Keywords

1 Introduction

Thanks to prevention programs and diagnostics improvements, together with significant treatment advances that have led to increased overall survival in patients with cancer, the detection of multiple synchronous or metachronous malignancies requiring surgery is becoming more and more frequent in clinical practice. The frequency of multiple primary cancers is reported to range between 2% and 17%. Particularly when faced with a patient with two or more simultaneously diagnosed active cancers, the goal is to find the best therapeutic strategy [1]. Following a multidisciplinary oncologic team discussion, a combined minimally invasive surgical approach can nowadays be considered a valuable option for synchronous malignancies of the gastrointestinal, colorectal, urological, and gynecological districts, representing an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy.

2 The da Vinci System

Since the introduction of the da Vinci Si system (Intuitive Surgical, Sunnyvale, CA, USA), similar or superior results to laparoscopic surgery have been observed for several surgical indications. This system has become increasingly popular, particularly in general surgery, urology, gynecology and thoracic surgery, but for single quadrant procedures. Indeed, combined multiple organ surgery was not initially considered a good indication for a robotic approach, mainly because of instrument collision and need for an increased number of trocars with the da Vinci Si version. This limitation involved also some single organ/multiquadrant surgeries such as rectal resection. In order to overcome these drawbacks, double docking or hybrid procedures were often performed, although showing poor results in terms of workflow, with significantly longer operative times compared to open surgery and laparoscopy.

The introduction of the da Vinci Xi in 2015 had a strong impact on these aspects, drastically improving the ability to perform combined and simultaneous procedures by enhancing the workflow with a fully-robotic approach. Indeed, aiming to overcome the described limitations of the previous version, the Xi system presented new important features such as the greater flexibility of the robotic arms, the magnetic connectors, the FLEX function, the rotating boom, as well as the wirelessly connected operating table, the da Vinci Table Motion (dV TM). Thanks to these characteristics and technologies, docking has become easier and faster, the work space range has been increased and, through the dV TM, it has become possible to start moving patients along with the instruments inside the abdomen and without the need for undocking and re-docking maneuvers.

Therefore, all these aspects significantly increased the ability to perform multiquadrant/multiorgan procedures [2].

3 Technical Notes

In detail, the main technical aspects to be considered in order to successfully face a multiquadrant/multiorgan surgery are: use of the FLEX function, use of the dV TM if available (optional), and management of the boom-rotating system. Also, facilitated docking/undocking by the magnetic connectors, the targeting function and pointer laser, and a particular trocar positioning strategy play an essential role [3].

3.1 Flex Function

While the da Vinci Si required the external arms to be widely spaced in order to maximize the working field, this is not applicable for the da Vinci Xi. In fact, the horizontal joints of the Xi need to be compacted, leaving one-fist-width spacing between each arm. This configuration also permits the arms to move in parallel with each other, a function called FLEX that is particularly important in multiquadrant procedures in which the targets are in the same side of the patient. The operative field can be extended beyond the alignment of the Xi FLEX joints as the robot arms can be manually redirected towards the new target anatomy without undocking the ports (Fig. 15.1).

Fig. 15.1
Three close-up photographs of a robot arm. It has four parts with spacing. These can move in parallel from one direction to another.

Thanks to the FLEX function the robot arms can be manually redirected toward the new target anatomy without undocking the ports

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3.2 Table Motion

Another important tool available for the da Vinci Xi is the dV TM. This operating table supports integrated table motion, enabling patients to be repositioned with instruments inside the abdomen and without undocking the robot [4]. These properties further enhance the workflow without the struggle and time needed to undock/re-dock the platform, allowing surgeons to maximize all the advantages of the robotic technique while reducing its specific drawbacks, enabling access to different quadrant/surgical target faster and more efficiently, especially during procedures with difficult anatomy.

In these situations, the da Vinci Xi plus the new operating table also enable the surgeon to optimize gravity exposure and provide the quick access to different surgical targets even in narrow spaces. Apart the positive influence of these facilities in reducing the operative time, the dV TM may increase patient safety as it can minimize the use of extreme position through graded Trendelenburg repositioning and stopping when surgical exposure is achieved. In fact, the dV TM enables what is best described as “controlled graded gravity exposure” by regulating the Trendelenburg and/or lateral tilt precisely and not beyond the required tilt. In addition, the anesthesiologist can control exactly the table position and display it to the entire surgical team in a cooperation manner. The dV TM is therefore a very interesting tool that specifically helps the surgeon to perform multiorgan and multiquadrant operations, enabling the patient’s repositioning without disrupting the surgical workflow and allowing the robotic instruments to reach safely all the targets.

3.3 Boom Rotating System, Targeting, Magnetic Connectors, Pointer Laser

Thanks to the previously described features, some combined procedures can be performed with a single docking, particularly if the target organs are in two closed quadrants (e.g., pelvis and left hypochondrium), with or without changing the patient’s position. However, in cases of opposite quadrants, or when the range of motion goes beyond the limits of the joints/collision, dual docking can be required. In these cases, the facilitated docking/undocking ensured by the magnetic connectors, the targeting function and the pointer laser can enhance the workflow as it is very fast to undock and dock again the robot.

In this regard, also the rotating boom mounted system, which can be rotated almost a full 360 degrees, is particularly useful as the robotic cart can achieve opposite surgical access without a need for changes of the robotic cart. The boom can be re-orientated to every part of the patient by undocking the port and performing a re-targeting and a new docking phase (opposite facing quadrant technique). This ability to rotate the boom while the robotic cart can remain in the same position makes this technique time-saving (Fig. 15.2).

Fig. 15.2
Two close-up photographs of the robotic arm with a boom. The arm has 4 parts. The boom helps to move the parts of the arm from one direction to another.

The boom system can be re-orientated to every part of the patient by undocking the port performing a re-targeting and a new docking phase

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3.4 Trocar Placement

To perform combined multiple organ/multiple quadrant procedures, trocar positions should be adjusted case by case, following some basic principles. The general rule of the straight line given by Intuitive for the da Vinci Xi is always followed. The starting point is the diagonal line from left subcostal area to right iliac fossa centered in the umbilical area, following the “classic” Universal Port placement guidelines suggested by Intuitive for “left lower” abdominal procedures. Based on the surgical site and the second target organ, however, it can be necessary to shift all trocars to the right or left side and/or change the angle of the alignment (Fig. 15.3). For example, in cases of right colectomy combined with left colectomy trocar alignment is centered at the level of the umbilical area, whereas if surgery predominantly involves the left quadrant (for example in the case of left colon resection plus distal pancreatectomy) all trocars should be moved 2 or 3 cm to the right. On the other hand, in cases of right hemicolectomy associated with right nephrectomy or hysterectomy, the trocar line should be moved 2–3 cm to the left, always in an oblique fashion. The assistant’s trocar could then be placed at the level of the right or left flank depending on the type of multiquadrant procedure.

Fig. 15.3
A diagram of the abdomen. The positions of placement are denoted for 8 m m and 12 m m in a linear line from top to bottom. The rotation of the line is present.

Different combined procedures are possible with an oblique linear trocar position, shifting the line to the left or right or by rotating the alignment to a more horizontal line based on the localization of the two surgical targets

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4 Combined Robotic Procedures

Below are described some examples reported in the literature of different combined procedures successfully performed through the described strategy [3, 5].

  • Right colectomy plus right adrenalectomy: the patient is in left lateral decubitus, and the trocars are positioned as a standard robotic adrenalectomy; the patient is afterwards moved to supine decubitus, and a new docking is completed to perform the right colic resection.

  • Right hemicolectomy plus right partial nephrectomy: trocar alignment is shifted about 3 cm to the left, the 12-mm assistant trocar is placed in the left flank, and the patient is positioned in 15° anti-Trendelenburg and tilted 15° to the left. Right hemicolectomy is performed initially, and then right partial nephrectomy is performed in the same position. Other authors describe the same procedure but with a need to undock the robot and reposition the patient. Starting with a supine decubitus, in 15° anti-Trendelenburg with parted legs, the robotic cart comes from the right of the patient. Targeting is performed at the level of the right flexure to reduce instrument collision. Then the right colectomy is performed as usual. However, before specimen extraction and fashioning of the intracorporeal anastomosis, partial nephrectomy with arterial clamping is performed usually with the patient in the same decubitus, but further tilting the table to the left. In other cases, in challenging partial nephrectomy cases, it is possible to undock the robot and place the patient on the left flank side with the right arm adducted over the head.

  • Anterior rectal resection plus pancreatic tail neuroendocrine tumor enucleation: trocar alignment is shifted about 3 cm to the right, the assistant’s 12-mm trocar is placed at the level of the right flank and using dV TM the patient’s position can be changed twice. In this way, for the access to the inferior mesenteric vein, mobilization of the splenic flexure and descending colon, and enucleoresection at the level of the pancreatic tail, the patient is placed in 15° Trendelenburg and tilted 25° to the right. Then, to perform total mesorectal excision the patient is tilted only 15° to the right and placed in 20° Trendelenburg.

  • Right hemicolectomy plus hysterectomy: the trocars are positioned centrally at the umbilical level, the 12-mm trocar for the assistant is at the left flank level. The patient is positioned in 30° Trendelenburg throughout the gynecologic phase, using dV TM to be able to precisely access to the pelvic cavity without compromising patient safety with extreme positions. Next, for the right hemicolectomy, undocking is performed, the boom is rotated 180° and the bed is tilted 10° to the left for ileocolic vessel ligation and mobilization of the right colon. Adjusting the tilt degree, the final steps of the intervention are accomplished and intracorporeal anastomosis is created.

  • Sigmoidectomy or anterior rectal resection plus right hemicolectomy: trocars are centered in the umbilical region, the 12-mm assistant’s trocar is placed at the level of the right flank. The procedure starts with right hemicolectomy and then the robot is undocked, the boom is rotated 180°, and the patient is tilted 15° to the right and 15° in Trendelenburg for mobilization of the left colon and access to the inferior mesenteric vein. Then, using the dV TM system, the patient is positioned 20° in Trendelenburg to complete the mobilization of the sigma and high rectum. Finally, the specimen extraction is performed through a suprapubic minilaparotomy and lastly colorectal anastomosis is performed.

  • Anterior rectal resection plus liver resection: the position of the trocars is centered at the level of the umbilical region while the 12-mm assistant trocar is placed in the left flank. After completing the anterior resection of the rectum, the robot is undocked, the boom is rotated 180°, and the patient is placed 15° anti Trendelenburg and tilted 25° to the left for the liver resection.

  • Ideally, by rotating the straight line of the trocars and/or shifting it towards the right or left, several other combined multiquadrant procedures can be performed.

5 Conclusions

According to the current literature, robotic multiorgan and multiquadrant combined procedures have already proved to be feasible and safe [6, 7], with a potential positive impact on postoperative outcomes, on global hospitalization time, as well as on an earlier start of adjuvant treatments [8, 9]. However, due to the great variety and heterogeneity of the described procedures, standardization is still completely lacking. In this setting, the potentialities of the da Vinci Xi and dV TM are fully exploited. Furthermore, the technology is advancing faster and faster leading to the development of new robotic platforms such as da Vinci SP, experimenting a single site approach to improve outcomes, allow better management of analgesia, and provide better cosmetic results and fewer long-term wall complications.