Video Summary

This video presents a case of robotic low anterior resection for rectal cancer performed by a single docking totally robotic approach. High ligation of IMA and full splenic flexure mobilization are carried out. Precision surgery is carried out in the avascular embryologic plane with the use of monopolar diathermy. A full TME is carried out to the pelvic floor with a primary end-to-end colorectal anastomosis. Key learning points and tips and tricks are highlighted during different phases of the operation. Consent was obtained from patient.

Video

Teaching Points

1- Planning the operation
2- Standardized technique
3- Understanding of the anatomy and surgical planes
4- Tips to avoid common pitfalls

Critical Steps

1- Positioning and docking

a. Avoiding soft tissue injuries

b. Prevent patient slipping

c. Single docking approach from left hip

d. Efficient docking to reduce time

e. Enhanced ergonomics

2- Laparoscopic setup

a. Staging

b. Adequate exposure: duodenojejunal flexure and iliac vessels

c. Use of a swab for retraction

3- Vascular dissection

a. Start of dissection at the sacral promontory

b. Anatomy of the ureter, hypogastric nerves, and iliac vessels

c. Working in the “holy plane”

d. Avoid traction injuries and bleeding

4- Colonic mobilization

a. Identify the plan between Gerota’s and mesocolic fascia

b. Preserve the fascia

c. Identify the ureter and gonadal vessels anatomy

d. Effective use of assistant for optimal exposure

5- Total mesorectal excision (TME)

a. Effective use of the third arm

b. Structured approach to perform TME

c. Preserve the mesorectal fascia

d. Transabdominal suture for lifting and retraction of the uterus and bladder

6- Anastomosis and closure

a. Use of indocyanine green to assess perfusion

b. Effective stapling technique in anteroposterior direction

c. Use of wound protector for specimen retrieval

d. Safe performance and assessment of circular anastomosis

Technical Pearls
1- Safe patient positioning results in better ergonomics and avoids the risk of pressure injuries
2- Start of dissection at the sacral promontory is useful to identify superior rectal artery and hypogastric nerves
3- Be careful with high ligation of inferior mesenteric artery (IMA) on the aorta to avoid damaging the sympathetic plexus resulting in retrograde ejaculation
4- IMV is divided high under the duodenojejunal flexure. Be careful with the tension with IMV to avoid avulsion and bleeding
5- Identify the ureter before division of IMA
6- Remove tension off of IMA before division between locking clips to reduce any risk of bleeding

Potential Areas for Injury or Complications
1- During high ligation of IMA avoid excessive traction that can result in avulsion of the vessel
2- Avoid injury to pancreas while entering the lesser sac with the inferior approach; it is possible to continue dissecting under the pancreas without realizing the mistake, and the surgeon can then encounter the splenic vein
3- Avoid excessive traction on the splenic flexure, which can result in damage to the splenic capsule and bleeding
4- Identify hypogastric nerves in the pelvis
5- In the lower third of the rectum, the presacral vessels are at risk of injury if correct surgical plane is not followed and can cause troublesome bleeding
6- Choose the correct pane of dissection anteriorly between seminal vesicles and Denonvallier’s fascia
7- Protect the neurovascular bundles of Walsh at 2- and 10-o’clock positions anterolaterally below the seminal vesicles, which can result in impotence and sexual dysfunction
8- Use of a pledget or swab in the left hand can protect the mesorectal fascia from injury