Robotic left hemicolectomy: Two‐surgeon dual‐console technique

This video vignette demonstrates our two-surgeon dual-surgeon technique for performing a robotic left hemicolectomy. For this technique, two surgeons are present, each at their own console. This allows all three instruments to be used simultaneously. Surgeon 1 controls arm 1 (bipolar grasper) and arm 4 (Prograsp) for retraction and blunt dissection. Surgeon 2 controls arm 3 (scissors/vessel sealer) for sharp dissection. This technique allows for greater time efficiency during dissection. Furthermore, it offers an excellent training approach for surgeons or trainees who are still on their learning curve. The case reported here is a 43 year old female who presented with altered bowel habit and nonspecific abdominal pain. A colonoscopy showed a bulky impassable lesion at 60 cm from the anal verge, with biopsy confirming moderately differentiated adenocarcinoma. A staging computed tomography (CT) scan showed a descending colon lesion without evidence of obstruction. There was no central lymphadenopathy or metastatic disease, and therefore she was staged as a cT3N0M0 descending colon adenocarcinoma. The surgical options for management of this lesion were left hemicolectomy or an extended resection, given that the proximal colon was not surveyed for synchronous lesions. The patient opted for a left hemicolectomy with early interval scope and proceeded to have a robotic left hemicolectomy. Our technique uses the Da Vinci Xi robotic platform. The patient is placed in the supine position, with a single docking system from the patient's left side. We use five ports which include an 8 mm right upper quadrant port (arm 1), 8 mm mid upper abdominal midline port (arm 2), 8 mm infraumbilical port (arm 3) and 12 mm left lower quadrant port (arm 4). An additional assistant 8 mm AirSeal port (ConMed) is placed in the right lateral position. We utilize a medial to lateral approach, first identifying and dissecting the inferior mesenteric vein and artery (IMV and IMA) and left colic vessels. We divide the IMV and left colic artery with a combination of Hemolock clips (Teleflex Inc.) proximally and vessel sealer. Dissection is then continued as far laterally as the descending colon and superiorly to the inferior border of the pancreas. The lesser sac is entered to mobilize the transverse colon and splenic flexure. There are two standard approaches – taking the omentum en bloc by dividing the gastrocolic ligament just below the gastroepiploic vessels or leaving the omentum in situ by dissecting between the omentum and colon. Our usual approach would be to take the omentum en bloc for any distal transverse colon cancer. However, with descending colon tumours without involvement of the omentum, aggressive resection may not be necessary. The splenic flexure is mobilized by dividing the gastrocolic ligament medially and mobilizing the descending colon laterally. Once mobile, the left branch of the middle colic vessel may be taken with the vessel sealer. The mesentery is then divided to the colon edge, and the colon divided proximally and distally. We use a Sureform (Intuitive Surgical, Inc.) 60 mm stapler with blue cartridges. We perform an intracorporeal stapled side-to-side isoperistaltic anastomosis using the Sureform 60 mm stapler with blue cartridges, with closure of the remaining colotomy in two layers. Vascularity is checked with indocyanine green, with 25 mg diluted in 10 mL of saline, using 3 mL at a time. We close the 12 mm port sites under vision with a Carter-Thomason closure device. The specimen is retrieved by extending the periumbilical port site along the midline. We routinely use a small wound protector. The total operating time was 159 min, with 112 min on the robotic console. The patient had an uneventful recovery and was discharged on day 2. Pathology revealed a pT3N0 moderately differentiated adenocarcinoma with lymphovascular invasion. The patient has subsequently undergone adjuvant chemotherapy. In conclusion, when a dual-console setup is available, the two-surgeon technique offers an excellent training opportunity and technical efficiency for robotic colorectal surgery. This video shows a robotic left hemicolectomy using a two-surgeon dual-console technique. This technique involves two surgeons, each at their own console, allowing all three instruments to be used simultaneously. This results in greater efficiency in dissection, a potentially shorter operating time with three active instruments, and importantly, a unique training approach. Disadvantages include the requirement for two robot-proficient surgeons and the availability of a dual console setup. The patient is a 43-year-old female with a left colon cancer. Colonoscopy was performed for investigation of altered bowel habit and nonspecific abdominal pain. This revealed a bulky circumferential lesion, 60 cm from the anal verge which was impassable by scope. CT showed the lesion in the splenic flexure extending to the proximal descending colon. There was no evidence of mesenteric or central lymphadenopathy, or metastatic disease. Therefore, this was staged as a cT3N0 colon cancer. Options were discussed with the patient. This included a left hemicolectomy or an extended resection, in light of the fact that the proximal colon was not surveyed for synchronous lesions. She elected for a left hemicolectomy with early interval follow-up colonoscopy. The planned operation was therefore a robotic left hemicolectomy. This diagram demonstrates the left hemicolectomy, which involves ligation of the left colic artery and left branch of the middle colic artery for lymph node harvest. We use the da Vinci Xi robotic platform, with a single docking system from the patient's left side, using a two right hand setting. We utilize five ports as shown. Port site 4 is a 12 mm port, to accommodate a robotic stapler. Dissecting instruments are placed in Port site 3, which is utilized by the junior surgeon or Surgeon 2. The senior surgeon or Surgeon 1 uses instruments through Port sites 1 and 4 and controls the camera. After pneumoperitoneum and port placements, laparoscopy is performed to exclude metastatic disease and the tattoo is identified to confirm tumour location. The patient is placed in Trendelenberg with left side up. The omentum is raised cranially and small bowel swept to the right. Gauze or an endoracheter can be used to retract the small bowel to the right if required. In this case, the tumour is visible in the proximal descending colon with the tattoo distal to it. The use of the three robotic arms can be seen here, with Surgeon 1 controlling graspers on arms 1 and 4, and Surgeon 2 controlling the scissors on arm 3. We use a medial to lateral dissection, starting with a sub-IMV approach, and separate the mesocolon from the retroperitoneum. In slender patients, as tissue planes are often very thin, care must be taken to stay in the right plane, ensuring that the retroperitoneum is pushed back. The IMV is identified and dissected. In this case, the IMA and its branches are closely associated and are dissected simultaneously. The left ureter is seen here. The IMV is identified here and separated from the artery. Here, dissection is aimed to clear the IMV at this level before we then dissect out the left colic artery. The left colic artery can be seen here branching from the IMA. Various methods can be used to take vessels such as the use of vascular staplers, Hemolocks or energy devices. Our preference is to use a combination of Hemolocks and the vessel sealer. The vessel is divided, preserving the IMA and superior rectal artery. The IMV is divided with a vessel sealer. Medial to lateral dissection is completed, as far laterally as the colon and superiorly until the inferior border of pancreas. The table is flattened, and the lesser sac is then entered to mobilize the distal transverse colon and splenic flexure. There are two standard approaches – taking the omentum en bloc by dividing the gastrocolic ligament just below the gastroepiploic vessels or leaving the omentum in situ by dissecting between the omentum and colon. Our usual approach would be to take the omentum en bloc for any distal transverse colon cancer. However, in this case the cancer is clearly in the proximal descending colon, with the omentum uninvolved. Therefore, we have not been as aggressive in taking all the omentum. The gastrocolic ligament is divided to the splenic flexure. The splenic flexure is then approached from the lateral side, to meet the dissection plane above. Here, we can see the colonic attachments being freed from the inferior border of pancreas, as part of the splenic flexure mobilization. Once the left colon and splenic flexure have been completely mobilized, the vasculature of the transverse colon is identified by tenting up the distal transverse colon. The left branch of the middle colic vessels is divided with a vessel sealer. The mesentery is then divided to the margin of the colon. A Sureform 60 mm blue robotic stapler is used to divide the colon. The distal margin is identified and divided in a similar manner. The specimen is placed in the upper abdomen. We perform an intracorporeal stapled side-to-side isoperistaltic anastomosis. The colon ends are aligned next to each other. Colotomy is then performed at each end. A Sureform 60 mm blue robotic stapler is inserted via Arm 4 and is used to create the anastomosis. The remaining colotomy is then closed in two layers, with continuous 3-0 Ethibond suture and a second layer of interrupted 3-0 Vicryl. Vascularity is confirmed with ICG. The specimen is grasped in preparation for retrieval, and the 12 mm port site is closed. The specimen can be extracted from the periumbilical site or a Pfannenstiel incision. In this case, we retrieved the specimen by extending the periumbilical port site along the midline. We routinely use a small wound protector. The total operating time was 159 min, of which 112 min was spent on the console. Estimated blood loss was 50 mL. The patient had an uneventful recovery and was discharged on day 2. Pathology revealed a pT3N0 moderately differentiated adenocarcinoma with lymphovascular invasion. The patient has since been receiving adjuvant chemotherapy. Geraldine J. Ooi: Conceptualization; writing – original draft; project administration; methodology; data curation; visualization. Vignesh Narasimhan: Methodology; conceptualization; data curation; writing – original draft; project administration. No funding was required for this submission. No relevant disclosures or conflicts of interest. Informed consent was obtained from the patient. This video demonstrates a unique technique for performing a robotic left hemicolectomy, using a dual console system with two surgeons. Data sharing is not applicable to this article as no new data were created or analyzed in this study. Video S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.