Rectal resection, robot-assisted with total mesorectal excision (TME)

• Ideally, positioning is done in lithotomy position on a large vacuum cushion (on the right side, the cushion supports the rib arch and the iliac crest, so that the weight of the patient in right lateral position does not press on the arm.
• It is recommended to position both arms adducted (caution: cotton wrapping when positioning with a cloth sling)
• Cotton wrapping of the knees and proximal lower legs is also performed to avoid pressure injuries.
• For leg positioning, so-called "swan fins" or padded "boots" are recommended, so that the legs can be moved separately and sterilely covered if necessary. Alternatively, the legs can be positioned in leg shells with fixation of the legs in them.
• The legs should also be adjustable in angle via the operating table control during the procedure.
• Before washing, a digital rectal examination (DRE) or a rectoscopy is always performed to ensure that nothing obstructs the perianal anastomosis site by a circular stapler.

Note: The positioning is particularly important due to the docking of the patient to the manipulator of the robot. The risk of injury to the abdominal wall when the patient slips must also be considered. With coupled tables in the Xi system, intraoperative position changes are possible without disconnecting. In the absence of "Table-Motion" technology, the surgical robot must always be disconnected and removed from the operating table before any position change.

Caution: Vacuum cushions may have leaks. Therefore, they should be checked again before sterile covering.

Establishment of a capnoperitoneum by inserting a Verres needle at Palmer's Point. Creation of the camera port. Insertion of the camera. Diagnostic overview. The four 8mm robotic trocars are positioned in a straight line. The angle of the line corresponds to the connection point of the left midclavicular line/rib cage and the right femoral head. The line itself runs parallel 5-8 cm further to the right. Trocar 1 is located in the left epigastrium. Trocar 4 is two centimeters ventral to the right anterior superior iliac spine. Ideally, there is a distance of 8 cm between the individual trocars (at least 7 cm to a maximum of 10 cm). The 12 mm assistant trocar is located 4 cm cranial to trocar 4 in the right anterior axillary line. The patient is positioned maximally to the right and moderately head down. The axis of the manipulator (laser marking) is aligned to point over the left anterior superior iliac spine towards camera trocar 3. Performing a laparoscopically controlled TAP block before inserting the trocars. The arms are connected with the four 8mm robotic trocars (docked). Subsequently, the instruments are introduced under visual control and parked under the ventral abdominal wall.

Caution: The trocars must be positioned with the wide black ring at the level of the muscular abdominal wall (so-called remote center) to avoid injury during movement.

Note: Ideally, the robotic trocars should be inspected with the camera via the assistant trocar when inserting the robotic instruments. This allows for easy verification of the position of all robotic trocars before the start of the surgery.