Table 3.

Robotic total mesorectal excision training modules at Portsmouth Colorectal

Module	Detail
1. Patient positioning and setup	Patient and robotic cart setup
	Port placement strategy with accurate pre-incision markings
	Access, exposure, and docking techniques (modified Lloyd-Davis position)
	Port placement variations based on the robotic platform (e.g., da Vinci Si/X, Intuitive Surgical Inc)
	Patient positioning (Trendelenburg 10°, 15° right tilt)
	Bowel management (small bowel retraction, greater omentum retraction)
	Patient cart docking from the left side
	Instrument insertion under direct vision
2. Anastomosis and closure	Rectal transection using a robotic stapler (EndoWrist, Intuitive Surgical Inc) via a 12-mm trocar
	Indocyanine green fluorescence for distal rectal blood supply assessment
	Suprapubic specimen extraction
	End-to-end stapled anastomosis creation
	Anvil placement and anastomosis completion using standard techniques
3. Inferior mesenteric vessels and dissection	Dissection starting at the sacral promontory and progressing cranially
	Careful dissection alongside the IMA
	IMA division at the origin using Hem-o-Lok clips (Weck Closure Systems)
	Hypogastric nerve identification and preservation
	IMV division just below the duodenojejunal flexure
	Development of a mediolateral plane above Gerota fascia
4. Splenic flexure mobilization	Division of lateral adhesions of the left colon
	Dissection to the splenic flexure using a single-docking, infracolic, 3-step approach
	Medial dissection below the IMV
	Pancreas identification and lesser sac entry
	Pancreas tail separation from the colonic splenic flexure
	Omentum release from the transverse colon
	Full splenic flexure mobilization
5. Rectal dissection	Dissection of the posterior total mesorectal excision plane following the superior rectal artery
	Lateral and anterior extension of the dissection plane
	Distal rectal dissection out of the pelvis
	Transabdominal suture placement for improved pelvic view during dissection

IMA, inferior mesenteric artery; IMV, inferior mesenteric vein.