Improving surgical fields management during DaVinci Xi Low Anterior Resection (R-LAR): A proposal of a new ports placement.

Giuseppe Spinoglio, MD, Paolo Bellora, MD, PhD, Manuela Monni, MD, Luca Portigliotti, MD. “Maggiore della Carita’ ” Hospital – Novara – Italy

INTRODUCTION: We propose a new robotic instruments placement to improve surgical fields management during R-LAR.

METHODS AND PROCEDURES : After having induced pneumoperitoneum (PNP) through Veress needle apposition in the left hypochondrium, an oblique line between left colonic flexure and pelvic bone is drawn. Airseal is introduced to maintain PNP, then four 8 mm robotic ports (P) are placed on a second parallel line, drawn 10-15 cm at the right side of the first. P placement is as follows: P1: 2-4 cm from the xyphoid and 0-2 cm at the left of the median line; P 2-3-4: equidistant 6-8 cm from P1 and one from each other, P4 being usually placed at 2-4 cm from the right iliac spine. Airseal dispositive lays 7-8 cm at the right side of P3 and 2 cm below. Patient is slightly turned on the right in Trendelemburg position. The robotic cart is approached to operating table and P2 is attached to arm 2, to target robotic camera on sigmoid colon. Once the target is completed we dock all the arms.

The first surgical step is vessel dissection and cutting (IMA and IMV): we place the camera in P3. We dissect the descending and sigmoid mesocolon between the two shits of the Toldt fascia in avascular plain until the lateral abdominal wall and the colon-parietal attachment. We then expose, in the same median to lateral way, the inferior bord of the pancreas and the gubernaculum lienis. We incise from below to above the inferior fold of the transverse mesocolon at the bord of the pancreas and we detache it until the pancreas tail. We place the camera in P2 and we detached the descending colon from the parietal wall, the splenic flexure and the epiploon from the colon. We start with the pelvic dissection with the same instruments placement (camera P2) using the lower instruments (P3 and P4) to retract and dissect. The main difference from the dVSi is that we have two instruments in the right abdomen and we use pelvic retractor from the right.

CONCLUSIONS: This placement, in our experience, allows to work better in splenic flexure mobilization and pelvic dissection with single docking.