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Page 2 of 12 Moroni et al. Mini-invasive Surg 2019;3:36 I http://dx.doi.org/10.20517/2574-1225.2019.34

INTRODUCTION
Colorectal cancer (CRC) is the most common malignant disease of the gastrointestinal tract and the third
most common cancer worldwide with over 1,000,000 new diagnoses and 500,000 deaths per year in the
[1]
[2]
United States . Approximately 40% of all CRCs are located in the right colon . In recent years, several
technical requirements have been established to improve the post-surgery outcomes for colon cancer. The
American Joint Committee on Cancer (AJCC) has defined that, for a radical colectomy, a minimum of
[3,4]
12 lymph nodes must be examined to avoid understaging . Other milestones include the introduction
[5]
of the principles of complete mesocolic excision (CME) and the introduction and widespread use of
[6]
minimally-invasive surgery (MIS) . For the resection of colon cancer, the use of conventional laparoscopy
seems to reduce the length of hospital stay, postoperative pain, and the time until daily activities return to
normal, as well as improve cosmetic outcomes when compared to the open approach [7-10] . Nevertheless, the
adoption of laparoscopic right colectomy (LRC) might not be as widespread as expected [11-15] , probably due
[16]
to the high complexity of the vascular anatomy of the right and transverse colon .

For minimally-invasive right colectomy (RC), the debate continues regarding whether the ileo-colonic
anastomosis should be performed intra- or extra-corporeally. The majority of the published series on
[16]
minimally invasive RC have reported an extra-corporeal anastomosis (EA) fashioning . Few studies
[17]
comparing EA with intra-corporeal anastomosis (IA) have been published recently . The principles of
CME require a meticulous dissection, which increases the technical challenge of LRC. In this scenario,
the use of robotic assistance may overcome the limitations of the straight conventional laparoscopic
instruments and allow performing a safer CME with central vascular ligation (CVL), especially in
[18]
obese patients . The latest da Vinci Xi® robotic system (dVXi) presents some additional advantages
for colorectal procedures when compared with previous versions (da Vinci S® and Si®), such as simpler
docking, possibility to position the optical system in all of its arms, which are thinner (width 1.7’ vs. 2.9’),
easier to move, and allow multi-quadrant surgery. The present narrative review aims to describe the main
technical aspects of robotic right colectomy (RRC) and compare the learning curve, the short- and long-
term outcomes, and the costs between LRC and RRC. A literature search was performed in MEDLINE
database (PubMed); articles published in English between 2000 and 2019 using the following terms were
screened: “MIS”, “RC/colon resection”, “robotic surgery”, AND “laparoscopic surgery” [Tables 1-3] [17,19-32] .

TECHNICAL ASPECTS OF RRC
Positioning
There is no consensus about the position of patient and robot in the operating room. In our center, we
put the patient in a supine position tilted on the left side (10°-25°) with the arms tight to the body and legs
closed. Generally, the table is positioned in Trendelenburg position (5°-10°) [33,34] and the robot is placed on
the right side of the patient [Figure 1].

Docking
The pneumoperitoneum is first established. Different options to position the ports have been described,
some of which are similar to the conventional laparoscopic approach [35,36] . Advances in robotic systems
allow variations of the port placement. Moreover, dVXi arms are thinner and have more flexibility, thus
decreasing the risk of external collisions when compared to previous robot versions.

Diagonal or oblique port placement
Four trocars are positioned drawing an oblique line from 4 cm above the pubic symphysis (Port 1) to the
left mid-clavicular line crossing over the left sub-costal margin (Port 4), separated by 7.5 cm. One assistant
[37]
port can be placed at the level of the umbilicus on the middle clavicular line [Figure 2, red points] .