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. 2021 Sep 24:48:e20213007.
doi: 10.1590/0100-6991e-20213007. eCollection 2021.

Technical essential aspects in robotic colorectal surgery: mastering the Da Vinci Si and Xi platforms

[Article in English, Portuguese]
Andre Luiz Gioia Morrell  1   2 , Alexander Charles Morrell-Junior  1   2 , Allan Gioia Morrell  1   2 , Elias Couto Almeida-Filho  3 , Duarte Miguel Ferreira Rodrigues Ribeiro  4   5 , Gladis Maria Pacileo Anchieta Rodrigues Ribeiro  4   5 , Francisco Tustumi  1 , Jose Mauricio Freitas Mendes  4   5 , Alexander Charles Morrell  1   2
Affiliations

Technical essential aspects in robotic colorectal surgery: mastering the Da Vinci Si and Xi platforms

[Article in English, Portuguese]
Andre Luiz Gioia Morrell et al. Rev Col Bras Cir. .

Abstract
in English, Portuguese

Background: laparoscopy surgery has many proven clinical advantages over conventional surgery and more recently, robotic surgery has been the emerging platform in the minimally invasive era. In the colorectal field, although overcoming limitations of standard laparoscopy, robotic surgery still faces challenging situations even by the most experienced colorectal surgeons. This study reports essentials technical aspects and comparison between Da Vincis Si and Xi platforms aiming to master and maximize efficiency whenever performing robotic colorectal surgery.

Methods: this study overviews the most structured concepts and practical applications in robotic colorectal surgery in both Si and Xi Da Vinci platforms. Possible pitfalls are emphasized and step-wise approach is described from port placement and docking process to surgical technique. We also present data collected from a prospectively maintained database.

Results: our early experience includes forty-four patients following a standardized total robotic left-colon and rectal resection. Guided information and practical applications for a safe and efficient robotic colorectal surgery are described. We also present illustrations and describe technical aspects of a standardized procedure.

Conclusion: performing robotic colorectal surgery is feasible and safe in experienced surgeons hands. Although the Da Vinci Xi platform demonstrates greater versatility in a more user-friendly design with technological advances, the correct mastery of technology by the surgical team is an essential condition for its fully robotic execution in a single docking approach.

Introdução:: a cirurgia laparoscópica demonstrou vantagens sobre a cirurgia convencional e, mais recentemente, a cirurgia robótica tem sido a plataforma emergente na era cirúrgica minimamente invasiva. Na prática colorretal, embora supere as limitações da laparoscopia, a cirurgia robótica ainda enfrenta situações desafiadoras, mesmo diante de cirurgiões colorretais experientes. Este estudo relata aspectos técnicos essenciais e comparação entre as plataformas Si e Xi Da Vinci com o objetivo de auxiliar e maximizar a eficiência na realização de cirurgia robótica colorretal regrada.

Métodos:: este estudo apresenta uma visão geral dos conceitos essenciais e aplicações práticas em cirurgia robótica colorretal nas plataformas Da Vinci Si e Xi. As potenciais dificuldades são enfatizadas e uma abordagem em etapas é descrita desde a colocação dos portais e seu processo de docking até a técnica cirúrgica. Também apresentamos brevemente dados coletados de um banco de dados mantido de forma prospectiva.

Resultados:: nossa experiência inicial inclui quarenta e quatro pacientes submetidos à cirurgia totalmente robótica padronizada na ressecção colônica e retal. Informações e aplicações práticas para uma cirurgia robótica colorretal segura e eficiente são descritas. Também são apresentadas ilustrações e dados breves da experiência.

Conclusão:: a cirurgia robótica colorretal é viável e segura nas mãos de cirurgiões experientes, no entanto ainda enfrenta desafios. Apesar da plataforma Da Vinci Xi demonstrar maior versatilidade em um design mais amigável com avanços tecnológicos, o correto domínio da tecnologia pela equipe cirúrgica é condição essencial para sua execução totalmente robótica em etapa única.

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Conflict of interest statement

Conflict of interest: no.

Figures

Figure 1
Figure 1. A. Patient positioning / B. Da Vinci Xi port placement.
Figure 2
Figure 2. A. Robotic targeting / B. IMA pedicle and peritoneum incision / C. Preservation of hypogastric nerves and retroperitoneal fascia / D. Isolation of the inferior mesenteric artery at 1cm from its origin.
Figure 3
Figure 3. A. Dissection developing the plane between the mesocolon and Gerota’s fascia / B. Isolation and ligation of the inferior mesenteric vein / C. Access of the lesses sac after identification of the upper border of the pancreas and peritoneum incision / D. Dissection toward the tail of the pancreas for a splenic flexure mobilization.
Figure 4
Figure 4. A. Initial lateral colonic mobilization by dividing the lateral peritoneal reflection / B. Bottom-up fashion colonic dissection along Toldt’ fascia / C. Division of the splenocolic ligaments and lateral attachments / D. Transverse colon retraction for gastrocolic ligament division.
Figure 5
Figure 5. A. Rectal dissection in the posterior avascular cleavage plane between the visceral and the parietal fascial sheets / B. Rectal artery isolated whenever not performing a total mesolectal excision / C. Rectum retraction and anterior dissection using monopolar scissors / D. Rectal division using a laparoscopic or robotic.
Figure 6
Figure 6. A. Colonic proximal margin settled and mesocolon division for specimen extraction / B. Rectal stump with a circular stapler prepared for a colorectal anastomosis / C. Conventional filter visualizing the colorectal anastomosis / D. Intravenous ICG and Firefly filter used accessing anastomosis integrity with real-time fluorescence guided image.
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