Surgical Steps: Rectal Division

The rectal division can be performed laparoscopically or, alternatively, with robotic assistance (performed by advanced surgical teams after initial learning curve). The right lower quadrant robotic 8 mm cannula is switched to a 12 mm port and the stapler is introduced here. Align the rectum cephalad with the robotic instrumentation (in arms (2) and (3)) within the open stapler jaw. Clear communication with the patient-side assistant during this step is essential.

• Before dividing the rectum, one member of the team performs a digital rectal examination under direct visualization, and the distal margin is carefully assessed. A distal margin of at least 1 cm is targeted.
• Choose correct level of distal division:
• for cancers of the middle and lower rectum perform total mesorectal excision
• for upper rectal lesion divide the mesorectum at least 3-5 cm distal to the tumor (partial mesorectal excision)
• Divide the superior hemorrhoidal arteries in the posterior upper mesorectum and clear the fat surrounding this area.
• Switch the right lower quadrant robotic 8 mm cannula to a 12 mm port and introduce stapler (Endopath^™ or roticulating Endo-GIA^™).
• Align stapler at a right angle to the long axis of the rectum as much as possible.
• Align the rectum cephalad within the open stapler jaw.
• Divide the rectum by firing a stapler after a rectal washout is performed.
• If one cartridge of the stapler does not completely transect the rectum, fire a second cartridge and overlap the initial staple line.
• Move transected specimen into abdominal space and inspect pelvic space for bleeding.

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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