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Contributors: Craig Rezac, MD
This video demonstrates the basic steps of a Robotic-Assisted Total Abdominal Colectomy for Ulcerative Colitis using the da Vinci Xi Robotic System.
DOI: http://dx.doi.org/10.17797/zr41dcfdmt
A) Using the da Vinci robot as assist, the descending colon is mobilized laterally along the white line of toldt using the hot endoshears. This allows for visualization of the left ureter and confirmation of stent placement. The iliac vessels are also then identified.
B)The left colon is rotated medially with further dissection of the lateral attachments cranially up the left paracolic gutter to the splenic flexure.
C)With the lateral attachments of left colon mobilized using the hot endoshears a window is created underneath the rectum, being careful to preserve the inferior mesenteric vessels for a future possible completion protectomy with creation of an ileoanal J-pouch.
D)The proximal rectum is then divided with the Robotic GIA stapler.
E)Medial mobilization of the left colon is continued by dissection and division of the mesentery with the Robotic Vessel Sealer towards the splenic flexure.
F)The division of the mesocolon is continued thru the mesentery of the transverse colon.
G) The middle colic vessels are identified and taken with the vessel sealer.
H) The gastrocolic ligament is divided allowing entry into the lesser sac and further mobilization of the superior attachments of transverse colon from the splenic flexure through to the hepatic flexure.
I) Mobilization of the transverse colon is completed by dividing the rest of its mesentery with the vessel sealer.
J) The duodenal sweep is identified in the RUQ allowing for safe dissection of the ascending colon.
K)The ascending colon�s white line of toldt is then dissected caudally down the paracolic gutter to the cecum. Medial mobilization of the right colon mesentery is completed while preserving the ileocolic vessels for possible future completion protectomy with creation of an ileoanal J-pouch.
L) We then finish the procedure by extending the suprapubic port incision and placing an Alexis wound protector and dividing the terminal ileum with a GIA stapler flush to the ileocecal valve, resulting in completion of the Total Abdominal Colectomy.
M) As part of a three stage operation for this patient the terminal ileum is brought through a created pre-determined ileostomy site, and an end ileostomy is matured and brooked in the normal fashion.
Indications for use of the robotic system are the same as the indication for total abdominal colectomy, which include:
1) Stage for creation of functional ileoanal J-pouch in multiple stages,
2) Familial Adenomatous Polyposis, 3) Ulcerative Colitis,
4)Indeterminate Colitis, 5)with ileostomy for failed J-pouch, and 6)with ileostomy for advanced fecal incontinence.
There are few contraindications for use of this minimally invasive approach to complete a total abdominal colectomy, which include: emergent cases secondary to colonic perforation, gross perforation, and extensive adhesive disease from previous surgery.
The patient is placed in lithotomy position in anticipation for possible J-pouch creation. Both arms are tucked to allow for docking of the da Vinci Robotic system on one side while an assistant is positioned opposite. The patient should be appropriately padded and restrained during the procedure this allows the operating table to be placed in steep Trendelenburg position and airplaned left or right.
Standard preoperative workup for use of the robotic system is similar to any type of operative procedure with a history and physical with digital rectal exam. The patient�s overlying pathology should be confirmed prior to surgery. If considering J-pouch reconstruction, a detailed discussion of the risks and benefits of J-pouch function and complications should be had. Confirmation of no fecal incontinence is essential.
Please see the operative description above for the important landmarks to note.
Advantages to robotic surgery: ergonomic positioning for the surgeon, improved dexterity compared to a laparoscopic approach, three dimensional visualization, and improved multidirectional dissection in areas with limited space.
Disadvantages to robotic surgery: increased length of operative time secondary to docking and undocking of robot, in earlier robotic systems limited operation to single quadrant, cost, and no tactile sensation.
Although the rate of complications utilizing a robotic approach are less when compared to open, complications are similar and include: infection, bleeding, and leak at the staple line of the dissected bowel.
Although the rate of complications utilizing a robotic approach are less when compared to open, complications are similar and include: infection, bleeding, and leak at the staple line of the dissected bowel.
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1)Harnsberger CR, Cajas-Monson LC, Oh SY, Ramamoorthy S. Robotic-Assisted Total Abdominal Colectomy. In: Ross H, eds. Robotic Approaches To Colorectal Surgery. Springer International Publishing; 2015.
Review da Vinci Total Abdominal Colectomy for Ulcerative Colitis.