Robotic Sigmoid Resection Overview

I'm Dr. Mark Solomon and in this video I want to take you through the entirety of a robotic sigmoid resection from skin to skin showing you the high points. But not only that, I want to show you some of the parts that are typically edited out of videos which are the transitions between the critical segments of an operation. And speaking of critical segments of the operation, I have in previous videos broken down this operation into 21 steps. And if you haven't seen those videos, I do suggest you watch them either before or after this video. And while you're at it, please make sure you subscribe to the channel and click the bell to receive notifications for when I add content to this channel and many other series on this channel as well. Little case context, this is a middle-aged Caucasian female with a recto-sigmoid adenocarcinoma that has a tattoo in it and some filmy lateral adhesions. And really what I want to do is, again, walk you through the choreography of this operation, putting the entire thing together from start to finish. Let's get the video started. This is about an hour from start to finish, but I'm going to... speed through certain segments of the operation like the setup and certain more mundane parts of the operation. The very first thing that I end up wanting to do in these cases is restore the normal anatomy. What I always tell my fellows and anyone that will listen, step zero of the operation is to restore normal anatomy. That includes dividing any of these lateral attachments. So these aren't really that bad, but really what you want to do is you want to make sure that these lateral attachments are taken down so that you can set yourself up for medial lateral dissection as you elevate. the recto-sigma junction and an anterior orientation. And basically what you're trying to do is you're trying to tent the IMA pedicle at a 90 degree angle to the aorta. And the only way that you can do this is if the lateral attachments are taken. So this one isn't that bad, but in bad diverticulitis cases you really got to get those lateral attachments laced so that you can pull up the recto-sigma junction at a right angle. And right here we're just doing basically some lateral attachment dissection. looking for the interdigitating sigmoid fossa and immediately deep to that fossa is the left ureter. So we're going to continue this dissection. I'll speed up the video just a touch, put on 2x, some of those lateral attachments. And this is pretty good at this point. I could probably transition now to a medial dissection. And in just a second, you'll see the left ureter. All right. So here, this is where now I'll begin to go medially. This is really the start of the case. What you're trying to do here is you're trying to tent the recto sigmoid junction anteriorly, as you see. Bring the third arm of the robot in. I may back that video up just a little bit so you see it. Backing up, go forward. The rectus sigma junctum gets sent to anteriorly by having the third arm come underneath the second arm, fanning out the mesentery and lifting up on the IMA pedicle. Once that's done, you may have to readjust this a little bit, begin coming underneath. That's the best way to exchange those instruments to and from. to avoid internal and external collisions. Once things are tented up nicely, look for the sacral promontory. And what I do is I lift up the mesosigmoid and the rectosigmoid junction, and I'm looking for, I'll pause the video right here because it shows it pretty well, you'll see that there's the mesorectum here, which is this light yellowish color versus this darker yellowish color in this patient. What I'm going to do here is I'm jiggling the peritoneum, and I'm trying to predict the junction between that. retroperitoneum and the mesorectum and that's the exact point right there along that line right there that I'm going to want to make that medial lateral incision so you'll see here and you're gonna get a big plume of big plume of pneumo dissection into the presacral space jiggling the peritoneum make an incision some pneumo dissection we'll start kicking in right there So that's the start of the medial lateral section. If you have seen the videos on the 21 steps of a lower anterior section, it's very similar to a sigmoid section, with the exception of the entirety of the mesorectal dissection and the diverting loop ileostomy. And the immediate thing that I do here right when I start the medial lateral is I identify the hypogastric nerves, and I preserve them by pushing them down. So the hypogastric nerves get immediately identified, get pushed down. Third arm hasn't moved, second arm really isn't doing much other than lifting up the mesorectum directly anteriorly. I'm going to poke my left hand in, spread my left hand in, and then lift my left hand. So that poke, spread, and lift maneuver you will see constantly throughout every single one of my operative videos. Poke, spread, and lift, right there. And what that does is it prevents you from giving more of an aggressive lifting maneuver and ripping or shredding any of the mesentery. poke spread lift and what I'm doing here is I'm looking for the left ureter and as you see what I'm doing I first headed into the pre-circular space I'm looking for the left ureter still haven't found it quite yet but I'm doing so in a cephalad and lateral manner so as soon as I find the the aerial or tissue plane I start pushing that down push the hypogastric nerves down Looking for the left ureter. I'm going to keep poking, spreading, lifting, and there's the left ureter right there. Right up there. I just pointed with my mouse. And I'm going to continue this mesorectal and mesosigmoid dissection approximately until I can get all the way to the takeoff of the IMA from the aorta. So I'm going to speed the video up just a smidge. You see I'm going to exchange the third arm to lift up the dissection point. I'm going to keep chucking. I'm going to keep moving up proximally, taking down these embryological attachments, peeling the IMA off of the retroperitoneum and off of the aorta. And I'm looking for the junction of the IMA and aorta and the T-shaped takeoff. What I mean by T-shaped, the aorta is kind of the base. The IMA is the base of the T. And the horizontal aspects of the T are the superior hemorrhoidal heading to the right and the left colic heading to the left. Again, the third arm coming in lifting up. Aorta is down at the bottom of the screen. IMA is right here. Trying to make that right angle, make it look like a T. So the lymph node I just burned right there. Coming around this corner here, trying to look and create a window around the IMA pedicle. Doing this with the scissors. Keep working our way around, trying to create a window around the IMA here. And now you can see right there that window was just created. Below me is the aorta. Above me is the mesodescending colon, descending mesocolon rather. Some of these areolar tissue attachments. Just deep to that is going to be the the IMV. You can see the IMV right there and IMA right there in our face. Just approximately To the left here, left of the screen, is going to be the left colic artery. To the right here, this is where the IMA changes name to the superior hormonal. So this right here, from down here to about right there, this maybe, let's call that 2 to 3 centimeter stump, is the IMA pedicle itself. I'm going to come around it and divide it with the vesticeal. Now I made extremely light edits in this video, just so the instrument exchanges aren't so painful. So no, I don't have a magical robot or a magical assistant that... instrument exchange did take some time. When I come across it I'm a little bit obsessive with how I divide my vessels and typically seal about four times, check the seal to make sure it's okay, and then cut it. And I edited that out as you see. Alright, once that pedicle is divided, I hand the divided IMA pedicle to my third arm and lift it directly north, or directly anterior, to the anterior abdominal wall. I'm going to speed the video up a little bit and then continue my medial dissection by pushing down the retroperitoneal structures, pushing in left ureter, pushing down gerodotus fascia, continue heading laterally. It's not uncommon that I'll get a little bit too deep or a little bit too superficial. Anytime you see bleeding, it means you're in the wrong plane. So I continue in this lateral dissection. Now, this patient's skinny. There's no doubt. I'm not going to lie about that. But even in heavier patients, the descending mesocolon is actually very thin. So it's a good idea to make sure that you're not going too deep, digging too deep. And look at that nice little plane right there. Every patient has this. And in general, you want to make sure that all the blood vessels are going down, and then the yellow stuff is going up. So I'm a little too deep in this patient. So eventually I'm going to have to come through that bridging mesenteric vessel, that retroperitoneal vessel, bring it down. It's coming down there. I got too deep. I'm going to make up for it by dividing it and then pushing it down, trying to restore the actual embryological plane. I'm going to keep working my way laterally. And watch what I do with my third arm here. I'm starting to use it more. I'm going to poke spread lift with my third arm, poke spread and lift, pushing down the retroperitoneal attachments, working my way as lateral as I possibly can. And I'll do this until I've really gotten as much lateral mobilization. and proximal mobilization as I need. So this is one of the main reasons why I actually don't take flexure down every single case. Because I find that if you do enough of this medial mesenteric mobilization, taking off the descending mesocolon, essentially off of the aorta, what this affords is plenty of mesenteric length. And of course you gotta get lateral length, but getting lateral length is not that difficult. It's the medial length that usually holds you up or the medial attachments. So if you take the mesenteric insertion points high enough the entire descending mesocolon and left colon will slide down into the pelvis mitigating a lot of the times the need for a splenic flexural mobilization, but there's no doubt I still have to take it down. I just don't have to take it on every case. As you see this lady had a pretty floppy Sigma and descending colon. So we're getting enough length there. I'm gonna bring in my scissors and I pick a midpoint. Let me pause this for a second here. So once I've done all that medial dissection, you saw IMV back there just a little bit ago. I don't necessarily take the IMV in every single case. Let me back the video up a little. If I wanted to take the splenic flexure down, what I would have done after IMA division, I would have continued in this direction here to the left of screen. There's duodenal-jejunal junction to your left. And I would have continued to the left, i.e. cephalad, and taken down the IMV as well. And if that wasn't enough to get me to where I needed, I would have then gone to the above the pancreas. And I have a video that I'll link in the description and in the card above showing the next steps on how to take a splenic flexure down. Once I've done the medial dissection, as far as I need to go, proximal and distally, I'm going to go now laterally. Put my scissors in, and then I'm going to basically pick a... point on the mid part of the lateral attachments anywhere, doesn't really matter, just get in a white line and basically make a nice full thickness incision into my previously dissected medial plane. So I'm trying to mature the dissection to meet the dissection that I did medially, I'm now trying to find it laterally. And look, there's nothing else other than some filmy lateral attachments. So I'm taking these lateral attachments from top to bottom, rather than this case, from the midpoint of the sigmoid say, all the way up as proximally as I need to go. In this case, I'm probably going to head up to the spundic flexure but not take the entire flexure down. Take all this down. That's a pretty quick dissection here because we've done a lot of the work immediately. And then once I've done that proximally as far as I need to go, I'm now going to go distally. So I'm going to meet my midpoint wherever I started at the midpoint on the left. And then I'm going to enter in the pre-circle space and just continue dividing the lateral attachments as far distally as I need to go. And typically in this case, in these cases, I'll take that down to either the partner reflection or just basically to meet where I started the dissection on the right-hand side. So wherever I started to meet a lot of dissection, I want to even out the dissection. So it's a good practice to maintain symmetry at all times in all these cases, especially a low anterior section. And it's critically important that when you start doing this stuff, you have to maintain symmetry, especially when doing an LAR. You've got to make sure you've done all the proximal division first or proximal ablation first. So that's the setup there for the pre-sequitur section. And as you saw what I did was I set up everything with my left and right hand. I'm going to back the camera up a little bit. I'm going to rewind it. Okay. So my left and right hand here, left hand here, right hand here, set up. It pulls up the mesorectum, cephalad, or actually anteriorly. The third arm is going to come in with the tip pointing away. It's going to grab the mesorectum at the recto-sigmoid junction, pinch, pull, and pull to the head. And they can see right there, it gives me exposure to the pelvis no problem. Now I'm going to do a little bit of a TME on this case because the lady had a recto-sigmoid tumor. Even though I consider this still basically a sigmoid or a section, it represents a lot of what a TME would look like as well, or tumor-specific mesorectal excision. So once I get into the presacral space, this is what I'm highlighting here in this video, is something that's pretty important. I highlighted it in a previous video about how to do the TME. It's very easy to get too deep on the TME dissection. And look at what my left hand is doing. My left hand is at a right angle, poking at the midline of the mesorectum, and lifting anteriorly, kind of in a circular motion. And what I'm going to point out here is how easy it is to get too deep. So I'm starting up here. It's very tempting to start down there where my mouse is mousing over. If you start down here, pretty easily you're going to scoop up the pre-sacral venous plexus, hypogastric nerves, nerve right, erythrocentes, all sorts of bad stuff is down here. So you want to be very careful that when you start this dissection, start where the nerves are not, which are up here. So you want to make sure you're above the nerves, push the nerves down. You can kind of see the filmy nerves right there. Those are the hypogastric nerve plexus. That's where they are. You want to make sure you're above that when you start this section. And what's happening here off screen, you can't even see it, is my left hand is doing nearly all of the work. My left hand is at a right angle. I'm poking right in the dead center. I'm poking, I'm pushing, and I just did it there. It's almost in a circular motion. I'm poking in the midline. I'm lifting anteriorly towards the abdominal wall, and then I'm pulling to the head. I'm pushing in the midline. Lifting anterior and I'm pulling to the head and I'm doing this constantly and I'm kind of reiterating the motion after every single After every single repositioning maneuver here and what you're gonna see As I'm going, I'm always starting the TME dissection at the dead center, right at the posterior midline. And then I'm going to mature the mesorectal dissection to the left. And the way I'm doing this is I'm pushing my left-handed instrument control-out of this. I'm pushing it to the right. When I'm doing the left-sided dissection, I'm pushing my left-handed instrument to the right. Give myself counter-traction. I'm going to do the exact same thing, but opposite, on the right. See here? Starting to dead center, work my way to the patient's right, and as I get to the pelvic side wall, I'm pulling the mesorectum as hard, basically as much as I can to the left. And why am I doing that? Is I'm trying to avoid entirely putting a hole in the pelvic side wall. It's very easy to get a little too deep, so that's why it's really important to really crank that rectum to the opposite side, pulling it away from the pelvic side wall. Now it looks like I'm repositioning here my third arm, which I don't normally have to do, but don't fight it, of course, if you have to. So what I'm doing here is I think the posterior dissection is pretty much done. So now I'm going to start taking the lateral attachments. And lateral attachments here, taking it down to just distal to the tumor. I'll speed the video up a little bit. Going just distal to the tumor. Give myself some counter traction there. Liberal use of the bipolar. Getting below the tattoo there. And I'll do that dissection on the left. I'm going to make it symmetric and always go to the exact same thing on the right. Get it nicely set up. Always come underneath your third arm. Sorry, bring your third arm always underneath your second arm. We'll start working on continuing the posterior mesorectal dissection here. Always start at the dead center, dead center, dead center. Work your way to the left, then work your way to the right. See the presicrovenous plexus right there in the middle? Everything you can to avoid that obviously. And I definitely went a little bit overboard on the pre-circular dissection or the mesorectal dissection. But I tend to do that on my sigmoid resections as well, even for diverticulitis, because I like being able to straighten the rectum out. It makes the EA staple much easier to bring up. Also, it gives a decent amount of practice for myself and my fellows when we do these dissections. And as you see, what we're doing now is just double-screen here, picture in picture. And we're getting the colonoscope set up. And what I'm going to do is just double check the distal margin of the tumor to make sure that there's no concern for the distal margin. I'm just finishing up the right lateral dissection here. You see we're well below tattoo. I'm not even going to take the anterior prontoneflexion in this case. Just got plenty of posterior mobilization done. And I'm estimating we're going to end up dividing, of course, just below the tattoo, but it was a pretty superficial adenocarcinoma, and I couldn't feel it or see it. All I saw was tattoo, but I always trust but verify. Speed it up a little bit more. The scope's going in. You can see the endoscopic image to the left there, and there's the lower edge of the tumor. I'm pretty happy that we're going to end up being just below the tattoo, and indeed I'm confirming what my gastroenterologist colleagues have outlined for me. We're going to then score the mesorectum. It's important here, I think, to really keep yourself honest here. And what that involves is I circumferentially score the rectum and the mesorectum. So I'm going to actually, I just went a little bit out of frame here. You don't quite see it in this picture, but I have actually scored circumferentially, scored on the rectum itself right there. So I know exactly where to divide the mesorectum and where to divide the rectum as well. I'm doing the posterior circumferential. scoring right now. And this is really just for more landmarks so that when I start coming through the mesorectum, I know exactly where I'm going so I don't skive too much. Speed this up a little bit. Now this posterior mesorectal dissection and the mesenteric division, mesorectal division, can be done with scissors or with a vessel sear. And I mean, it depends on the case and depends on the anatomy of the patient, but I'll typically almost always use the... the scissors for these patients. Then once they, if the bleeding gets bad, the superior haremortal is difficult to identify or whatever the case may be, I will liberally switch back to a vessel sealant. But in this case, what we'll do is we'll basically skeletonize, skinny down, and find the superior haremortal, divide it with the bipolar. And here, already, pretty much you can see the rectum there. Patient had very favorable anatomy, of course, as you can tell. Finally separate hermortil, dividing it, bringing the vestibular in to take it. Just again, I edited out, very lightly edited out the instrument exchanges in this video just to save everyone of the pain waiting for the instruments to come in. Finishing up these mesorectal attachments here. Doing so basically perpendicular to the rectum itself. Speed it up. And once this is done circumferentially, I'm gonna bring in a stapler. Most typical, if it's a sigmoid dissection, I will almost always use a blue load. In this case, since we're a proximal rectum, I'm gonna guess I was using a green load, but we'll find out here in a second. Pretty sure it's a green load. One little tip here that I have, stapling. There's going to be a time where you just can't quite get across the recto sigmoid with a single fire of a 45 blue or 45 green or whatever you have. So this is the trick. I go to 100% clamp on the robot, put my two arms, my left hand here, my third arm there, basically kind of straddle the stapler. Make sure it's clamped down 100%. Make sure you get a full clamp. And then I'm going to open the stapler, advance it a little bit more. There's a tip I picked up in residency that allows you to get a little bit more tissue into the stapler, not forcing it or cramming it. You definitely don't want to do that, but just allowing that first clamp to push out any of the edema and fluid that's in the tissue, and then opening the stapler in advance to get just a little bit more affords a little bit more tissue safely within the stapler. Now we're going to clamp down, make sure we're at 100% clamp, and then fire the stapler. Speed up the video. Now we've divided the mesorectum, we've divided the rectum, now I'm going to find my proximal division point. Put the Vestal Sealer in next, rotate the sigmoid colon out of the pelvis. Looking for the descending sigmoid junction, I'm going to tent the descending sigmoid junction that I anticipate will be my anastomotic site. I'm going to hold that now to the anterior midline. And what I did was once I figured out that's a good spot for the dissection to be, I flip the specimen back into the pelvis. I'm going to now find the divided IMA pedicle, adjusting my proximal division point. Now I'm going to find the proximal division point of my IMA pedicle. I want to keep that with the specimen because that's where all the lymphovascular is. All the lymph nodes are harvested. There's a lymph node to the right. It was just at a frame there. Now I'm going to start double burning there with the specimen to the right, i.e. the IMA pedicle to the right. And then I'm going to, with a vessel sealer, double burn on the mesentery from that point there with the IMA pedicle all the way up to my third arm. It is incredibly important to make sure that you're using your third arm, very liberally in these cases, as a reference point for where to divide the mesorectum, or rather the mesosigmoid or mesodescending colon in this case. If you don't have a fixed third arm that you're referencing constantly, it's very, very, very easy, incredibly easy, please take it from me, to deviate. You can go to the left and actually accidentally take the descending colon or the proximal aspect of it, or hang a right and end up hitting it. at the recto sigmoid. So I'm using my third arm, constantly referencing it exactly where to take the mesentery in which direction to point the vessel sealer so that I don't mess up the mesenteric division, which is arguably one of the more important parts of the operation. Here I'm just skinning down the final attachments of the mesentery with the vessel sealer and I'm announcing the anesthesia. I need 2.5 cc of ICG with a 10 cc flush right now. Right, the second I take that last little bit of attachment, that's when I ask for the ICG, and in just a second, we'll see it go in. Checking for length again, it's looking pretty good. Speed the video, ICG goes in, and everything is illuminating quite nicely. Very nice. Anvo just went in. Now, how did that go in? Well, that's for another video I think. But basically what I ended up doing in that case, and pretty much all my cases now, is my bedside assist will remove the stapler port, extend the skin incision, usually just a little bit, and basically in the most delicate and elegant way possible, shove the anvil into the abdomen. And it typically will require... A little bit of stretching of the fascia and peritoneum. Of course, larger patients, deeper sub-Q is a little more difficult, but whatever works typically. Now I'll do this in a couple different ways. I'll divide the descending sigmoid junction either with the scissors or the vessel sealer. Actually, I find that the vessel sealer gives you a much straighter cut, and so I tend to favor that way. As you see right here, a 3-0 V-lock just went in the abdomen. Probably getting a little bit impatient here, so I'm going to start suturing with a vessel sealer until my needle driver comes in. But most traditionally, I'm going to use a needle driver, a non-cutting large needle driver. And I start at the 7 o'clock position on the descending colon conduit here. And I start at the 7 o'clock position. I'll speed the video up a little bit. I'm holding up with my third arm about 4 centimeters proximal to that cuff. And once the needle driver goes in, we'll get this thing completed. Needle driver goes in, I've started at the 7 o'clock position on the cuff, going in to out, and then I'm going to work my way around the descending colon conduit in this cuff. In an in-to-out fashion, sewing in a baseball stitch configuration, in-to-out, in-to-out, in-to-out. Now I do this in about a 1 cm increment. I travel about a centimeter and take about a half centimeter bite each time. Now I know the measurements because The fenestrated bipolar mode, which is my left-hand instrument, I've said it in different videos, my left-handed instrument, the width of it is 5 millimeters. Opened jaw-to-jaw or tip-to-tip is 2 centimeters, so I kind of split the difference between the two, and that's about a centimeter. I travel a centimeter, take a half a centimeter or a 5 millimeter bite each time, and I typically go from 7 o'clock, run it in a clockwise fashion, back to 7 o'clock. Once I get that done, go back to where I started. Third arm's going to grab at the 12 o'clock position. Left hand's going to pull down in the 6 o'clock position, once I get the anvil. Pull down in the 6 o'clock position, get the anvil in place, cinch down the suture, grab the descending colon conduit, cinch it down tight. Probably the majority of the cases I end up having to do a second round with this same suture. Sometimes the cuff doesn't cinch down nice enough. And so what I'll do in this case is I'll run around a second time with the same V-lock. And that's why I don't cut the needle off. And more and more regularly what I do is actually take a vical endo loop. And just cinch that down real tight around the cuff of the descent and colon conduit. right around the base of the anvil there. And I've liked that more and more, but this certainly works because the suture's already in. It works nice and it works just fine. So run around a second time here. Speed up the video a little bit. And I always like to keep the needle attached because if I find another tick, I can keep running around if I need to. And then what I'll do is, just like we would do in an open case, I'm going to get scissors in there. And we would clean off the mesentery. And these open cases, when we do the extra-crop wall fixation of the anvils, we get a right angle and start bovying, and it's exactly what I'm going to do here on this robotic case. So there's nothing different. The technique is identical. It's just using a different instrument, basically. So we're going to get this set up, exchanging the third arm, so I can get good exposure, skinny down the mesentery. I'll speed the video up. Getting it down nice and symmetric all the way around, nice and flat. Of course, there's a delicate balance of not burning the bowel like I just did there, even though it's very superficial, and not devascularizing it, but just having it just enough to where you can see what you're doing. Make sure everything is nice and hemostatic. Checking the orientation. Cutting the suture. Handing it to my assist. And now setting up for the anastomosis. Place the specimen in the right lower quadrant. Get it out of your face. And then let your assistant go down. Start doing the transdental dilatation with the EEA sizers. I use a vestless here for this. Checking the orientation right there. IMA. Actually looks like I'm going to get some more length. There's IMA. You can see it right there. Inserting to the splenic vein. It's actually just nice anatomy there, making sure we have plenty of length. And again, don't forget, we mobilize a ton of rectum, so the rectum comes out really nicely in this case. And in most cases, even the larger patients, whatever the case may be, there's plenty of mobilization of the rectum. Clean the camera off. Assistant is down, EA sensors are going up, second sensor went up, now the stipper is going to go up. I'll go to 2x speed. Now typically what I do is, as you see right there, I like to bring out a spike to one side of the rectal cuff. I'll link to the video the reason why. But I'll briefly say as this anastomosis is getting constructed. The less number of intersecting staple line points you can do, the better for the patient. Which is why I now abhor these anastomosis where we bring the spike of the stapler through the direct midline of the stapler, of the transverse staple line of the rectum, and we have the stapler on the EEA anvil side through the middle of the staple line there. So you've converted something now to O. quadruple staple line intersecting staple line technique. So what I do here, and several studies that support this, is bringing the anvil spike, the transanal anvil spike, through one side of the rectal cuff so that you only have one intersecting staple line point. In this case, I brought it out to the patient's left-sided stump, the left side of the stump, and I'm checking mesenteric orientation here just to make sure we're nicely oriented. And what that does is back to the anastomotic surface, there's only one intersecting staple line on the right-hand side here of the anastomosis, which is right to the right here. And that's acceptable. I'm going to link to a video that I talked about this, that showed an anastomotic leak rate of, actually in this study, zero when you have zero intersecting staple lines, or zero when you have one intersecting staple line. But when you had two intersecting staple lines, the leak rate in that study went up to 12%. I do whatever I can to not have these intersecting staple lines occur. Speed the video up a little bit here. E-A-Sizer gets fired. See to my left, my assist is just about to bring the colonoscope up. Pelvis gets instilled with saline. Clamp off with the third arm. Make sure we're hemostatic. Very, very, very liberal use of any energy down here. If there's any issues, I mean, I'll get a 3-O Vicryl out or something like that to suture off any bleeding, but anything superficial like that, not too bad. So I just reinjected ICGs. You see, it looks very nicely perfused. I'm very happy with it. The rectum always comes in in terms of perfusion after the sigmoid, very nicely perfused. And the endoscopic image on the left, you'll see... It's not the best image, but you'll see that we're distending up quite nicely. It'll get nice. There's the anastomosis there. There it is. And it looks intact, not bleeding. Distending up decently, actually. Not the best. That's pretty much it. So I'll speed this up a little bit more. And I did see that there's a little bit of a thermal hickey, let's call it, on the left side of the anastomosis there. So I'm going to go ahead and just put an interrupted suture just to cover that. Remember, this is actually a case observation day. Most people actually missed that. They didn't see why I was doing that. But now I'm reviewing the video. I'm really glad I did. And that's the cool thing about robotics is that you're not really limited to doing stuff like this. So if you ever worry about it, I just throw a stitch in it. Makes me feel a whole lot better. I sleep better. Even though it probably wasn't going to be an issue. But, I mean, the last thing I wanted to do was try to get away with something. So, at least I know that I did everything possible. And it was technically pretty easy to do. Obviously, this is a really easy spot. But even the lower, even if there's a low, low, low colorectal, even a coloanal, I've over-sown defects in the astimosis or weaker spots in the astimosis for these ultra-low colorectal anastomosis. You see I used the Vessel Seeder to suture that, which you can certainly do. The Vessel Seeder works as a decently off-label needle driver. Not the most delicate instrument for that, but it certainly works. Unclamp. Now I'm switching back to full screen view. Now what I'm going to do is my Vessel Seeder is going to go away. I'm going to switch the master controls on the console here in just a second. So that arms number one and two are now my left and right hands. I dunk the specimen into a specimen bag, pull the specimen out through the extension of the staple port, and we're done with the case. All right, that about wraps up this video on a skin-to-skin robotic sigmoid, but let's call it a kind of a semi-law and terror section, and how I do it, the choreography for the entire thing. Now, if you're interested, I have an entire video series on exactly how... every single step of this operation is done into the 21 steps of the operation and how best to do it how to do it in multiple different ways all the different nuances tips and tricks on how to get them done but this operation that i just showed here i hope shows kind of how you put it all together let me know down in the comments if you do anything differently and please subscribe to the channel as i'm adding content to this series and many others pretty regularly thanks take care

Little case context, this is a middle-aged Caucasian female with a recto-sigmoid adenocarcinoma that has a tattoo in it and some filmy lateral adhesions. And really what I want to do is, again, walk you through the choreography of this operation, putting the entire thing together from start to finish. Let's get the video started.

This is about an hour from start to finish, but I'm going to... speed through certain segments of the operation like the setup and certain more mundane parts of the operation. The very first thing that I end up wanting to do in these cases is restore the normal anatomy. What I always tell my fellows and anyone that will listen, step zero of the operation is to restore normal anatomy.

That includes dividing any of these lateral attachments. So these aren't really that bad, but really what you want to do is you want to make sure that these lateral attachments are taken down so that you can set yourself up for medial lateral dissection as you elevate. the recto-sigma junction and an anterior orientation. And basically what you're trying to do is you're trying to tent the IMA pedicle at a 90 degree angle to the aorta.

And the only way that you can do this is if the lateral attachments are taken. So this one isn't that bad, but in bad diverticulitis cases you really got to get those lateral attachments laced so that you can pull up the recto-sigma junction at a right angle. And right here we're just doing basically some lateral attachment dissection. looking for the interdigitating sigmoid fossa and immediately deep to that fossa is the left ureter.

So we're going to continue this dissection. I'll speed up the video just a touch, put on 2x, some of those lateral attachments. And this is pretty good at this point.

I could probably transition now to a medial dissection. And in just a second, you'll see the left ureter. All right. So here, this is where now I'll begin to go medially. This is really the start of the case.

What you're trying to do here is you're trying to tent the recto sigmoid junction anteriorly, as you see. Bring the third arm of the robot in. I may back that video up just a little bit so you see it. Backing up, go forward. The rectus sigma junctum gets sent to anteriorly by having the third arm come underneath the second arm, fanning out the mesentery and lifting up on the IMA pedicle.

Once that's done, you may have to readjust this a little bit, begin coming underneath. That's the best way to exchange those instruments to and from. to avoid internal and external collisions. Once things are tented up nicely, look for the sacral promontory. And what I do is I lift up the mesosigmoid and the rectosigmoid junction, and I'm looking for, I'll pause the video right here because it shows it pretty well, you'll see that there's the mesorectum here, which is this light yellowish color versus this darker yellowish color in this patient.

What I'm going to do here is I'm jiggling the peritoneum, and I'm trying to predict the junction between that. retroperitoneum and the mesorectum and that's the exact point right there along that line right there that I'm going to want to make that medial lateral incision so you'll see here and you're gonna get a big plume of big plume of pneumo dissection into the presacral space jiggling the peritoneum make an incision some pneumo dissection we'll start kicking in right there So that's the start of the medial lateral section. If you have seen the videos on the 21 steps of a lower anterior section, it's very similar to a sigmoid section, with the exception of the entirety of the mesorectal dissection and the diverting loop ileostomy.

And the immediate thing that I do here right when I start the medial lateral is I identify the hypogastric nerves, and I preserve them by pushing them down. So the hypogastric nerves get immediately identified, get pushed down. Third arm hasn't moved, second arm really isn't doing much other than lifting up the mesorectum directly anteriorly.

I'm going to poke my left hand in, spread my left hand in, and then lift my left hand. So that poke, spread, and lift maneuver you will see constantly throughout every single one of my operative videos. Poke, spread, and lift, right there.

And what that does is it prevents you from giving more of an aggressive lifting maneuver and ripping or shredding any of the mesentery. poke spread lift and what I'm doing here is I'm looking for the left ureter and as you see what I'm doing I first headed into the pre-circular space I'm looking for the left ureter still haven't found it quite yet but I'm doing so in a cephalad and lateral manner so as soon as I find the the aerial or tissue plane I start pushing that down push the hypogastric nerves down Looking for the left ureter. I'm going to keep poking, spreading, lifting, and there's the left ureter right there.

Right up there. I just pointed with my mouse. And I'm going to continue this mesorectal and mesosigmoid dissection approximately until I can get all the way to the takeoff of the IMA from the aorta.

So I'm going to speed the video up just a smidge. You see I'm going to exchange the third arm to lift up the dissection point. I'm going to keep chucking.

I'm going to keep moving up proximally, taking down these embryological attachments, peeling the IMA off of the retroperitoneum and off of the aorta. And I'm looking for the junction of the IMA and aorta and the T-shaped takeoff. What I mean by T-shaped, the aorta is kind of the base. The IMA is the base of the T.

And the horizontal aspects of the T are the superior hemorrhoidal heading to the right and the left colic heading to the left. Again, the third arm coming in lifting up. Aorta is down at the bottom of the screen. IMA is right here. Trying to make that right angle, make it look like a T.

So the lymph node I just burned right there. Coming around this corner here, trying to look and create a window around the IMA pedicle. Doing this with the scissors.

Keep working our way around, trying to create a window around the IMA here. And now you can see right there that window was just created. Below me is the aorta. Above me is the mesodescending colon, descending mesocolon rather. Some of these areolar tissue attachments.

Just deep to that is going to be the the IMV. You can see the IMV right there and IMA right there in our face. Just approximately To the left here, left of the screen, is going to be the left colic artery.

To the right here, this is where the IMA changes name to the superior hormonal. So this right here, from down here to about right there, this maybe, let's call that 2 to 3 centimeter stump, is the IMA pedicle itself. I'm going to come around it and divide it with the vesticeal. Now I made extremely light edits in this video, just so the instrument exchanges aren't so painful. So no, I don't have a magical robot or a magical assistant that...

instrument exchange did take some time. When I come across it I'm a little bit obsessive with how I divide my vessels and typically seal about four times, check the seal to make sure it's okay, and then cut it. And I edited that out as you see. Alright, once that pedicle is divided, I hand the divided IMA pedicle to my third arm and lift it directly north, or directly anterior, to the anterior abdominal wall.

I'm going to speed the video up a little bit and then continue my medial dissection by pushing down the retroperitoneal structures, pushing in left ureter, pushing down gerodotus fascia, continue heading laterally. It's not uncommon that I'll get a little bit too deep or a little bit too superficial. Anytime you see bleeding, it means you're in the wrong plane.

So I continue in this lateral dissection. Now, this patient's skinny. There's no doubt. I'm not going to lie about that.

But even in heavier patients, the descending mesocolon is actually very thin. So it's a good idea to make sure that you're not going too deep, digging too deep. And look at that nice little plane right there.

Every patient has this. And in general, you want to make sure that all the blood vessels are going down, and then the yellow stuff is going up. So I'm a little too deep in this patient. So eventually I'm going to have to come through that bridging mesenteric vessel, that retroperitoneal vessel, bring it down.

It's coming down there. I got too deep. I'm going to make up for it by dividing it and then pushing it down, trying to restore the actual embryological plane.

I'm going to keep working my way laterally. And watch what I do with my third arm here. I'm starting to use it more.

I'm going to poke spread lift with my third arm, poke spread and lift, pushing down the retroperitoneal attachments, working my way as lateral as I possibly can. And I'll do this until I've really gotten as much lateral mobilization. and proximal mobilization as I need.

So this is one of the main reasons why I actually don't take flexure down every single case. Because I find that if you do enough of this medial mesenteric mobilization, taking off the descending mesocolon, essentially off of the aorta, what this affords is plenty of mesenteric length. And of course you gotta get lateral length, but getting lateral length is not that difficult. It's the medial length that usually holds you up or the medial attachments.

So if you take the mesenteric insertion points high enough the entire descending mesocolon and left colon will slide down into the pelvis mitigating a lot of the times the need for a splenic flexural mobilization, but there's no doubt I still have to take it down. I just don't have to take it on every case. As you see this lady had a pretty floppy Sigma and descending colon. So we're getting enough length there. I'm gonna bring in my scissors and I pick a midpoint.

Let me pause this for a second here. So once I've done all that medial dissection, you saw IMV back there just a little bit ago. I don't necessarily take the IMV in every single case. Let me back the video up a little. If I wanted to take the splenic flexure down, what I would have done after IMA division, I would have continued in this direction here to the left of screen.

There's duodenal-jejunal junction to your left. And I would have continued to the left, i.e. cephalad, and taken down the IMV as well. And if that wasn't enough to get me to where I needed, I would have then gone to the above the pancreas. And I have a video that I'll link in the description and in the card above showing the next steps on how to take a splenic flexure down. Once I've done the medial dissection, as far as I need to go, proximal and distally, I'm going to go now laterally.

Put my scissors in, and then I'm going to basically pick a... point on the mid part of the lateral attachments anywhere, doesn't really matter, just get in a white line and basically make a nice full thickness incision into my previously dissected medial plane. So I'm trying to mature the dissection to meet the dissection that I did medially, I'm now trying to find it laterally.

And look, there's nothing else other than some filmy lateral attachments. So I'm taking these lateral attachments from top to bottom, rather than this case, from the midpoint of the sigmoid say, all the way up as proximally as I need to go. In this case, I'm probably going to head up to the spundic flexure but not take the entire flexure down. Take all this down.

That's a pretty quick dissection here because we've done a lot of the work immediately. And then once I've done that proximally as far as I need to go, I'm now going to go distally. So I'm going to meet my midpoint wherever I started at the midpoint on the left. And then I'm going to enter in the pre-circle space and just continue dividing the lateral attachments as far distally as I need to go.

And typically in this case, in these cases, I'll take that down to either the partner reflection or just basically to meet where I started the dissection on the right-hand side. So wherever I started to meet a lot of dissection, I want to even out the dissection. So it's a good practice to maintain symmetry at all times in all these cases, especially a low anterior section. And it's critically important that when you start doing this stuff, you have to maintain symmetry, especially when doing an LAR. You've got to make sure you've done all the proximal division first or proximal ablation first.

So that's the setup there for the pre-sequitur section. And as you saw what I did was I set up everything with my left and right hand. I'm going to back the camera up a little bit. I'm going to rewind it. Okay.

So my left and right hand here, left hand here, right hand here, set up. It pulls up the mesorectum, cephalad, or actually anteriorly. The third arm is going to come in with the tip pointing away.

It's going to grab the mesorectum at the recto-sigmoid junction, pinch, pull, and pull to the head. And they can see right there, it gives me exposure to the pelvis no problem. Now I'm going to do a little bit of a TME on this case because the lady had a recto-sigmoid tumor.

Even though I consider this still basically a sigmoid or a section, it represents a lot of what a TME would look like as well, or tumor-specific mesorectal excision. So once I get into the presacral space, this is what I'm highlighting here in this video, is something that's pretty important. I highlighted it in a previous video about how to do the TME. It's very easy to get too deep on the TME dissection. And look at what my left hand is doing.

My left hand is at a right angle, poking at the midline of the mesorectum, and lifting anteriorly, kind of in a circular motion. And what I'm going to point out here is how easy it is to get too deep. So I'm starting up here. It's very tempting to start down there where my mouse is mousing over.

If you start down here, pretty easily you're going to scoop up the pre-sacral venous plexus, hypogastric nerves, nerve right, erythrocentes, all sorts of bad stuff is down here. So you want to be very careful that when you start this dissection, start where the nerves are not, which are up here. So you want to make sure you're above the nerves, push the nerves down. You can kind of see the filmy nerves right there. Those are the hypogastric nerve plexus.

That's where they are. You want to make sure you're above that when you start this section. And what's happening here off screen, you can't even see it, is my left hand is doing nearly all of the work.

My left hand is at a right angle. I'm poking right in the dead center. I'm poking, I'm pushing, and I just did it there.

It's almost in a circular motion. I'm poking in the midline. I'm lifting anteriorly towards the abdominal wall, and then I'm pulling to the head. I'm pushing in the midline.

Lifting anterior and I'm pulling to the head and I'm doing this constantly and I'm kind of reiterating the motion after every single After every single repositioning maneuver here and what you're gonna see As I'm going, I'm always starting the TME dissection at the dead center, right at the posterior midline. And then I'm going to mature the mesorectal dissection to the left. And the way I'm doing this is I'm pushing my left-handed instrument control-out of this. I'm pushing it to the right. When I'm doing the left-sided dissection, I'm pushing my left-handed instrument to the right.

Give myself counter-traction. I'm going to do the exact same thing, but opposite, on the right. See here? Starting to dead center, work my way to the patient's right, and as I get to the pelvic side wall, I'm pulling the mesorectum as hard, basically as much as I can to the left. And why am I doing that?

Is I'm trying to avoid entirely putting a hole in the pelvic side wall. It's very easy to get a little too deep, so that's why it's really important to really crank that rectum to the opposite side, pulling it away from the pelvic side wall. Now it looks like I'm repositioning here my third arm, which I don't normally have to do, but don't fight it, of course, if you have to. So what I'm doing here is I think the posterior dissection is pretty much done.

So now I'm going to start taking the lateral attachments. And lateral attachments here, taking it down to just distal to the tumor. I'll speed the video up a little bit. Going just distal to the tumor. Give myself some counter traction there.

Liberal use of the bipolar. Getting below the tattoo there. And I'll do that dissection on the left.

I'm going to make it symmetric and always go to the exact same thing on the right. Get it nicely set up. Always come underneath your third arm. Sorry, bring your third arm always underneath your second arm. We'll start working on continuing the posterior mesorectal dissection here.

Always start at the dead center, dead center, dead center. Work your way to the left, then work your way to the right. See the presicrovenous plexus right there in the middle?

Everything you can to avoid that obviously. And I definitely went a little bit overboard on the pre-circular dissection or the mesorectal dissection. But I tend to do that on my sigmoid resections as well, even for diverticulitis, because I like being able to straighten the rectum out. It makes the EA staple much easier to bring up. Also, it gives a decent amount of practice for myself and my fellows when we do these dissections.

And as you see, what we're doing now is just double-screen here, picture in picture. And we're getting the colonoscope set up. And what I'm going to do is just double check the distal margin of the tumor to make sure that there's no concern for the distal margin. I'm just finishing up the right lateral dissection here. You see we're well below tattoo.

I'm not even going to take the anterior prontoneflexion in this case. Just got plenty of posterior mobilization done. And I'm estimating we're going to end up dividing, of course, just below the tattoo, but it was a pretty superficial adenocarcinoma, and I couldn't feel it or see it. All I saw was tattoo, but I always trust but verify.

Speed it up a little bit more. The scope's going in. You can see the endoscopic image to the left there, and there's the lower edge of the tumor.

I'm pretty happy that we're going to end up being just below the tattoo, and indeed I'm confirming what my gastroenterologist colleagues have outlined for me. We're going to then score the mesorectum. It's important here, I think, to really keep yourself honest here.

And what that involves is I circumferentially score the rectum and the mesorectum. So I'm going to actually, I just went a little bit out of frame here. You don't quite see it in this picture, but I have actually scored circumferentially, scored on the rectum itself right there. So I know exactly where to divide the mesorectum and where to divide the rectum as well. I'm doing the posterior circumferential.

scoring right now. And this is really just for more landmarks so that when I start coming through the mesorectum, I know exactly where I'm going so I don't skive too much. Speed this up a little bit. Now this posterior mesorectal dissection and the mesenteric division, mesorectal division, can be done with scissors or with a vessel sear. And I mean, it depends on the case and depends on the anatomy of the patient, but I'll typically almost always use the...

the scissors for these patients. Then once they, if the bleeding gets bad, the superior haremortal is difficult to identify or whatever the case may be, I will liberally switch back to a vessel sealant. But in this case, what we'll do is we'll basically skeletonize, skinny down, and find the superior haremortal, divide it with the bipolar. And here, already, pretty much you can see the rectum there. Patient had very favorable anatomy, of course, as you can tell.

Finally separate hermortil, dividing it, bringing the vestibular in to take it. Just again, I edited out, very lightly edited out the instrument exchanges in this video just to save everyone of the pain waiting for the instruments to come in. Finishing up these mesorectal attachments here. Doing so basically perpendicular to the rectum itself. Speed it up.

And once this is done circumferentially, I'm gonna bring in a stapler. Most typical, if it's a sigmoid dissection, I will almost always use a blue load. In this case, since we're a proximal rectum, I'm gonna guess I was using a green load, but we'll find out here in a second.

Pretty sure it's a green load. One little tip here that I have, stapling. There's going to be a time where you just can't quite get across the recto sigmoid with a single fire of a 45 blue or 45 green or whatever you have. So this is the trick.

I go to 100% clamp on the robot, put my two arms, my left hand here, my third arm there, basically kind of straddle the stapler. Make sure it's clamped down 100%. Make sure you get a full clamp. And then I'm going to open the stapler, advance it a little bit more.

There's a tip I picked up in residency that allows you to get a little bit more tissue into the stapler, not forcing it or cramming it. You definitely don't want to do that, but just allowing that first clamp to push out any of the edema and fluid that's in the tissue, and then opening the stapler in advance to get just a little bit more affords a little bit more tissue safely within the stapler. Now we're going to clamp down, make sure we're at 100% clamp, and then fire the stapler. Speed up the video. Now we've divided the mesorectum, we've divided the rectum, now I'm going to find my proximal division point.

Put the Vestal Sealer in next, rotate the sigmoid colon out of the pelvis. Looking for the descending sigmoid junction, I'm going to tent the descending sigmoid junction that I anticipate will be my anastomotic site. I'm going to hold that now to the anterior midline. And what I did was once I figured out that's a good spot for the dissection to be, I flip the specimen back into the pelvis.

I'm going to now find the divided IMA pedicle, adjusting my proximal division point. Now I'm going to find the proximal division point of my IMA pedicle. I want to keep that with the specimen because that's where all the lymphovascular is.

All the lymph nodes are harvested. There's a lymph node to the right. It was just at a frame there.

Now I'm going to start double burning there with the specimen to the right, i.e. the IMA pedicle to the right. And then I'm going to, with a vessel sealer, double burn on the mesentery from that point there with the IMA pedicle all the way up to my third arm. It is incredibly important to make sure that you're using your third arm, very liberally in these cases, as a reference point for where to divide the mesorectum, or rather the mesosigmoid or mesodescending colon in this case.

If you don't have a fixed third arm that you're referencing constantly, it's very, very, very easy, incredibly easy, please take it from me, to deviate. You can go to the left and actually accidentally take the descending colon or the proximal aspect of it, or hang a right and end up hitting it. at the recto sigmoid.

So I'm using my third arm, constantly referencing it exactly where to take the mesentery in which direction to point the vessel sealer so that I don't mess up the mesenteric division, which is arguably one of the more important parts of the operation. Here I'm just skinning down the final attachments of the mesentery with the vessel sealer and I'm announcing the anesthesia. I need 2.5 cc of ICG with a 10 cc flush right now.

Right, the second I take that last little bit of attachment, that's when I ask for the ICG, and in just a second, we'll see it go in. Checking for length again, it's looking pretty good. Speed the video, ICG goes in, and everything is illuminating quite nicely. Very nice. Anvo just went in.

Now, how did that go in? Well, that's for another video I think. But basically what I ended up doing in that case, and pretty much all my cases now, is my bedside assist will remove the stapler port, extend the skin incision, usually just a little bit, and basically in the most delicate and elegant way possible, shove the anvil into the abdomen.

And it typically will require... A little bit of stretching of the fascia and peritoneum. Of course, larger patients, deeper sub-Q is a little more difficult, but whatever works typically. Now I'll do this in a couple different ways. I'll divide the descending sigmoid junction either with the scissors or the vessel sealer.

Actually, I find that the vessel sealer gives you a much straighter cut, and so I tend to favor that way. As you see right here, a 3-0 V-lock just went in the abdomen. Probably getting a little bit impatient here, so I'm going to start suturing with a vessel sealer until my needle driver comes in.

But most traditionally, I'm going to use a needle driver, a non-cutting large needle driver. And I start at the 7 o'clock position on the descending colon conduit here. And I start at the 7 o'clock position.

I'll speed the video up a little bit. I'm holding up with my third arm about 4 centimeters proximal to that cuff. And once the needle driver goes in, we'll get this thing completed.

Needle driver goes in, I've started at the 7 o'clock position on the cuff, going in to out, and then I'm going to work my way around the descending colon conduit in this cuff. In an in-to-out fashion, sewing in a baseball stitch configuration, in-to-out, in-to-out, in-to-out. Now I do this in about a 1 cm increment. I travel about a centimeter and take about a half centimeter bite each time.

Now I know the measurements because The fenestrated bipolar mode, which is my left-hand instrument, I've said it in different videos, my left-handed instrument, the width of it is 5 millimeters. Opened jaw-to-jaw or tip-to-tip is 2 centimeters, so I kind of split the difference between the two, and that's about a centimeter. I travel a centimeter, take a half a centimeter or a 5 millimeter bite each time, and I typically go from 7 o'clock, run it in a clockwise fashion, back to 7 o'clock.

Once I get that done, go back to where I started. Third arm's going to grab at the 12 o'clock position. Left hand's going to pull down in the 6 o'clock position, once I get the anvil. Pull down in the 6 o'clock position, get the anvil in place, cinch down the suture, grab the descending colon conduit, cinch it down tight. Probably the majority of the cases I end up having to do a second round with this same suture.

Sometimes the cuff doesn't cinch down nice enough. And so what I'll do in this case is I'll run around a second time with the same V-lock. And that's why I don't cut the needle off.

And more and more regularly what I do is actually take a vical endo loop. And just cinch that down real tight around the cuff of the descent and colon conduit. right around the base of the anvil there. And I've liked that more and more, but this certainly works because the suture's already in. It works nice and it works just fine.

So run around a second time here. Speed up the video a little bit. And I always like to keep the needle attached because if I find another tick, I can keep running around if I need to. And then what I'll do is, just like we would do in an open case, I'm going to get scissors in there.

And we would clean off the mesentery. And these open cases, when we do the extra-crop wall fixation of the anvils, we get a right angle and start bovying, and it's exactly what I'm going to do here on this robotic case. So there's nothing different. The technique is identical. It's just using a different instrument, basically.

So we're going to get this set up, exchanging the third arm, so I can get good exposure, skinny down the mesentery. I'll speed the video up. Getting it down nice and symmetric all the way around, nice and flat. Of course, there's a delicate balance of not burning the bowel like I just did there, even though it's very superficial, and not devascularizing it, but just having it just enough to where you can see what you're doing. Make sure everything is nice and hemostatic.

Checking the orientation. Cutting the suture. Handing it to my assist.

And now setting up for the anastomosis. Place the specimen in the right lower quadrant. Get it out of your face. And then let your assistant go down.

Start doing the transdental dilatation with the EEA sizers. I use a vestless here for this. Checking the orientation right there. IMA.

Actually looks like I'm going to get some more length. There's IMA. You can see it right there.

Inserting to the splenic vein. It's actually just nice anatomy there, making sure we have plenty of length. And again, don't forget, we mobilize a ton of rectum, so the rectum comes out really nicely in this case.

And in most cases, even the larger patients, whatever the case may be, there's plenty of mobilization of the rectum. Clean the camera off. Assistant is down, EA sensors are going up, second sensor went up, now the stipper is going to go up.

I'll go to 2x speed. Now typically what I do is, as you see right there, I like to bring out a spike to one side of the rectal cuff. I'll link to the video the reason why.

But I'll briefly say as this anastomosis is getting constructed. The less number of intersecting staple line points you can do, the better for the patient. Which is why I now abhor these anastomosis where we bring the spike of the stapler through the direct midline of the stapler, of the transverse staple line of the rectum, and we have the stapler on the EEA anvil side through the middle of the staple line there.

So you've converted something now to O. quadruple staple line intersecting staple line technique. So what I do here, and several studies that support this, is bringing the anvil spike, the transanal anvil spike, through one side of the rectal cuff so that you only have one intersecting staple line point. In this case, I brought it out to the patient's left-sided stump, the left side of the stump, and I'm checking mesenteric orientation here just to make sure we're nicely oriented. And what that does is back to the anastomotic surface, there's only one intersecting staple line on the right-hand side here of the anastomosis, which is right to the right here.

And that's acceptable. I'm going to link to a video that I talked about this, that showed an anastomotic leak rate of, actually in this study, zero when you have zero intersecting staple lines, or zero when you have one intersecting staple line. But when you had two intersecting staple lines, the leak rate in that study went up to 12%.

I do whatever I can to not have these intersecting staple lines occur. Speed the video up a little bit here. E-A-Sizer gets fired.

See to my left, my assist is just about to bring the colonoscope up. Pelvis gets instilled with saline. Clamp off with the third arm. Make sure we're hemostatic. Very, very, very liberal use of any energy down here.

If there's any issues, I mean, I'll get a 3-O Vicryl out or something like that to suture off any bleeding, but anything superficial like that, not too bad. So I just reinjected ICGs. You see, it looks very nicely perfused.

I'm very happy with it. The rectum always comes in in terms of perfusion after the sigmoid, very nicely perfused. And the endoscopic image on the left, you'll see...

It's not the best image, but you'll see that we're distending up quite nicely. It'll get nice. There's the anastomosis there. There it is. And it looks intact, not bleeding.

Distending up decently, actually. Not the best. That's pretty much it.

So I'll speed this up a little bit more. And I did see that there's a little bit of a thermal hickey, let's call it, on the left side of the anastomosis there. So I'm going to go ahead and just put an interrupted suture just to cover that.

Remember, this is actually a case observation day. Most people actually missed that. They didn't see why I was doing that. But now I'm reviewing the video.

I'm really glad I did. And that's the cool thing about robotics is that you're not really limited to doing stuff like this. So if you ever worry about it, I just throw a stitch in it.

Makes me feel a whole lot better. I sleep better. Even though it probably wasn't going to be an issue. But, I mean, the last thing I wanted to do was try to get away with something. So, at least I know that I did everything possible.

And it was technically pretty easy to do. Obviously, this is a really easy spot. But even the lower, even if there's a low, low, low colorectal, even a coloanal, I've over-sown defects in the astimosis or weaker spots in the astimosis for these ultra-low colorectal anastomosis. You see I used the Vessel Seeder to suture that, which you can certainly do.

The Vessel Seeder works as a decently off-label needle driver. Not the most delicate instrument for that, but it certainly works. Unclamp. Now I'm switching back to full screen view. Now what I'm going to do is my Vessel Seeder is going to go away.

I'm going to switch the master controls on the console here in just a second. So that arms number one and two are now my left and right hands. I dunk the specimen into a specimen bag, pull the specimen out through the extension of the staple port, and we're done with the case. All right, that about wraps up this video on a skin-to-skin robotic sigmoid, but let's call it a kind of a semi-law and terror section, and how I do it, the choreography for the entire thing.

Now, if you're interested, I have an entire video series on exactly how... every single step of this operation is done into the 21 steps of the operation and how best to do it how to do it in multiple different ways all the different nuances tips and tricks on how to get them done but this operation that i just showed here i hope shows kind of how you put it all together let me know down in the comments if you do anything differently and please subscribe to the channel as i'm adding content to this series and many others pretty regularly thanks take care

Transcript for:Robotic Sigmoid Resection Overview

Transcript for:
Robotic Sigmoid Resection Overview