Robot-assisted laparoscopic rectal resection

Transcription

1 Journal of Visceral Surgery (2014) 151, Available online at ScienceDirect 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, 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 technical 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. address: avalverde@hopital-dcss.org (A. Valverde) / 2014 Published by Elsevier Masson SAS.

2 378 A. Valverde et al. 1 Description of the stages of the procedure The three principal colorectal resections (colorectal anastomosis [CRA], colo-anal anastomosis [CAA] and abdominoperineal resection [APR]) all begin with the same initial stage: after patient positioning and installation of the instrumentation, the surgeon begins with laparoscopic exploration of the peritoneal cavity. The trocars are then inserted and attached to the robotic arms. The surgeon then installs himself at the robotic console to perform the procedure. When CRA is planned, the operator performs a proctectomy with complete mesorectal excision or partial mesorectal excision. The distal rectum is stapled and transected. The trocars are then disconnected and a mini-laparotomy is performed to remove the resected rectum and to insert the anastomotic anvil into the proximal colon. After closure of the abdominal incision, the trocars are reconnected to the robot and the surgeon returns to the console to complete the anastomosis while his assistant manipulates the circular stapler inserted trans-anally. The surgery is completed by drain placement, peritoneal lavage, and eventual diverting ileostomy, if indicated. When ACA is performed, the surgeon may occasionally begin with the perineal dissection in order to facilitate the laparoscopic dissection. Otherwise, he performs the entire mesorectal excision under robotic control at the console. When the colorectal specimen can be exteriorized through the anus, the peritoneal dissection is completed by drain placement and preparation of an ileal loop for diverting ileostomy without returning to the console. Should the colorectal specimen be exteriorized through a mini-laparotomy, the robot must be disconnected from the trocars while the ACA is performed manually and then reconnected to complete the intra-peritoneal stage. When APR is performed, a single robotic session is required comprising dissection of the upper portion of the mesorectum and performance of an end colostomy. After disconnection of the robotic arms, the resection is completed through a perineal approach.

3 Robot-assisted laparoscopic rectal resection The two dissection fields Rectal resection requires takedown of the splenic flexure and therefore free access to the entire peritoneal space. Schematically, this implies the ability to visualize both an abdominal field (1) and a pelvic field (2). Each field of dissection is defined by specific positioning of robotic trocars. The patient cart is placed at the patient s left hip but two specific dockings are required to work in the two fields. The first instrument docking configuration provides access for dissection of the splenic flexure and the upper rectum. This is all that is needed for a left colectomy with anastomosis at the pelvic brim. In some favorable cases (non-obese patient with a tumor located in the mid-rectum), this first docking will be adequate to allow completion of the entire resection although this may require placement of the subxiphoid trocar somewhat lower in the midline.

4 380 A. Valverde et al. 3 Patient installation The patient is positioned in lithotomy position to allow access to both the abdominal cavity and the perineum. The legs are placed in boots that can be repositioned during the course of the procedure: fully flexed for the perineal dissection and anastomosis, and lowered during the laparoscopic dissection. The patient is solidly fixed to the table, ideally with a bean bag mattress to prevent slipping and to avoid pressure points. The position is verified before draping with the robotic arms in 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]. During the laparoscopic portion of the procedure, the table is tipped into Trendelenburg position and rolled to the right. The thighs should be positioned below the plane of the iliac crests to avoid interfering with the freedom of motion of Robotic Arm No. 1. Ideally, the drapes should lie across the patient s head with no elevation by an ether screen. The patient cart (CP) stands at the patient s left hip at a 45 angle from the axis of the table. The video screen (V) is positioned at the left shoulder. The surgeons stand on the patient s right side, while access to the perineum is available at any point during the procedure. 4 The laparoscopic phase before the surgeon moves to the robotic console After introduction of the optical trocar just to the right of the umbilicus, the robotic camera must be hand-held during abdominal exploration and introduction of the other trocars. The optical cable tends to get in the way and should be kept sterile, temporarily placed on a table along the patient s left flank. The other trocars are now inserted under direct laparoscopic vision. At this point, it is useful to determine whether there are abdominal adhesions, which can be lysed at this time. It is particularly important to ascertain that the greater omentum is freely mobile to be retracted upward and that the last ileal loop is free for eventual ileostomy. Exposure of the inferior mesenteric vein is obtained by displacing the jejunal loops to the right of the mesenteric axis. Once these maneuvers have been completed, the instruments can be docked to the robot and the surgeon can take his seat at the console.

5 Robot-assisted laparoscopic rectal resection Trocar positions: three-arm configuration The optical trocar (O) is positioned at the level of the umbilicus. The deeper the pelvic dissection, particularly in obese patients, the closer the optical trocar should be to the umbilicus (but always to the right). The robotic Trocar No. 1 is placed along a line between the superior iliac crest and the umbilicus, at least 8 cm from the umbilical trocar. This trocar and arm must be free from interference by the right thigh. The robotic Trocar No. 2 is placed in a right subcostal position close to the midline. Placing this trocar lower or to the left of the midline facilitates the pelvic dissection but makes dissection of the splenic flexure more difficult. The best position depends on the patient s body habitus. Finally, a trocar for the assistant s instruments (A) is placed in the right flank somewhat behind a line between the No. 1 and No. 2 trocars. Ideally this trocar A is placed between the optical trocar and the No. 1 trocar. If a stapled anastomosis is planned, this trocar should not be placed too high since it will make the stapling procedure difficult. Finally, a third robotic Trocar (No. 2 ) is placed in the left lower quadrant; this will be used during re-docking for the second phase as the No. 2 arm for the pelvic dissection. This trocar should be placed well laterally and not too low.

6 382 A. Valverde et al. 6 Trocar positions: four-arm configuration The use of a fourth robotic arm can be particularly useful for the pelvic dissection, but in small patients with only a short distance between the iliac crests, it is not particularly useful and may actually get in the way. The external positioning of the robotic arms can be critical: the No. 3 arm should be horizontal and pass medial to and beneath the No. 2 arm. The trocar positioning is similar to that described in Fig. 5 but the attribution of instruments at each site is somewhat different (sketch). Arm No. 3 is connected to the sub-xiphoid trocar while arm No. 2 is attached to the left flank trocar. The left flank trocar should be placed at the height of the umbilicus and well lateral and away from the potential site of an eventual left lower quadrant colostomy. During the mobilization of the splenic flexure, use of arm No. 2 may not be needed, but all four arms are required for the pelvic dissection.

7 Robot-assisted laparoscopic rectal resection Console-directed surgery: the sequence of steps for abdominal dissection When the surgeon moves to the robotic console, the abdominal dissection is typically performed first. However, one can, on occasion, begin by performing the pelvic dissection, profiting from a better arrangement of the small bowel loops facilitated by the pneumoperitoneum. The sequence of operative steps can be performed by progressively approaching each area of dissection in a circular manner, from cephalad caudad and from medial to lateral, leaving the lateral attachments in place until the last (arrow). The three major steps are performed in the following order: division of the inferior mesenteric vein (IMV) and medial 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 less critical in robotic surgery than in traditional laparoscopy since the robot enables the operator to work in a very small area adjacent to the structures to be dissected. Similarly, the surgeon should exploit this excellent quality of dissection made possible by the robot to the maximum, dissecting the mesenteries from medial to lateral. 8 Console-directed surgery: first step of the abdominal procedure The IMV is identified, isolated and clipped close to its insertion at the underside of the pancreas (the clip applier is introduced and manipulated by the assistant) and the mesentery is then freed from the retroperitoneum above the pancreas, taking care to avoid injury to the pancreatic capsule. The assistant s grasper applies tension to the V of the insertion of the left transverse mesocolon. Dissection proceeds toward the tail of the pancreas after breaking through into the lesser sac and exposing the posterior gastric wall. Care should be taken to avoid extending the dissection behind the pancreas or too far toward the splenic hilum, which increases the risk of pancreatic or splenic injury. The disinsertion of the mesocolic root is often incomplete due to the depth of the sub-phrenic space. This might need to be completed after freeing up of the external attachments in the left gutter.

8 384 A. Valverde et al. 9 Console-directed surgery: second step of the abdominal procedure The left mesocolon is freed from medial to lateral taking care to respect the pre-renal fascia. Tension on the inferior mesenteric artery facilitates dissection by tenting up the mesentery. The angulation provided by robotic instruments makes this dissection simpler and more natural whereas the maneuver is often quite difficult in traditional laparoscopy. The gas insufflation helps to separate the plane and to push the retroperitoneal elements (ureter and left spermatic vessels) posteriorly. The excellent optical resolution facilitates identification and sparing of the splanchnic nerves during lymphadenectomy. The angulatory ability of the robotic instruments renders the circumferential isolation of the IMA relatively easy. The IMA is then clipped and transected (the clip applier is introduced through the assistant s trocar). The remainder of the left mesocolon is then freed up from medial to lateral. During this first robotic installation, it is possible to begin the pelvic dissection and to carry it more or less deeply into the pelvic basin (pelvis?). However, we will specifically address the robotic configuration for proctectomy in Fig Console-directed surgery: third step of the abdominal procedure The lateral peritoneal attachments of the left colon are freed from the sigmoid colon up to the splenic flexure. The left side of the greater omentum is freed from the colon allowing the left colon to be drawn caudad and medially exposing the distal attachments of the left side of the transverse mesocolon. Once these have been divided, the left colon is completely freed to be brought down into the pelvis.

9 Robot-assisted laparoscopic rectal resection Console-directed surgery: the pelvic dissection While the initial robotic set-up may be adequate for complete pelvic dissection in certain patients, a specific robotic set-up for pelvic dissection is more commonly required. With a three-arm robotic set-up, a re-configuration and docking is necessary moving Arm No. 2 from the sub-xiphoid trocar to the left flank trocar. The patient cart remains in the same position. The assistant plays an active role as the third element of the instrument triangulation, which is essential for the rectal dissection. When a four-arm robotic set-up has been installed, there is no need for a re-arrangement of the robotic docking; one must simply choose whether to place the bipolar hemostatic instrument in Arm No. 2 or Arm No. 3. In this configuration, the surgeon has control of three instruments to perform the rectal dissection. Just as in traditional laparoscopic surgery, the pelvic stage begins with circumferential incision of the pelvic peritoneum followed by dissection of the posterior pre-sacral plane. The proctectomy is completed by bilateral and anterior dissection. The great advantage of the robotic instrumentation lies in the angulation of the graspers, which facilitates dissection along the left side when the telescope is inserted to the right of the umbilicus, with perfect vision and stability and no need for repeated lavage of the optical lens. In addition, the robotic approach allows improved visualization and dissection of the fascia recti and of the mesorectum, which is less likely to be torn or breached by application of graspers.

10 386 A. Valverde et al. 12 Stapling of the rectum For low colorectal anastomosis, the distal rectum is closed with a linear stapler. In the near future, this stapler will be included in the armamentarium of instruments specifically designed for robotic use, allowing the stapled closure to be performed by Arm No. 1 with great precision. At this time, the rectum is stapled with a linear stapler introduced through the assistant s trocar. In most cases, this is quite feasible thanks to short angulated linear staplers, unless placement of the assistant s trocar was too high. 13 Mini-laparotomy to remove the resected specimen This stage is performed without pneumoperitoneum. It is absolutely essential to un-dock the robotic instruments before evacuation of the pneumoperitoneum. Without the distention provided by insufflation, the rigid positioning of the trocar arms may result in trauma to the abdominal musculature. There is no need to move the patient cart. The robotic arms must simply be folded back to allow the surgeon and assistant free access to the abdominal field. The telescope is temporarily left attached to the optic Arm. The operative specimen can then be removed through a mini-laparotomy and the anvil for the stapled anastomosis introduced into the left colon. The perineal dissection can be performed simultaneously by elevating the legs into lithotomy position. The colon with anvil in place is returned to the abdomen, the laparotomy is closed, and the stapled anastomosis is then performed under laparoscopic observation.

11 Robot-assisted laparoscopic rectal resection 387 Disclosure of interest The authors declare proctoring events for INTUITIVE SURGI- CAL Company. Reference [1] Valverde A, Goasguen N, Oberlin O. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. J Visc Surg 2014;151(3):