Lecture Notes: Robotic Sigmoid Resection

Presenter

• Dr. Mark Solomon

Overview

• Comprehensive walkthrough of a robotic sigmoid resection procedure.
• Emphasizes full procedure including typically edited-out transitions.
• Encourages watching previous videos on the 21 steps of the operation for more detail.

Case Context

• Patient: Middle-aged Caucasian female with recto-sigmoid adenocarcinoma.
• Surgical goal: Restore normal anatomy and perform medial lateral dissection.

Key Surgical Steps

Initial Setup

• Step 0: Restore normal anatomy.
  • Divide lateral attachments for optimal setup.
  • Elevate the recto-sigma junction at a 90-degree angle to the aorta.
  • Dissection of lateral attachments to identify the left ureter.

Medial Dissection

• Tent the recto-sigmoid junction anteriorly.
• Use the third arm of the robot to lift the mesentery and IMA pedicle.
• Identify the mesorectum and determine medial-lateral incision points.
• Preserve hypogastric nerves by pushing them down.

Identification of Structures

• Locate left ureter while maintaining cephalad and lateral dissection.
• Identify IMA, IMV, and the superior hemorrhoidal artery.
• Create a window around the IMA pedicle.

Lateral Mobilization

• Perform extensive medial mesenteric mobilization.
• Ensure blood vessels are properly oriented.
• Use third arm for consistent referencing during mesenteric division.

Post-Dissection Steps

Preparing for Anastomosis

• Use the scissors for a precise mesorectal division.
• Score the mesorectum and mesenteric tissue.
• Ensure accurate stapling by using open and close techniques for better tissue engagement.

Anastomotic Techniques

• Discusses the importance of avoiding multiple intersecting staple lines.
• Method: Bring the spike of the anvil through one side of the rectal cuff.

Final Steps

• Confirm perfusion with ICG.
• Finalize with anastomotic checks using endoscopic evaluation.
• Correct any potential weak spots with sutures.

Conclusion

• Highlights the importance of maintaining symmetry in dissection.
• Encourages reviewing the complete 21 steps in separate detailed series.
• Suggests leaving feedback and subscribing for further content updates.