Robotic assisted sigmoidectomy

PREOPERATIVE AND URETERAL STENTS
The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, SCDs were applied. General anesthesia was induced, and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded and placed in the [position] for placement of ureteral stents. Dr. [ ] performed the stent placement, see procedure note for full details. After this the patient was returned to the [position] and the abdomen prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement.

ABDOMINAL ACCESS, PORT PLACEMENT AND SURVEY
Access to the abdomen was achieved with [5 vs 8] mm optical trocar entry. The abdomen was insufflated to 15 mmHg and there was noted to be no injury made on entrance. The abdomen was surveyed and found [findings].

Additional trocars were placed triangulating the RLQ and pelvis, under direct vision without noted injury.
12 mm RLQ
8 mm right mid abdomen
8 mm supraumbilical
[**] The original 5 mm entry trocar was exchanged for an 8 mm robotic trocar

[**] Lysis of adhesions were done for [ ] minutes.
The colon was examined and was noted [ ].

COLON DISSECTION AND DISTAL TRANSECTION.
The sigmoid colon mesentery was placed on tension to help identify the IMA pedicle. Adjacent to this the avascular retromesenteric space was entered and the mesentery was separated from the retroperitoneum, ensuring preservation of the neurovascular bundles. Next the sigmoid was dissected laterally from the pelvic brim to meet this plane. The colon was further mobilized by releasing the white line of Toldt and blunt separation from Gerota's fascia to the level of the [colon].

At the level of the proximal rectum the bowel was cleared of fat and mesentery, and it was transected with the linear robotic stapler with blue cartridge.

PROXIMAL TRANSECTION AND ANASTMOSIS
The robot was undocked and a Pfannenstiel incision was made and carried down to the peritoneal cavity, sparing the rectus muscles. An [wound protector] wound protector was placed. The proximal bowel was delivered and noted to have [findings], the proximal transection line was decided based off a lack of colonic thickening and diverticula. An automatic purse string device was used and the colon sharply resected. The anvil was placed and secured with this purse string and an additional 0 Vicryl tie. The bowel was returned to the abdomen; the cap placed on the wound protector and the abdomen reinsufflated and the robotic redocked.

The proximal bowel was freed from remaining attachments, and it reached the rectal stump easily. The anus and rectum were sequentially dilated. The [mm] mm EEA [powered vs non-powered] stapler was passed, the spike opened and mated with the anvil and a circular [anastomosis type] was created. The anastomotic donuts were inspected and noted to be [findings].

Flexible sigmoidoscopy was done which showed intact anastomosis circumferentially and the leak test was negative.

The abdomen was again inspected and noted to be hemostatic. Bilateral TAP blocks were done with [cc] cc of [local anesthetic]. The robot was undocked and abdomen desufflated.

CLOSURE
The peritoneum was closed with [suture] in a [fashion]. The facia of the Pfannenstiel incision waws closed with [suture] in a [type] fashion. The skin was closed throughout with 4-0 Monocryl. The port sites were dressed with Dermabond and the Pfannenstiel with Prevena. The final counts were correct. The stents were removed and noted to be intact. The foley had hematuria which is expected. The patient was liberated from anesthesia, extubated without issue and transported to PACU in stable condition.

Dr. [ ] was present and participated for the entire case.