Tips and Tricks

• To avoid intraoperative complications:
  • Create adequate exposure
  • Use proper traction and countertraction
  • Develop the right planes
  • Standardize the assistant's role
  • Beware of the variations of vasculature and anatomy
• Should visualization be compromised during the procedure it is easy to switch to a 30° endoscope down for a more topographical view. Applying the angled 30° endoscope up/down can also be helpful to manage external arm collisions during tight set-up situations, as the camera arm angle changes depending on the endoscopy used. Additionally, with angled 30° endoscopes the surgeon has the ability to rotate the viewing angle of the scope (out of the horizontal image plane) and minimize collisions as well.
• Leave 1.0-1.5cm on either side of the transected IMA and IMV so that if any bleeding occurs grasping of the vessel is still possible to allow application of the hemostatic technique (clips, LigaSure^™ or suture).
• The motions of instrument arms 2 and 3, which facilitate retraction and exposure of the pelvis during the rectal dissection and division step, have a tendency to cause some minor outside collisions especially in smaller patients. It is therefore of utmost importance to distance the ports as much as possible from each other during initial port placement (minimum of 8-10 cm). Placing the patient in a steeper Trendelenburg position can increase the vertical spacing between the arms and potentially eliminate or minimize arising collisions. It is also advisable to switch the clinical tasks that the instruments perform in the robotic arms by having arm 2 become the dissecting instrument and arm 3 the retracting instrument (exchange instrument between arms).
• Before dividing any tissues, identify the ureter and gonadal vessels one more time.
• During all procedure steps clear communication with the patient-side assistant is essential.

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