Robotic Low Anterior Resection with Diverting Loop Ileostomy for Locally Advanced Rectal Cancer

CHAPTER 1

Todd Francone, I'm a colorectal surgeon at Mass General, and I also function as the chief of colorectal surgery here at Newton-Wellesley Hospital. And today, we're gonna be doing a robotic low anterior resection with a diverting loop ileostomy. Patient has a mid-rectal tumor and underwent total neoadjuvant therapy with FOLFOX followed by chemoradiotherapy, and now has presented for her surgical resection. So we'll start the case out by putting the patient in a supine, split-leg position. Typically, most surgeons may put them in lithotomy. We like the supine, split leg because the legs aren't up in the air and there's less risk for nerve injury. Once we do that, the patient will undergo TAP blocks as part of our enhanced recovery protocol. And then we'll outline our port placement. We typically will start with a Pfannenstiel incision to gain entry, but oftentimes, that may not be feasible, or we don't want to commit to a Pfannenstiel. So we'll do an Optiview or Hasson technique at one of our port placements, but for today's case, we'll start with a Pfannenstiel incision. We'll likely do a diverting stoma for this patient because of all the neoadjuvant chemotherapy. And it's a likely a low anastomosis. So once we get into the belly, we'll take a look around. We may have to tack up to the uterus to get some exposure, and we typically will start with a medial-to-lateral mobilization for patients, unless they're very thin. Then a lateral-to-medial immobilization is oftentimes more helpful. We may have to mobilize the splenic flexure based on the redundancy of the colon. And then once we have full mobilization to do a low anastomosis, we'll plan on doing our TME dissection, and then identifying where we need to resect in the distal rectum by using TilePro and a flexible sigmoidoscopy. We'll staple below our tumor, then we'll extract through the small Pfannenstiel, we'll undock the robot, put our anvil in for our EEA anastomosis, and then re-dock the robot to perform the anastomosis. And then do some oversewing and some little tricks that we do to reinforce our anastomosis for some patients. After that, we'll do an air leak test and then plan to do a diverting loop ileostomy in the right lower quadrant.

CHAPTER 2

So the first thing we're gonna do is just mark out our port placement. So we always just mark out our AS spines and then our midclavicular line to outline our rectus muscle and then a line drawing from the apex of the AS to the midclavicular line - that gives us an idea of where our ports need to be for any low anterior. Most people will, or surgeons will use a straight line for their low anteriors, although they'll struggle at the splenic flexure, and we know even with the newer system, you can still struggle with your port placements and they could also struggle with how you angulate your line. So this kind of helps us make sure that we have the right angle. And then we'll mark our ports two fingerbreadths up and to the side from the AS spine. That'll usually be our staple line. And then we do a handsbreadth on the opposite side, along that line, and then another port placement, a handsbreadth. She's got kind of a short torso, so we'll just adjust our ports a little bit and use this as our camera, this as our stapler. This will be our bipolar, and then you could shrink these all down and try to put them in a line -our goal here, or what we normally do is put our, our fourth arm over here on the side, so it looks like a hockey stick. And this will be our cardiae, and this will help us function up and down the paracolic gutter. So we can with one docking system, get our splenic flexure, sweep down, and really cover this whole left lower quadrant. We also wanna mark out our Pfannenstiel, she's got a prior C-section scar, so we can use that. And we usually will keep it, you know, 3 cm to start, but may need to get bigger because of her tumor. And then over here as a triangle, we'll leave our assist port. Here's our stoma, some people like to try to utilize the stoma for one of their ports. This would be difficult to her, because she's such a - a small torso that you'll struggle with your camera and you'll be clustered as you enter into the pelvis. So you'll really be limited, especially if you're trying to get your splenic flexure, so no need to try to minimize your ports. You just wanna get a good dissection, so, you know, keep your port away from the stoma site.

CHAPTER 3

So typically we start with a Pfannenstiel incision. There's other ways to get into the abdomen with an OptiView or an Hasson, but we like doing our extraction site first. So we start making our extraction site because we'll put our patient in steep Trendelenburg and then make our, and put our anvil in and having our extraction site already done just makes it a lot easier when we redock the robot. Yep. Can we get a Richardson? So we just make a small Pfanny here. We'll go down to the anterior rectus fascia, and she's already had a Pfanny here, so - another one? She's got some scar tissue here. So down to the anterior rectus fascia, and we'll incise in the midline. There it is, I'm gonna give that to you. Can I have a tonsil? So there's just all the scar tissue, and once we see muscle, we can open it up a little bit. Yep. Right up towards me. There's part of her right rectus muscle, we're just trying to find her left rectus muscle, or her right rectus muscle. Yep. That should come down through this a little bit. Here's her muscle. So once the fascia is divided, we can make little flaps to help us - our wound open up. I'm just getting a little hemostasis here on the rectus muscle. All right, Kocher. So we'll put a Kocher on the anterior rectus fascia, and then - make a little flap here. Thank you. Take this out here. And you just have to be careful here, especially if they've had a prior Pfanny because the small bowel can be stuck to the posterior fascia as you head up and you can enter into the abdomen and just not know it and then you'll hit the small bowel, so you just wanna be careful and go slow. You have to create these flaps - one for closure and two, it helps your Pfanny open up a little wider. So just sweeping it down here. If you can hold that, that'd be great. And then I'm going to take this off here. And just a little atypical anatomy because of the prior incision. So then once that sweeps down, that's good, I'm gonna take two forceps, please. So we'll grab the underlying peritoneal cavity here at this - grab opposite, yep. So again, just carefully go in. You really just wanna have upward retraction here. Make sure you're not grabbing the small bowel. Yep, grab here. Can I have this light on now? I'm about to - yep. I was just wondering if it's small bowel or not, and whether we're in the right spot, but you have to be careful when you start this low, because you could also get into your bladder. So you wanna make sure that you're in the right spot. So this is in the right spot. We're in the peritoneal cavity. So I was just gonna divide that. And going down if you're low, like this, just go off to the side of the bladder. So head to your side a little bit, yep. Okay, we'll take the sleeve. So we use a wound protector just like we would when we extract, some people can just drop the anvil in and do it intracorporeally. Today we're gonna extract and put our anvil in extracorporally, so it's nice that we have our extraction site. So we'll put this cap on the wound protector and get pnuemo that way and place our ports, and it just ends up being a little quicker for us. Can we have our gas on, please? Yep. Okay, we'll take this, yep. We use the stapler port because it fits nicely here. It doesn't leak when we're putting our ports in. All right. Pnuemo on. So whenever you get your pnuemo, you just double-check your port placement, and you wanna - now you've got a nice dome so you can spread your ports out. All right, so here's where our stoma's going to go, right here. And so right now, like we have a nice dome so we can potentially just kind of readjust our ports here. So one up, one, two over here and it's up. So that's where we're gonna end up there. We actually might be able to use this as part of our stoma if we shift up a little bit. So let's go here, put our camera port. So we'll just do a quick TAP block here. No matter what, you want to at least give yourself 5-6 cm between each robotic port. And when you're doing an LAR, that can be hard when you're moving throughout the abdomen, because it's a multiquadrant surgery, so you kind of have to think about it at all quadrants. Did you get us the extra dull one? She's made of steel. All right. So here, you know, down into the pelvis, my fingers are probably about 2 cm each, so you want 6 cm. We can maybe catch the end of her stoma. So when we're here, we want to be 6 cm apart - 6, 6, 6, 6, and then maybe some tightness over at the splenic flexure if you have to go here, but usually you're going to be over here, so we should be good. So we'll make this right here, and then that'll be one of our ports. And it's usually the stapler port, so it's a wider port anyway. And then we don't have to close it, which is always nice. All right, can I have a grasper? Just gonna put those two ports in. Then I like to look at my anatomy just to get an idea where everything is. She's got some omentum attached to her… All right, so she has a mid rectal tumor. You can see here's her uterus, we'll have to tack this up. Can I get the patients tilted over to the right side? So just to get the small bowel, I typically will put the proximal bowel over to the right side first before putting them in Trendelenburg. This will help kind of expose the IMV. Yep. And then I'll take some Trendelenburg. So again, get this small bowel out of the left, upper quadrant first and see your anatomy here. And so omentum's kind of keeping us from doing that, but we'll get that eventually. Sometimes you can get all your small bowel in the right spot, right from the beginning, a nice, thin patient like this, will be nice. And we can kind of see if we have some redundancy, which we do. Oh hey, yeah. That looks very nice. All right, so we'll lift this up for some exposure. This doesn't really require some splenic flexure mobilization, but we'll at least do our lateral margin here. And we can talk about mobilization if we need to. So, the one thing that we want to do is see where our transverse colon is in relation to our epigastric port here. So it's gonna be a handsbreadth. And so we'll shift this over a little bit. So here's our port here, handsbreadth. You don't want to go too medial, because this will keep you from doing a medial-lateral dissection. And you also don't wanna be too low. You wanna be either above your stomach or above, or at least cephalad to your transverse colon. Otherwise, if you're down here, your arm will hit the robotic arms when you're trying to get to that splenic flexure and you don't want to do that. So you wanna be higher so your arms are always swinging towards the head. So Sarah's gonna put a TAP block right here. Big gauze, sponge. All right, so - and then, our splenic flexure - we're gonna go all the way out here. So here's her rib right here, costal margin. We'll go out lateral, here. So right there. Yep. Yeah. Okay, good, so we'll put this here. I'm gonna put my assist port… And again, it's gonna be triangulated between these two ports here. You don't wanna be too lateral because then your assistant will have trouble getting over the small bowel. They'll hit the small bowel while they're trying to assist you and then you'll lose your exposure. So you really want to have them in the position, you can see that this is gonna be a good spot for Sarah. We use an AirSeal port. So it's jet insufflation, so it constantly will adjust your pressure. You have the adapter for that. Put our stapler port in now. That means it's ready. We don't do it right away because sometimes we think we might not staple so we'll leave the 8 in, but we feel confident that we should be able to do it today. You have the adapter for the 8's? Yep. All right, now we're gonna dock.

CHAPTER 4

All right, come on straight in. Yep. Come on straight in, straight, keep coming. Come straight, don't turn yet. Keep coming, all right start to turn. Yep, keep turning and come in as you're turning, turn up towards the head, come in a little bit more, pull back a little bit, stop. Good job. Push all arms behind the green laser line. Install the endoscope for targeting. Workspace may be limited if targeting is skipped. So because we put that arm one over on the left upper quadrant, we cluster all our two, three and four over into the right lower quadrant. And that gives us access, we can swing around, but when this is out perpendicular, this arm can move up and down the paracolic gutter on the left side pretty easily. If you find that it's hitting two, then you can drop the elbow on two, you can shift everything over to the right a little bit. Sometimes this port placement will limit you on trying to get the IMV, which means you can shift four, three, two over to the patient's left side. That'll give you more medial access and then this arm one will be more of an up and down motion or it'll bring the left colon down to the pelvis to commute, give you that traction. That's the dock. Okay.

CHAPTER 5

So here's her, yep, here's her pelvis. Here you can see her right ureter right here, coursing over her iliac, sacral promontory is right here. Bifurcation's up here. We know that we have to operate in the pelvis for her. She's got a mid-rectal tumor, so we need to get this out of the way. So we'll start by tacking this up with a Prolene. So the system's gonna put this through. Might be hitting our - good? There you go. We'll put this right through the dome of the uterus here. And we just start out by getting that out of the way. Can you pull it up a little tighter? Yeah. All right. I'll take a scissors when you're ready. Okay, so again, here's our anatomy here. You can see the right ureter pretty nicely over there. The left ureter will sit over here underneath the colonic mesentery. Sometimes if they're really thin, you can see it. There's an iliac there. She is super thin. Sometimes being thin is not as good because the planes are a little tougher, but you can see her ureter right there. Ureter, gonadal, psoas tendon, so we'll just start by mobilizing this colon here. And again, this doesn't look like a patient we'll need to mobilize her splenic flexure, but we can do some lateral-to-medial immobilization. So we use monopolar just to free this up and we always just want to be on the inside of the white line of Toldt. Otherwise, you end up in the retroperitoneum. It's just immobilizing this in the lateral-to-medial fashion, here. And again, staying on the mesentery side of the white line. Don't forget about your fourth arm, which can help retract your anatomy off your RP and keep it out of - keep your RP structures out of harm's way. So we try to teach our residents to do small, quick movements, utilize your fourth arm. It's much easier than it is with laparoscopic because you don't have to try to keep your camera in one spot. So here we'll just do some lateral-to-medial mobilization. Sarah's grabbing upstream on the colon to help outline the anatomy. So we can take this omentum off, which seems to be holding up our dissection. So here, just restore our anatomy - Spot's here. I'm just taking the omentum off - attachments to the sigmoid colon. Using that fourth arm just to retract this way, we could probably burp that arm, Sarah. So don't be afraid to use both arms. Okay. So you can see she's still got small bowel hiding, and Sarah will move that over. Yep. Okay. I'm just looking at the anatomy, here. Here's our descending colon. Here's our splenic flexure, probably distal transverse colon here, at this point. You can see her IMV, right here. It's coming off, it's got a branch right there. Here's our ascending branch of the left colic. IMA's coming down. See her underlying anatomy. There's her kidney, and you can see how that comes down. Here's her marginal artery coming down and that's what the majority of us - you can see how long that left colic, ascending colic branch is, typically this is not a limiting factor for length. You can see how this is in relation to our ureter here. Gonadal vessel. Sometimes you see too much, right Sarah? All right, so we can still mobilize, here now, just to kind of show you our lateral-to-medial mobilization. We oftentimes will do a medial-to-lateral, but when it's… Ah, I think her plane is out here, what do you think? Her mesentary's so thin that sometimes it's hard to see. So thin. You can see here with the arm one that if you have a higher flexure than you plan on it, it can be limited in regards to what it can do for you. So it will oftentimes just be an up-and-down motion or just bringing the colon down into the pelvis. Again, this is not somebody that I think we need to mobilize our splenic flexure for. So here just trying to get into the right plane here. Most of the time, these vessels all go down. There's the Psoas. So here, you're getting close to your ureter. Here's your iliac. Your ureter is right here. Just because you can see it doesn't mean it's out of harm's way. So again, this lateral arm, one, is just retracting stuff off the RP. Maintain that anatomy - again, sometimes these thinner patients are harder because their planes are so thin. So this arm can swing up. As it swings up that paracolic gutter, it may hit arm two. So again, you can drop the elbow of arm two if it's hitting it. You can see this can rotate on itself here pretty easily. So now I'm operating above. It's moving this way. This arm's moving this way. There's our kidney. Okay. I don't wanna do too much more, but if we want to just show them the IMV again. So another approach to doing is splenic flexure, if you were gonna do it, that's just the stomach flopping down, here. Her mesentery is so thin, we would, if we need length, pick this up and dissect this down, get underneath here, and sweep it out this way. Nice anatomy. Okay, let's swing down to the pelvis. Can you burp this port? She's gonna pull that port out, I can feel it, I just feel restricted. She's got a small peritoneal cavity here. As you sweep down, you gotta move as a unit, or else your arms will collide at the bedside. So you can see her ink down here and we'll check the location of the tumor too. So we're gonna push all this over here. We actually want to do a medial-lateral start here. So the way to do that is to sometimes just grab the mesentery here. You can see the IMA - the IMA is right here. You can see it kind of coursing. Here's her iliacs. And what you're normally looking for is this arch - along the mesenteries, so something like this. So if it goes to the colon, it's usually just a branch. If it's going down into the pelvis, then it usually is right. And what you want to do is… Start the dissection. Let the pneumo dissection kind of tell you where to go, like that. As you're holding up here, the next maneuver is to take this, your bipolar, and then just sweep up. Again you wanna give yourself enough traction to get your anatomy up and going, never digging a hole, just opening this up. And again, now I'm trying to get into the right plane. There's her ureter again. Through the mesentery. Keep that ureter down. and now you're getting into the right plane, here, underneath the mesentery. So this was through. And before you start your TME dissection, it's really nice to get the anatomy just squared away. Push this ureter down. Just nice C-actions like this. Put that ureter down. You have to get this all the way back here. Well, some people, when they do a TME, they want to ligate very quickly and free this up, I actually don't do that. I like keeping my IMA intact. I think it provides better retraction as I get into the pelvis, we can see that ureter still coming up, right here. Okay. So again here - here's your iliac, here's your ureter coursing over the iliac.

CHAPTER 6

So, as we head into our TME, you want to get retraction. So if you're gonna be operating here, you wanna get traction right here. So I'm gonna switch hands. All right, so heading down into the pelvis on the right side, on the posterior side, you have your suction here, or it can give you lateral retraction, if you need it. This hand does the pulling the rectum out, and these are your two operating, with two and four - two and four. When it's the left, the assistant will hold the rectum over to the patient's right side, and we'll operate along the left side. She's got a little bit of a floppy mesentery. I think this part of the TME dissection can be sometimes difficult. You wanna get the hypogastric nerves down, I'll show them to you. So you wanna stay on the mesorectum. You can start to see some nerve being pulled up here. So you wanna stay along the mesorectum. If you stay too low, then you're more likely to get the nerves. See the ureter in the background. There's our nerve right there, left hypogastric. And you start to see the aerial plane through the TME holey plane here. Again just giving myself good traction here. Here's her right ureter, so I don't wanna pull up too much. You can see it right here. And again, don't dive into here. This is sacral promontory, but if you go - too deep and you try to stay away from your mesorectum, then you can get into the presacral plexus, the venous plexus, and then that causes a whole lots of bleeding and problems. So she's got this floppy mesentery, I'm giving good retraction here. I'm not really seeing it, but you can always accommodate this way. You can start to see her right nerve right there. There's her nerve. And then you can see that left hand, retracting back, really lifting up, giving you that areolar plane. Let's see here. Again, staying up real higher. There's her nerve. And just backing up, you can see parts of her pelvis here. So you wanna make sure you're not going just straight across and going into your side wall. So as you go around, you're sweeping up. You give gentle sweeps like that to help outline your mesorecal fascia And again, the planes - staying on the mesorectal fascia, and away from your presacral. You see here, if they have a narrow pelvis, as you try to go to the left side, you may hit your camera, so you want to frame shift. This is your retraction up and then over. And then I'll give you a little idea of where to go, and you can even use your wrist to accommodate. So we're going down, and we can do our right side. You can see how I'm getting lateral retraction from Sarah. And then you do kind of like these sweeping motions up, because it opens it up like a zipper. Or a "zippah" if you're from Boston. Right Sarah? "Zippah" All right here, so here we're gonna do anterior. So Sarah's gonna hold this out for me. You wanna get a camera? I got a dot on my left eye. Okay. So you can see here's where her tumor likely is, so we wanna stay away from that. So we're gonna start by mobilizing her anterior peritoneal reflections. So you can start here and head over. I like to kind of just give myself an idea of where the plane is. You want to see where her vagina is. Here's her uterus. Here's the junction between the two, so we'll start here. So what you're looking for is to get the rectovaginal septum here. If you're getting into bleeding, usually you're too low, you're too high into the vagina. The vagina will bleed on you. Thinner patients, you can get into the rectal wall too, so you just wanna go slow until you get that right plane. Let me see, we've got a nice plane here. Lets see here, the plane's not as nice, but maybe in the wrong plane, so we just wanna make sure - we get ourselves back on track. That looks like close to vagina, right? So we want to get this vaginal wall here. It's okay to be in the wrong plane when you start, just make sure you recognize it. Okay, we're gonna - yep. Come on over. She's gonna keep holding this over to the left side. Now we're gonna take down the left side to even this out. So here's our mesentery, and if we did a nice dissection, we should be able to slide this down, and you can see that. So as you're coming down here, we always tell the residents, don't do a lot of grabbing along your side wall. This is gonna give you your lateral retraction. This wrist bends up. This wrist will bend down so that you can operate between the two. And then your arm two will pull out to the right upper quadrant as you pull down to give you that tension, counter-tension. And you can see here again… Following our dissection down. And you can see, as we're coming down here, the dissection's not as clear, getting the promontory. Again just doing a little posterior here. And once you outline your poster, this helps outline your lateral. You wanna make sure you don't go too lateral with the nerves, okay? You come back. Hold this out like this, Sarah. So at some point we're gonna check and see - sometimes the ink gets so diffusely spread that we can't tell where our tumor is, so we're gonna do a flex sig check. You can see here, the plane might be a little off here. All right, Sarah, I'll grab it. So right side, I grab, I'm gonna go like this, just follow this up. You can see here, this goes lateral, you can see kind of this mark here, this C-action here. So that's where I'm gonna aim for my dissection. Hold on there. So you're just trying to get down and even out our dissection. So here you can see again, remember that you haven't taken your IMA yet, so don't pull up too much, and you want to again, stay up on your… So with the robot, you can really get down into the pelvis. Sometimes the patient's anatomy can be obstructive such as the promontory, as you can see here, our camera's a little limited, but we still have good access. That's side wall, I can tell. Little sweeps up like this can outline your anatomy pretty nicely. Let's see here. And we'll just keep working around in a circle, as we work down, whether they're thinner or big, you can still use this technique to clear out your rectum. You can see here, just a little close to the vagina here. Here's rectal wall. Okay, let's check.

CHAPTER 7

Yep, we're gonna do TilePro. Yep. So we're gonna occlude this and just kind of see where we're at. So if you're by yourself, you can always leave this here, kind of see where your instrument is and then we'll do a flex sig at the bedside. So TilePro's a picture-in-picture. It'll put the flex sig right onto your console. So if you have somebody with you like a resident, they can do the flex sig and then that can be helpful. We don't have a resident today, so we are gonna do the flex sig on our own. Oh yeah. All right. So here we are. Are you occluded, Sarah? Mm-hmm, I'm occluded. So here's her ink. And there's her tumor there, see it? Here's her residual tumor. This patient got total neoadjuvant therapy. This is what we would consider, not a complete response. So the question is… There's our indentation of our port, see how it's indenting? Yeah. Can you move that? Can you move that instrument up and down? Yep. So if that's where we are - so that's where our dissection is. You can see we're well below our tumor. So that's where we can dissect. We'll do a little bit more, but we wanna make sure we have a good margin. You can see here's our tumor, and then do that again, Sarah. You can see, even when you don't have a resident or someone helpful, you can have somebody do that just by leaving the instrument there, and then you can see you're gonna leave her with good distal rectum for function. Okay.

CHAPTER 8

So just a little bit more just to clear it off. Oh wow. What happened there? You can see here, just clearing off this dissection here. And at this point she'll cone down. That's her mesorectum already coned down. All right, Sarah, can you grab this from me here? Yep. Sarah, can you pull it straight out for me? We're just gonna get this vagina off here. Here's our rectal wall. Here's our ink. This is where we were. We're gonna staple right here. Most of the mesorectum is up. All the mesorectum is up, posteriorly. This fat, we can just clear off. The mesorectum, you can really get into easily. Put the bipolar here, we can facilitate this. Might as well take these now. You don't wanna staple across them, they'll bleed. You can see here, we're cleared off. This is where we were, yeah. Should we check again? Just to be sure?

So you're gonna hold it like that, So this is where I'm looking at right here. Here you go, thank you. She's tough to distend. Her anus is like patchless, so you got to put a… Okay. All right, can you move it? Yeah. So we could even go a little higher. Yep. Okay. So do it again? Okay. All right.

CHAPTER 9

All right, we'll take the stapler. Yep and I'll take a camera clean. So lots of ways to do the stapler. We're gonna use a 60 green. I always use a green on the rectum. See the pelvis is dissected down here. We've cleared off the rectum here. This is where we were gonna go. A lot of people get set and stuck on trying to come across like this, but it's very reasonable to come across like this from down, from a vertical to - or ventral to dorsal. When they're a nice wide pelvis, you can try to come down like this. On her it's pretty feasible to do. What you don't want to do is hit the vagina. So we're gonna… See the rectum, oftentimes - and oftentimes you're not gonna get it in one. Sarah, can you hold this up for me? Sometimes you need assistance here. If you're not gonna come across them once, not a big deal. Just make sure you get your mesorectum up. I see we have a defect in our mesorectum there from retraction. And I'm just trying to pull this up. So we know we've coned down. So before they take it out, you gotta straighten it out for them. You can see that we did do a vertical. All right, we want to keep the vagina out of the way. There's the vagina, make sure it's nice and clean. We'll need a second load. Yep, you can retract. I'll take a scissors. She got a little bleed from the mesentery down there. This is just… You can see here - here's the end of our rectum here. There's the end of our staple line, so we're good. You can see the retraction defect for our mesorectum here. The rest of it - looks good. Okay. Sometimes we will oversew our anastomoses. There we go. Okie doke, that looks better. All right, so there's our rectal stump.

CHAPTER 10

Put this back in, our specimen. So now we're gonna dissect off our pedicle. Here's our very redundant colon. Here's our, IMA pedicle. I'll always try to preserve my left branch middle colic, which is gonna be right here. This is a high ligation, here. So you can see here, here's our IMV. Here's our left branch - here's our left colic, so we're gonna take it upstream from that. I'll take the vessel sealer.

You can see that the ureter is down.

That's the IMV that we took, and now we're gonna take our left colic - or IMA. Make sure you come across the vessel in one piece you can see it's got a big burn there. I usually slide up, double burn.

CHAPTER 11

Okay, so once the IMA is taken, we're gonna take a look and see what reaches down and where we're gonna do our anastomosis. We got lots of length. So something like that. Usually I like to use the descending colon, it's better tissue. So once we do that, there's our pedicle. Make sure your mesentery is straight. Sarah, I was gonna come in and help lift this up for you. Then we're gonna just march, making sure your ureter is down. Are we gonna get ready for ICG, please? So we'll check ICG to assess the perfusions. This is particularly helpful when it's intracorporeal. When we extract, we'll put the anvil in, we'll also be able to look at the perfusion as well. If you're doing everything intracorporeally, then the ICG is very helpful. Okay, let's give it.

CHAPTER 12

So we'll not only check our ICG of the- perfusion of the colon, but also our rectal stump. There we go. Nice perfusion up to where we transected. And then we'll check our rectal stump, which also has nice perfusion. Okay. So…

CHAPTER 13

Now we are going to give Sarah our end of our specimen. And then we're gonna go to the bedside and put our anvil in. So here's our extraction sites, which we've already made. Where is it? Right there? Ooh, that was almost close. That was close. So as long as the rectal tumor is not too big, we can get this out- another babcock. And again, I think we have one retraction injury of our mesorectum, but as long as you're not leaving mesorectum behind, that's the biggest story, so here… Let's see here. You can feel the tumor right there. Yep. Yep, and there's our staggered staple line that we came across, but that's okay because we're gonna use that to- where we come across our stoma. So again, when you pull out, you wanna make sure you're not twisting anything. So we gotta check our orientation and see that that's twisted a little bit. So untwist and then double check. So that's where we divided. We'll go a little bit more. Can we open up the 28 French Covidien EEA stapler, please. Great. Can I have a Kelly? I'll tie. Yep, just divide that. You can see, we got good perfusion there. Confirms what we were doing with ICG. Right? That's the thing. Yep. Nice and tight. I'll take a scissors. So we've got our site where we're gonna put our anvil. It's nice and perfused. No tension to the anastomosis.

So now we're just gonna put our purse-string in so we can secure the anvil. And we use a purse-string device, it's a reusable. You can see here, it's got holes on each side. I'll just put it across the clamp here. And then we use a 2-0 Prolene on a Keith needle. You always go down first. That'll slide in. And it should slide nice and easily. Comes out the other side, and then we go up. Yeah. The tiny holes are hard to see. All right, so we can cut the needle off. Then we need a snap. All right I'll take a curved mayo. You have a lap pad for me? And I'll take a Kelly clamp. Make sure you're not gonna spill. Cut across that. Here's our specimen.

CHAPTER 14

Yep, we're gonna open it up. So our purse-string's already in place. It's nice and fast here. We usually will dilate the colon a little bit with my finger, make sure this goes in correctly And then… I should have let you do this. That's alright. I'm sorry. I don't know why, in the mode. So we wanna slide that down. Here. Okay. Now we're gonna tie this. Okay, scissors, I got them. I'll take a tonsil. You know, I'm not from Boston because I say tonsil, Boston people say Schnidt. All right you can hold that up like that, and then we're just gonna clear these vessels off because they'll bleed. And you're stapling All right? And then just Bovie here. That's good. That's it. Looks pretty good. We're gonna just put that back in. If it fits through our tiny hole. Okay, then we just put the cap on and put our pnuemo. That's it. So that's like one of the benefits of just doing this Pfanny first because then it's super quick. Especially if you have a bigger patient and a steeper Trendelenburg, it's sometimes harder to make the Pfanny and then do the anvil, it just takes a little longer. So when you're doing it right off the bat, it's kind of nice. The only thing that you're doing is committing to a Pfannenstiel, so if you end up converting to an open, that may be a bigger issue. Got plenty of length. It's nice to have no tension, so again, you wanna make sure that you're not twisted. So just checking our mesentery here, mesentery is without twist. All right, so I do a few things that some people may not do, which is putting a purse-string around my distal spike, which gives me a good distal donut. Usually we'll aim right for where it crosses, which keeps me away from the vagina as well as gives me an ability to over-sew the anastomosis, if I need to.

So first things first, make sure you're in the right hole. Always make sure your spike is back when you're putting your stapler in. And Robin was dilating the anal sphincters, so we're just gonna look and see, and we just want that crossing staple line right there. Does that look good? Looks good, right? So I'm gonna just open it. Okay Robin, just hold it like that. Gotcha. Got it? Yep. So she'll hold it like that, I'll push the spike- push the bowel on the spike. And again, this is to give me a good distal donut, which is usually the weaker donut. Most people worry about, you can see that we- we'll slide that down so that crossing staple line will be gone, keeping the- okay, I'll take my needle driver.

And it's something that you really can't do, unless you have a robot. Because suturing in the pelvis is made that much easier. So again, taking this and just ensuring that I'm getting this staple line in my donut, so it doesn't- I don't have any crossing staple lines here. Okay. You can just give me the vessel sealer.

So when we're attaching this, you really don't need any special instruments here. The key is just to grasp on the lateral aspect of this, so it hangs down. And then your other instrument can just guide it. And you wanna make sure it's nice and- see how it slides and you wanna make sure it clicks. Click. And then you can test it. And make sure. So again, making sure your mesentery is not twisted. Robin, bring your hands over towards the patient's left. There you go, nice. Okay, just give it a close. Nice and slow, you'll see it pop out. Yep, keep going. She's gonna close it until it turns green. Just go slow, Robin. Look at the stapler, is it green? Green. Or as my mentor says, always trust, but verify, make sure it looks good. Feels good? All right, so put the safety back down first. Gotcha. And then we'll wait 20 seconds, get the edema out, and then we'll try to tighten it some more. All right, tighten it some more. It's good. Okay, safety up. White knuckle grip. Oh, all right, I'll do it. All right, so… So we're gonna fire it, white knuckle grip here, hold it for five seconds. Five, then the safety goes back down, then four half turns: one, two, three, four, hear a click, another half turn. And then we're just slowly… Shooting this out. Sometimes, if it gets stuck… So if the stapler gets stuck, you gotta push it in and then you push it out. There we go. Don't panic. So we're just gonna check our donuts. Our distal donut will get sent because this is a cancer case. You can see it's a nice, beefy donut. Similar to our proximal donut. So that'll get sent to pathology.

And so now I'll oversew my anastomosis, especially, you know, prior, before total, neoadjuvant therapy. With just chemoradiotherapy, we used to just let these patients ride without any stoma if you can oversew them like this, But with total neoadjuvant therapy, it's a little bit different. So these are full thickness. I'm just going through, 360 around our anastomosis, to reinforce our staple line. Sarah, can I just get a quick camera clean? So this is just, some of our donut got spit out when we stapled. That's not a problem. Let's see here with the 30-degree camera and the control of your own camera and the articulating instruments, it's pretty easy to- or it facilitates at least, sewing in the deep pelvis here. So we like to do this for our anastomoses, especially if we're not planning on diverting. It helps to have an amazing assistant. Sarah's gonna hold us over to the patient's right. And we'll just continue our sewing. Let's see, we're already around the majority of it. Okey doke. So that's a 360 oversew of your distal anastomosis. And now we just check our connection. We're gonna put the patient back in a little bit of a reverse Trendelenburg. Actually we should be good, because she's in 17, yeah.

CHAPTER 15

Okie doke. We're gonna do our leak test. So the TilePro is on. Any bubbles? No bubbles. So looking at the screen, no bubbles, you can see here. There's our anastomosis, nice pink and pink. Most people worry about stricture or stenosis of oversewing. You can see that, that's not the case. And we're down in the distal rectum. So it's less than 7 cm from the anal verge. She's gotten T and T, so she's getting diverted, but it's nice to know no air leak, no bubbles, pink and viable above and below the anastomosis. And then we give the highly, highly specific tap test, just to make sure there's no bubbles coming out. Okay, we look good.

CHAPTER 16

Looks good. So we're gonna just get our mesentery here, our omentum. If I can see it. All right. I need to find our TI. Here's our TI, you can see the veil. Okay. So you gotta cut this before you're done, or else it'll bleed on you. Sarah, can you just suction some more of this out? I typically, depending on the case, will leave a drain, but she's nice and dry. So here's our TI, about 15-20 cm upstream. Right here, Sarah's gonna grasp. You ready? Yep. And we're gonna grab it through the 12 port, which is gonna be our ostomy port. All right, looks good. Undocking the robot.

This 12-mm trocar port is gonna be our stoma site. So we're just gonna make a 1-cm disc incision here. Sarah, can you hold that up? So I like to bevel my incision, leave the dermis there, so it's easier to sew to. And we're lucking out, obviously, because she's super thin. You kind of hate to divert in this case because everything went so well, but we really never know what the chemo and the radiation therapy do. All right, can we get an S retractor? So we're just making a cruciate incision in our fascia just to kind of get enough to, yep, and then we're gonna divide the posterior, the same way. All right, and we're gonna pull the bowel up like this. And then we just have to check our orientation. Yep, so we'll just check it from here, just to make sure we're not twisted here. That's our distal, and then here's our distal limb. And then there's the veil, and here's our proximal limb here. If we were to dump that down, it comes up. Here you go, you just clamp this off to the side. I actually don't wanna pull too much out. Then you just clamp the mesentery, and we can shut the air off. And that is it. So we're gonna close our incisions. All right, we'll close our Pfanny first. Can we get a number one Vicryl, Rich, and two forceps. So we're gonna close the peritoneal cavity first. I'll take a tooth forceps too. So she got a little scar. So yeah, start on my side, start this way. Come like this, yep. Yeah. Tiny. I know. It's a big needle for a tiny incision. Come- no, inside out. Yeah, yeah, yeah, yeah. Good. All right, we'll tie it up and then we're gonna run it. So again, if the tumor's bigger or it's a bigger mesorectum, then you'll have to make the Pfanny bigger, but this is a good start and it's something easy to do. Number one thing is to make sure you don't disrupt your oncologic specimen when you're extracting, but it is nice to be able to do it through a small incision. You can take it in one. Whatever. I can take it in one? Sure. So as you're closing this, make sure you're not getting small bowel. Then you go through your checklist of like when you're closing. So you make sure your anastomosis looked good, mesentery, there was no twist, put your omentum where it belonged. We're gonna take a number one PDS. Can we have Bonney's too? Can I have the other… So then we use a PDS just to close this. Our fascia, so I'll start on the inside. You wanna make sure you don't get muscle. This is a big needle for a small… I know, this was my struggle. I think they got the wrong needle, although it's all right, we can just keep it right here. So again, try not to get any muscle, if the muscle tears it'll bleed. You can get a big hematoma in your Pfannenstiel incision and you won't even know it. So, we'll just get the fascia here. Relax on that. Do you want me to follow you or no? Yeah. Part of it's- because she has the scar, so the scar's not stretching with it. No, don't pull up. I'm just gonna see if I can get the corner. Just gotta make sure when you're, you're not just taking scar, you're actually getting fascia with these Pfannys, because you don't want to get a hernia. That should be the last one. With the fascias closed, then we just close skin. Do you have a 3-0 Vicryl? We'll just tack this knot down so it doesn't pop up on her. I'm just gonna free this up here. We're just releasing the scar here. So we're just tacking this down. Yep, go ahead, yep. Needle back. We're just getting hemostasis on our wound here. So we'll just do a running subcuticular. I'm just gonna do a- interrupted subcuticular. She's kind of thin, huh? All right so, can we have Dermabond? And- oh, thanks. I'm just gonna put some more local in. local's going in. All right so, I'll take Dermabond. And then I usually do a terminal Brooke ileostomy. So a loop ileostomy, but it looks like an end. I'm gonna show you how I do it.

So the first thing we do while that's drying is we'll- here's our distal limb at the inferior aspect of the aperture. And then we will- can I have an Adson here? Mark out a smiley face here. Like that. And as we go in- Sarah, can you get an Adson? Yep. So we're getting to our distal limb here a little bit. There's our distal limb, we'll take a Vicryl. So, covering our wounds up. And then the distal limb is just in a simple fashion. So just a simple- right to the dermal here. I'll tie these right away, and Sarah's gonna take a stitch in a second. I'm gonna do this side and that side. So the key here is to kind of bunch up your distal limb to the inferior aspect of the aperture, so- so I'll take this here. I'm gonna grab this corner. So here's the distal limb, here's the corner here. This is gonna come all the way down here. Grab the dermis, needle back, Stitch to Sarah. So again, here's the distal limb. So she's just gonna just grab the serosa here. Come in right there. Yep. And then just come all the way down, all the way down next to this last stitch right here. Yep. Here? Yep, as far as you can come. Yep. Yep, and then tie that up. Okay so then, once we do that, we can kind of trim our proximal limb a little bit, so that it flips over on itself nice. Hold up on this. Okay, I'll take a 3-0 Vicryl. So now you can see you've got your distal wall right here. So then we put our Brookes in here. So you're just gonna just gently hold up like that. So I'll put my Brooke here, and make sure that I'm along the antimesenteric border. And these will- snap, snap, little stitch. So we'll put them- I'll put the 9 o'clock one here. Full-thickness bite. To seromuscular at the same level. And you really wanna just go right where it lies at the skin. You don't wanna take a bite up here and then bring it down because then you'll lose your Brooke. Needle down. You can see how it's starting to Brooke naturally already. Another stitch. You can see here, we don't wanna take a bite up here, we wanna take the bite down here because we wanna maintain that elevation off of the abdominal wall. And then the second thing we want to do- is bring this bowel here, but the proximal limb down here. Needle down. Same thing, 3 o'clock stitch here. Just grabbing the serosa, right there. We're gonna pull this up, so that this comes down. If this comes down here, take your bite at the 3 o'clock. Here? Yep. Yep, now go right into your dermis. Snap. And then another stitch? How many more would you like? We'll just need two more. Yep. Pull on this here. And then again, this thing here- is gonna come down like that. Yep. Right here. Yep. Okay. So then we can start tying these. Snap. So sometimes you want this to come a little bit more like this, so you could have taken a bigger bite to scrunch that down, but this is gonna be fine because it's gonna sit, it's gonna sit in the - is this tied? It's gonna sit in the stoma, it's well above the skin, it's well brooked, it's not gonna retract, and that's all you want. All right we'll take a stitch. So I'll put several other simple sutures for additional security. Yep, and just filling in a gap. So this is just a simple… Just go straight across. Do you want a snap for this? Nope, I'm just gonna, it's not a pop, so I'll just… And here you're just gonna take a bite. When you're bringing the suture down, make sure you bring it down sideways, so that the mucocutaneous junction joins. Actually, that will bring this down a little bit. Needle down. One last stitch. I'll take that one back. And I think we're done. Okay, you can cut the other ones. So it looks like an end, but it's a loop. So it's a terminal Brooke end. Okay.

CHAPTER 17

So we just finished our robotic LAR. The patient was obviously a thin patient, so we elected to do a lateral-to-medial mobilization. You can see the ureter and the anatomy, which is great. Sometimes when they're too thin, it can be more challenging to get into the right plane, versus someone who has a little bit more intraperitoneal, or visceral, fat. But the dissection went well. We didn't need to mobilize the splenic flexure because the patient had a tremendous amount of redundant colon, which facilitated today's case. Once we got into the correct plane, we had good mobilization, we did a nice TME mobilization down to the level of the pelvic floor. And the flexible sigmoidoscopy- using the TilePro, we're able to see the picture-in-picture on the console. We were able to identify the tumor. The patient had a good response, but not what we would consider a complete clinical response. And we were able to staple in the distal rectum without difficulty. I do oversew my anastomoses. This is not a common thing. We find that this has helped us reduce our leak rate. And it's obviously facilitated by the robotics platform and the articulating instruments and be able to operate down in the distal pelvis. Now this was a female, she had a wide pelvis, but we can often do this in, even in the morbidly obese narrow pelvis, if we want to. We elected to divert her, even though this was a nice, straightforward case because of the low anastomosis and really the effect of total neoadjuvant therapy can be quite devastating to patients, especially in their wound healing. So this is one of the reasons why we elected to do the right lower quadrant diverting loop ileostomy.