Rectal Resection

Once the dissection proceeds distally of the sacral promontory into the pelvis, instrument arms (2) and (3) are re-docked to the left sided da Vinci instrument ports and the remaining steps are performed in a 4-arm set-up again [Figures 37-38].

 

Anatomical overview and arm set-up:

Figure 40: Arms (1), (2) and (3) aligned for pelvic procedure steps

 

• Instrumentation: 0^° endoscope, Fenestrated Maryland Bipolar (left (3)), Hot Shears^™ (Monopolar Curved Scissors) (right (1)), Grasping Retractor or ProGrasp^™ (in arm (2)) - if visualization is compromised, switch to a 30^° endoscope down for better view into the pelvis.
• The rectal dissection is performed using an elliptical dissection pattern of posterior first (1), continuing laterally to the left side (2), then to the right side (3) and finally to the anterior side of the rectum (4) down to the levator ani muscle level [Figure 41]. The left lateral side dissection should be performed before the right, since without small bowel interference on the left the surgeon can achieve a well defined dissection level as a reference for the right lateral side later on. Performing the lateral dissection first on the right side would potentially make the surgeon struggle with bowel loops descending into the pelvis, which will slow the surgery down and get in the way of creating a defined reference dissection level.

View Surgical Steps:

1. Initial Exposure
2. Primary Vascular Control
3. Medial to Lateral Mobilization of Sigmoid & Descending Colon
4. Splenic Flexure Mobilization
5. Rectal Dissection & Division
• Posterior Dissection
• Lateral Dissection
• Anterior Dissection
• Rectal Division

 

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