Video Summary

This is a demonstration of a robotic right colectomy with the integrated table motion. Instruments used and trocar positioning are illustrated at the beginning of the video. The integrated table motion is used in the patient’s position changes. Key passages of the procedure are underlined point-by-point. The possible use of a barbed suture, the vascular cartridge of the stapler, and indocyanine green are also shown at the end of the video.

Video

Teaching Points

1. Patient preparation
   1. Preoperative bowel preparation per institutional protocol
   2. Preoperative oral antibiotics preparation
2. Patient positioning
   1. Supine position
   2. Arms tucked at the patient’s side with appropriate padding
   3. Adequately secured for appropriate positioning (Trendelenburg)
   4. A Foley catheter and orogastric tube are placed.
3. Critical steps
   1. Identification of the ileocolic pedicle
   2. Development of the avascular plane using blunt dissection, identifying the duodenum
   3. Section of the origin of ileocolic vessels between clips
   4. Identification and section of the right colic vessels (if present)
   5. Development of the avascular plane between the mesocolon and retroperitoneum
   6. Lateral mobilization of the right colon and the right flexure
   7. Division of the greater omentum and the gastrocolic ligament
   8. Section of colon and ileum
   9. Intracorporeal anastomosis
4. Technical pearls/tips
   1. Initial position (30° left tilted, 10° Trendelenburg) is important, particularly in patients with high BMI.
   2. The ileocolic pedicle is identified by gently placing the ileocecal junction on stretch by pulling it away from the retroperitoneum.
   3. The mesentery just inferior to the vessel should be opened using the monopolar scissors and the avascular plane begins to develop.
   4. The duodenum is an important landmark for identifying the origin of the ileocolic vessels.
   5. After sectioning the origin of ileocolic vessels between clips, the mesenteric axis is followed upward to obtain the necessary lymphadenectomy. Moreover, following the anterolateral surface of the mesenteric axis allows identification of the right colic vessels.
   6. The avascular plane between the mesocolon and retroperitoneum is developed using blunt dissection.
   7. The greater omentum is divided from the transverse colon, and the gastrocolic ligament is divided.
   8. During the hepatic flexure mobilization, the position of the patient is changed (30° left tilted, 10° anti-Trendelenburg).
   9. Careful closure of the enterotomy. Barbed suture is a valid alternative that can make the suture safer and easier.
5. Potential areas for injury or complications
   1. Take care not to injure the duodenum during the development of the avascular plane.
   2. Take care in the vascularization of the colonic and ileal stumps after the resection (possible use of indocyanine green).
   3. Manual closure of the enterotomy