anatomic situations (obese patient, male patient with a narrow pelvis, large bulky tumor). Robotic assistance can provide a real benefit by increasing the feasibility of the laparoscopic approach in such patients. We describe the technical principles for rectal resection using the only robotic system that is currently available worldwide. Given the continuous improvement and evolution of technologies, it is clear that the technical principles we describe may evolve with time. Corresponding author. E-mail address: [email protected] (A. Valverde). http://dx.doi.org/10.1016/j.jviscsurg.2014.07.006 1878-7886/© 2014 Published by Elsevier Masson SAS.

Upload: ngoliem

Post on 21-Apr-2018

231 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Journal of Visceral Surgery (2014) 151, 377—387

Available online at

ScienceDirect

www.sciencedirect.com

SURGICAL TECHNIQUE

Robot-assisted laparoscopic rectal resection

A. Valverde ∗, N. Goasguen, O. Oberlin

Service de chirurgie viscérale, groupe hospitalier Diaconesses Croix Saint-Simon, 125, rued’Avron, 75020 Paris, France

Available online 20 August 2014

KEYWORDSRobot;Laparoscopy;Telemanipulation;Gastrointestinalsurgery

The prognosis of rectal cancer is directly related to the quality of the mesorectal excision.While the laparoscopic approach has been validated for rectal cancer, it poses real tech-nical difficulties, particularly for certain unfavorable anatomic situations (obese patient,male patient with a narrow pelvis, large bulky tumor). Robotic assistance can provide areal benefit by increasing the feasibility of the laparoscopic approach in such patients.We describe the technical principles for rectal resection using the only robotic systemthat is currently available worldwide. Given the continuous improvement and evolution oftechnologies, it is clear that the technical principles we describe may evolve with time.

∗ Corresponding author.E-mail address: [email protected] (A. Valverde).

http://dx.doi.org/10.1016/j.jviscsurg.2014.07.0061878-7886/© 2014 Published by Elsevier Masson SAS.

Page 2: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

3

1piaWTttmeWdsotrWaa

78 A. Valverde et al.

Description of the stages of the procedureThe three principal colorectal resections (colorectal anas

erineal resection [APR]) all begin with the same initial snstrumentation, the surgeon begins with laparoscopic exploratnd attached to the robotic arms. The surgeon then installs himhen CRA is planned, the operator performs a proctectomy with che distal rectum is stapled and transected. The trocars are then

he resected rectum and to insert the anastomotic anvil into the

rocars are reconnected to the robot and the surgeon returns to

anipulates the circular stapler inserted trans-anally. The surgeventual diverting ileostomy, if indicated.hen ACA is performed, the surgeon may occasionally begin with

issection. Otherwise, he performs the entire mesorectal excisiopecimen can be exteriorized through the anus, the peritoneal df an ileal loop for diverting ileostomy without returning to thhrough a mini-laparotomy, the robot must be disconnected fromeconnected to complete the intra-peritoneal stage.hen APR is performed, a single robotic session is required com

nd performance of an end colostomy. After disconnection of thepproach.

tomosis [CRA], colo-anal anastomosis [CAA] and abdomino-tage: after patient positioning and installation of theion of the peritoneal cavity. The trocars are then insertedself at the robotic console to perform the procedure.omplete mesorectal excision or partial mesorectal excision.

disconnected and a mini-laparotomy is performed to removeproximal colon. After closure of the abdominal incision, thethe console to complete the anastomosis while his assistantry is completed by drain placement, peritoneal lavage, and

the perineal dissection in order to facilitate the laparoscopicn under robotic control at the console. When the colorectalissection is completed by drain placement and preparatione console. Should the colorectal specimen be exteriorized

the trocars while the ACA is performed manually and then

prising dissection of the upper portion of the mesorectum robotic arms, the resection is completed through a perineal

Page 3: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Robot-assisted laparoscopic rectal resection 379

2 The two dissection fieldsRectal resection requires takedown of the splenic

flexure and therefore free access to the entire peritonealspace. Schematically, this implies the ability to visualizeboth an abdominal field (1) and a pelvic field (2). Each fieldof dissection is defined by specific positioning of robotic tro-

cars. The patient cart is placed at the patient’s left hip buttwo specific dockings are required to work in the two fields.The first instrument docking configuration provides accessfor dissection of the splenic flexure and the upper rectum.This is all that is needed for a left colectomy with anastomo-sis at the pelvic brim. In some favorable cases (non-obesepatient with a tumor located in the mid-rectum), this firstdocking will be adequate to allow completion of the entireresection although this may require placement of the sub-xiphoid trocar somewhat lower in the midline.
Page 4: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

3

3labi‘DtATpa

4AtaTsllwagaEpOmh

80 A. Valverde et al.

Patient installationThe patient is positioned in lithotomy position to allow access to both the abdominal cavity and the perineum. The

egs are placed in boots that can be repositioned during the course of the procedure: fully flexed for the perineal dissectionnd anastomosis, and lowered during the laparoscopic dissection. The patient is solidly fixed to the table, ideally with a beanag mattress to prevent slipping and to avoid pressure points. The position is verified before draping with the robotic armsn place to simulate their operative position; this has been described in a previously published surgical technique entitled‘Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy’’ [1].uring the laparoscopic portion of the procedure, the table is tipped into Trendelenburg position and rolled to the right. Thehighs should be positioned below the plane of the iliac crests to avoid interfering with the freedom of motion of Robotic

rm No. 1. Ideally, the drapes should lie across the patient’s heahe patient cart (CP) stands at the patient’s left hip at a 45◦

ositioned at the left shoulder. The surgeons stand on the patieny point during the procedure.

The laparoscopic phase before thesurgeon moves to the robotic console

fter introduction of the optical trocar just to the right ofhe umbilicus, the robotic camera must be hand-held duringbdominal exploration and introduction of the other trocars.he optical cable tends to get in the way and should be keptterile, temporarily placed on a table along the patient’seft flank. The other trocars are now inserted under directaparoscopic vision. At this point, it is useful to determinehether there are abdominal adhesions, which can be lysedt this time. It is particularly important to ascertain that thereater omentum is freely mobile to be retracted upwardnd that the last ileal loop is free for eventual ileostomy.xposure of the inferior mesenteric vein is obtained by dis-lacing the jejunal loops to the right of the mesenteric axis.nce these maneuvers have been completed, the instru-ents can be docked to the robot and the surgeon can take

is seat at the console.

d with no elevation by an ether screen.angle from the axis of the table. The video screen (V) is

nt’s right side, while access to the perineum is available at

Page 5: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Robot-assisted laparoscopic rectal resection 381

5 Trocar positions: three-armconfiguration

The optical trocar (O) is positioned at the level of the umbili-cus. The deeper the pelvic dissection, particularly in obese

patients, the closer the optical trocar should be to theumbilicus (but always to the right). The robotic Trocar No. 1is placed along a line between the superior iliac crest andthe umbilicus, at least 8 cm from the umbilical trocar. Thistrocar and arm must be free from interference by the rightthigh. The robotic Trocar No. 2 is placed in a right subcostalposition close to the midline. Placing this trocar lower or tothe left of the midline facilitates the pelvic dissection butmakes dissection of the splenic flexure more difficult. Thebest position depends on the patient’s body habitus. Finally,a trocar for the assistant’s instruments (A) is placed in theright flank somewhat behind a line between the No. 1 andNo. 2 trocars. Ideally this trocar A is placed between theoptical trocar and the No. 1 trocar. If a stapled anastomosisis planned, this trocar should not be placed too high sinceit will make the stapling procedure difficult. Finally, a thirdrobotic Trocar (No. 2’) is placed in the left lower quadrant;this will be used during re-docking for the second phase asthe No. 2 arm for the pelvic dissection. This trocar shouldbe placed well laterally and not too low.
Page 6: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

3

6sTbTdleb

82 A. Valverde et al.

Trocar positions: four-arm configurationThe use of a fourth robotic arm can be particularly useful

hort distance between the iliac crests, it is not particularly usehe external positioning of the robotic arms can be critical: theneath the No. 2 arm.he trocar positioning is similar to that described in Fig. 5 buifferent (sketch). Arm No. 3 is connected to the sub-xiphoid troeft flank trocar should be placed at the height of the umbilicuventual left lower quadrant colostomy. During the mobilization

ut all four arms are required for the pelvic dissection.

for the pelvic dissection, but in small patients with only aful and may actually get in the way.e No. 3 arm should be horizontal and pass medial to and

t the attribution of instruments at each site is somewhatcar while arm No. 2 is attached to the left flank trocar. Thes and well lateral and away from the potential site of anof the splenic flexure, use of arm No. 2 may not be needed,

Page 7: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Robot-assisted laparoscopic rectal resection 383

7 Console-directed surgery: thesequence of steps for abdominaldissection

When the surgeon moves to the robotic console, the abdomi-nal dissection is typically performed first. However, one can,on occasion, begin by performing the pelvic dissection, prof-iting from a better arrangement of the small bowel loopsfacilitated by the pneumoperitoneum.The sequence of operative steps can be performed by pro-gressively approaching each area of dissection in a circularmanner, from cephalad caudad and from medial to lat-eral, leaving the lateral attachments in place until the last(arrow). The three major steps are performed in the follow-ing order: division of the inferior mesenteric vein (IMV) andmedial portion of the root of the transverse mesocolon (1),control and division of the inferior mesenteric artery (IMA)(2), and division of the lateral attachments of the left colon.Displacement and arranging of the small bowel loops is lesscritical in robotic surgery than in traditional laparoscopysince the robot enables the operator to work in a very smallarea adjacent to the structures to be dissected. Similarly,the surgeon should exploit this excellent quality of dissec-tion made possible by the robot to the maximum, dissectingthe mesenteries from medial to lateral.

8 Console-directed surgery: first step ofthe abdominal procedure

The IMV is identified, isolated and clipped close to its inser-tion at the underside of the pancreas (the clip applieris introduced and manipulated by the assistant) and themesentery is then freed from the retroperitoneum abovethe pancreas, taking care to avoid injury to the pancre-atic capsule. The assistant’s grasper applies tension to the

V of the insertion of the left transverse mesocolon. Dissec-tion proceeds toward the tail of the pancreas after breakingthrough into the lesser sac and exposing the posterior gastricwall. Care should be taken to avoid extending the dissectionbehind the pancreas or too far toward the splenic hilum,which increases the risk of pancreatic or splenic injury. Thedisinsertion of the mesocolic root is often incomplete dueto the depth of the sub-phrenic space. This might need tobe completed after freeing up of the external attachmentsin the left gutter.
Page 8: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

3

9TcmmmmTtsilTcitmDppt

1Tflaevc

84 A. Valverde et al.

Console-directed surgery: secondstep of the abdominal procedure

he left mesocolon is freed from medial to lateral takingare to respect the pre-renal fascia. Tension on the inferioresenteric artery facilitates dissection by tenting up theesentery. The angulation provided by robotic instrumentsakes this dissection simpler and more natural whereas theaneuver is often quite difficult in traditional laparoscopy.he gas insufflation helps to separate the plane and to pushhe retroperitoneal elements (ureter and left spermatic ves-els) posteriorly. The excellent optical resolution facilitatesdentification and sparing of the splanchnic nerves duringymphadenectomy.he angulatory ability of the robotic instruments renders theircumferential isolation of the IMA relatively easy. The IMAs then clipped and transected (the clip applier is introducedhrough the assistant’s trocar). The remainder of the leftesocolon is then freed up from medial to lateral.uring this first robotic installation, it is possible to begin theelvic dissection and to carry it more or less deeply into theelvic basin (pelvis?). However, we will specifically addresshe robotic configuration for proctectomy in Fig. 11.

Console-directed surgery: third

0 step of the abdominal procedurehe lateral peritoneal attachments of the left colon arereed from the sigmoid colon up to the splenic flexure. Theeft side of the greater omentum is freed from the colonllowing the left colon to be drawn caudad and mediallyxposing the distal attachments of the left side of the trans-erse mesocolon. Once these have been divided, the leftolon is completely freed to be brought down into the pelvis.
Page 9: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Robot-assisted laparoscopic rectal resection 385

11 Console-directed surgery: thepelvic dissection

While the initial robotic set-up may be adequate for com-plete pelvic dissection in certain patients, a specific roboticset-up for pelvic dissection is more commonly required. Witha three-arm robotic set-up, a re-configuration and dockingis necessary moving Arm No. 2 from the sub-xiphoid trocarto the left flank trocar. The patient cart remains in the sameposition. The assistant plays an active role as the third ele-ment of the instrument triangulation, which is essential forthe rectal dissection.When a four-arm robotic set-up has been installed, thereis no need for a re-arrangement of the robotic docking; onemust simply choose whether to place the bipolar hemostaticinstrument in Arm No. 2 or Arm No. 3. In this configuration,the surgeon has control of three instruments to perform therectal dissection.Just as in traditional laparoscopic surgery, the pelvic stagebegins with circumferential incision of the pelvic peri-toneum followed by dissection of the posterior pre-sacralplane. The proctectomy is completed by bilateral andanterior dissection. The great advantage of the roboticinstrumentation lies in the angulation of the graspers, whichfacilitates dissection along the left side when the telescopeis inserted to the right of the umbilicus, with perfect visionand stability and no need for repeated lavage of the opti-cal lens. In addition, the robotic approach allows improvedvisualization and dissection of the fascia recti and of themesorectum, which is less likely to be torn or breached byapplication of graspers.

Page 10: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

3

1ipscAiiu

1TabdtcrgtTmscltat

86 A. Valverde et al.

2 Stapling of the rectumFor low colorectal anastomosis, the distal rectum

s closed with a linear stapler. In the near future, this sta-ler will be included in the armamentarium of instrumentspecifically designed for robotic use, allowing the stapledlosure to be performed by Arm No. 1 with great precision.t this time, the rectum is stapled with a linear stapler

ntroduced through the assistant’s trocar. In most cases, thiss quite feasible thanks to short angulated linear staplers,nless placement of the assistant’s trocar was too high.

3 Mini-laparotomy to remove theresected specimen

his stage is performed without pneumoperitoneum. It isbsolutely essential to un-dock the robotic instrumentsefore evacuation of the pneumoperitoneum. Without theistention provided by insufflation, the rigid positioning ofhe trocar arms may result in trauma to the abdominal mus-

ulature. There is no need to move the patient cart. Theobotic arms must simply be folded back to allow the sur-eon and assistant free access to the abdominal field. Theelescope is temporarily left attached to the optic Arm.he operative specimen can then be removed through aini-laparotomy and the anvil for the stapled anastomo-

is introduced into the left colon. The perineal dissectionan be performed simultaneously by elevating the legs intoithotomy position. The colon with anvil in place is returnedo the abdomen, the laparotomy is closed, and the staplednastomosis is then performed under laparoscopic observa-ion.

Page 11: Robot-assisted laparoscopic rectal resectionlib.ajaums.ac.ir/booklist/1-s2.0-S187878861400099X-main.pdf · laparoscopic rectal resection A. ... of the stages of the procedure The

Robot-assisted laparoscopic rectal resection

Disclosure of interest

The authors declare proctoring events for INTUITIVE SURGI-CAL Company.

387

Reference

[1] Valverde A, Goasguen N, Oberlin O. Fundamentals of roboticsurgery or of robotic-assisted telemanipulated laparoscopy. JVisc Surg 2014;151(3):213—21.