**7. Robotic low anterior resection of rectal cancer**

After creating the pneumoperitoneum with the help of the Veres needle, the place of insertion of the future trocars for the 4 arms of the robot is marked. Unlike previous models for the Xi model, the 4 trocars of 8 mm must be placed in line. The distance between two trocars should be 6 to 8 cm. It starts with the trocar intended for the endoscope, which will be placed above the umbilical scar at about 3–4 cm on the right side (**Figure 5**). The insertion line of the following trocars should be slightly oblique between the right flank and the left hypochondrium. Thus, all stages of the intervention can be carried out without difficulty. In order for the possibility of losing pneumoperitoneum during the intervention and also for the immediate removal of the smoke resulting from electrocoagulation, the use of the AirSeal System Insufflation system is welcome. For this, the corresponding 12 mm trocar will be inserted in the right iliac fossa. Through this trocar, the assistant surgeon will introduce various tools: traction forceps, clip applicator, vessel sealing tools, linear staplers, etc. Sometimes, especially in obese patients, in order to maintain the intestinal loops in the right half of the abdomen, it is necessary to insert an additional trocar of 5 mm in the right hypochondrium (**Figure 6**).

**Figure 5.** *Positioning of the cart.*

In the first stage of the operation, the large omentum is picked up and placed in the splenic fossa, after which the loops of small intestines are removed from the pelvis and kept in the right half of the abdomen, to have easy access from the duodenojejunal angle to the pelvis. In women, it is recommended that the uterus be raised to have

#### *The Robotic Approach in Rectal Cancer DOI: http://dx.doi.org/10.5772/intechopen.100026*

enough working space in the pelvis. The uterus can be lifted either by using a uterine manipulator or by anchoring to the anterior abdominal wall with the help of a traction wire (**Figure 7**). The exploration of the peritoneal cavity begins by which the liver, colon and rectum are inspected with the identification of the area to be removed. At the same time, the anatomical landmarks are identified, and the length of the remaining colic partner is established, which will have to descend into the pelvis for the rectal anastomosis. In principle, there are two variants: a generous sigmoid loop sufficient for future anastomosis or a normal sigmoid loop and in this case, it will be necessary to perform a lowering of the splenic angle of the colon. In this situation it is good that the first stage of the intervention is this mobilization of the splenic flexion of the colon because it is a time-consuming step, which requires special attention to avoid damage to surrounding organs, spleen or tail of the pancreas. If done at the end of the procedure, when the surgeon is tired, the risks increase. The best approach of this part of procedure is to start the dissection from the medial to the lateral (**Figure 8**).

The vascular approach follows. The dissection must be performed in the vast majority of cases from the medial to the lateral. There are rare cases in which due

**Figure 7.** *Uterus mobilization.*

**Figure 8.** *Splenic flexure mobilization.*

to local factors the dissection will take place starting from lateral. At this stage it is very important to correctly highlight the dissection space between the Toldt fascia and the Gerota fascia where we will identify the left ureteral and the genital vascular pedicle. The dissection at the level of the inferior mesenteric artery is performed meticulously for a correct and complete lymphadenectomy. For neoplastic pathology, high ligation of the inferior mesenteric artery is mandatory, followed by ligation of the inferior mesenteric vein (**Figure 9**).

After vascular time, the mesorectum can be completely dissected. Here the role of the robot becomes crucial for an accurate dissection, identification of hypogastric nerve plexuses and their preservation and maintenance in the avascular plane between the rectal fascia and the presacral fascia. At the level of the anterior wall, a complete dissection can also be performed at the level of the Denonvilliers fascia, with the highlighting of the seminal vesicles and the prostate lobes.

As a last stage, the lateral mobilization is performed, followed by the transection of the rectum with the help of linear staplers. They can be inserted through the AirSeal trocar or more recently through the staplers mounted on the robot's arms.

The specimen is currently extracted through a minimal Phanenstiel incision, protected by a system that covers the edges of the wound and thus avoids parietal dissemination. An alternative of extracting the specimen is the transanal extraction, in which the use of the robot proves once again its superiority over the laparoscopic approach [36]. The stapled rectal abutment is sectioned, and the colon is extracted transanal. After resection the specimen, the anvil is mounted either terminally or laterally and the colon is reintroduced into the peritoneal cavity. The stapler is inserted transanal and the rectal stump is circularly sutured around it, after which the anastomosis is created.

For a correct anastomosis, several principles must be observed: we need two healthy partners, well vascularized, with an adequate length and without tension in the future anastomosis. We must not forget that in most cases the tension does not exist at the level of the lateral portion, but at the level of the mesentery, which often appears as a rope at the level of the promontory.

The use of ICG in anastomosis perfusion testing has become a defining moment, especially since the robot is equipped as standard with the near-infrared firefly system (**Figure 10**) [37, 38].

**Figure 9.** *Inferior mesenteric artery ligation.*

**Figure 10.** *Firefly fluorescence technology 2015 Intuitive Surgical, Inc. with permission.*

**Figure 11.** *Air test.*

**Figure 12.** *Postoperative colonoscopy.*

Finally, the colorectal anastomosis is checked by air test and colonoscopy. In this way we make sure that the anastomosis is sealed and there is no bleeding at the level of the stapling line (**Figures 11** and **12**).
