Total robotic radical rectal resection with da Vinci Xisystem: single docking, single phase technique

Q1 Anup Sunil Tamhankar1

Sudhir Jatal1

Avanish Saklani2*

1Department of Surgical Oncology,Tata Memorial Hospital, Mumbai,India2Department of Gastro-IntestinalSurgery, Department of SurgicalOncology, Tata Memorial Hospital,Mumbai, India

*Correspondence to:Avanish Saklani, Department ofGastro-Intestinal Surgery,Department of Surgical Oncology,Tata Memorial Hospital, Mumbai,India. Email: asaklani@hotmail.com

Abstract

Objective This study aims to assess the advantages of Da Vinci Xi system inrectal cancer surgery. It also assesses the initial oncological outcomes after rec-tal resection with this system from a tertiary cancer center in India.

Introduction Robotic rectal surgery has distinct advantages over laparos-copy. Total robotic resection is increasing following the evolution of hybridtechnology. The latest Da Vinci Xi system (Intuitive Surgical, Sunnyvale,USA) is enabled with newer features to make total robotic resection possiblewith single docking and single phase.

Methods and results Thirty-six patients underwent total robotic resection in asingle phase and single docking. We used newer port positions in a straight line.Median distance from the anal verge was 4.5 cm. Median robotic docking timeand robotic procedure time were 9 and 280 min, respectively. Median blood losswas 100mL. One patient needed conversion to an open approach due to advanceddisease. Circumferential resection margin and longitudinal resectionmargins wereuninvolved in all other patients. Median lymph node yield was 10. Median post-operative stay was 7 days. There were no intra-operative adverse events.

Conclusion The latest Da Vinci Xi system has made total robotic rectal sur-gery feasible in single docking and single phase. With the new system, fourarm total robotic rectal surgery may replace the hybrid technique of laparo-scopic and robotic surgery for rectal malignancies. The learning curve for thenew system appears to be shorter than anticipated. Early perioperative and on-cological outcomes of total robotic rectal surgery with the new system arepromising. Copyright © 2016 John Wiley & Sons, Ltd.

Keywords Total robotic rectal resection; Carcinoma Rectum; MultiquadrantSurgery; Single Docking and single phase resection

Introduction

Minimal invasive surgery for rectal cancers has gained acceptance overopen surgery. Results from MRC CLASICC and COLOR-II have shown no in-feriority of laparoscopic rectal resection compared with an open approach.Laparoscopic surgery is associated with better short-term outcomes withless pain and blood loss and is associated with early return of bowel activityand decreased hospital stay (1,2). However, it was associated with high

ORIGINAL ARTICLE

Accepted: 21 December 2015

Copyright © 2016 John Wiley & Sons, Ltd.

THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERYInt J Med Robotics Comput Assist Surg (2016).Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1734

Journal Code Article ID Dispatch: 23.01.16 CE:R C S 1 7 3 4 No. of Pages: 6 ME:

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

conversion rates to open surgery (up to 29%), andpatients who were converted, showed suboptimaloutcomes. Weber et al. were the first to perform arobotic-assisted colorectal procedure in 2002. It in-volved mobilization of the right and sigmoid colon(3). Since then, many studies have shown the feasibilityand safety of robotic colorectal surgery (4–7). Recently,three meta-analyses comparing robotic rectal cancersurgery with laparoscopic surgery have shown lowerconversion rates (8–10). Robotic pelvic dissection hasshown better preservation of sexual function (11). Allother outcomes including early recovery, safety, and on-cological outcome were similar (8–10). Robotic surgeryhas certain advantages over open and laparoscopic sur-gery such as a stable operating platform, fine motionscaling, three-dimensional imaging, articulated instru-ments providing superior dexterity, and a stablesurgeon-controlled camera. These benefits of roboticsurgery are essential in areas where access is problem-atic such as the pelvis in which laparoscopic operationsand visualization are technically difficult and less accu-rate (4,5,7). It may facilitate ultralow dissection(intersphincteric plane) and improve functional out-come (urogenital) while maintaining oncological safety.

The Da Vinci robotic system is the pioneer in this field.Recently, it introduced its latest version, Da Vinci Xi (Intu-itive Surgical, Sunnyvale,USA) in April 2014. We are thefirst center to install this latest version in India. We pres-ent our initial experience with the use of this new systemat a tertiary referral cancer center (Tata Memorial Center,Mumbai, India).

Materials and methods

We operated 36 rectal cancer cases from 6 October 2014,to 14 June 2015, robotically. Total robotic technique wasused in all the patients. The data were evaluated prospec-tively. The demographic details, body mass index (BMI),perioperative outcomes, pathology results, and postopera-tive complications were noted.

Technique

Four 8-mm robotic ports were used for the procedure. Thecamera port was placed 2 cm above the umbilicus on mid-line (open access). After creating pneumoperitoneum, weused a 30° robotic camera to place the remaining ports un-der direct vision; the three ports were placed along astraight line joining the right anterior superior iliac spine(ASIS) and the camera port, extending toward the leftcostal margin. Average distance among ports was 7 cm

to avoid clashing of the robotic arms. The farthest portswere positioned at least 2 cm away from the bony land-marks (i.e. right ASIS and left costal margin) (Figure F11).An assistant port was placed on the right side, in triangu-lation with right side ports at 7 cm distance. We used anAir-seal cannula (Surgiquest, Intuitive Surgical) as an as-sistant port. This port was used for suctioning, pelvic trac-tion, and occasionally for stapling the bowel. The patientwas positioned in lithotomy with a 30° Trendelenburg po-sition and 15° right tilt (left up). The position was notchanged throughout the procedure. Robotic camera (ligh-ter and less bulky than the previous Si version) was usedinitially to place the small bowel in the supracolic com-partment and to expose the duodenojejunal (DJ) flexurewith the help of laparoscopic instruments.

Before docking, the settings on the patient cart were setto lower abdomen, left side, and the robotic arms were de-ployed. The patient cart was brought in from left side.With use of the laser pointer, the overhead boom was cen-tered on to the camera port (Figure F22). The camera wasattached to Arm 2, although it can be introduced throughany of the arms. The camera was pointed toward the infe-rior mesenteric artery, and ‘targeting’ was used to alignthe other arms (automatic) (Figure F33). We used monopolarscissors in Arm 3, fenestrated bipolar forceps in Arm 1, andprograsp forceps in Arm 4 (Intuitive Surgical). Dissection ofthe inferior mesenteric (artery and vein) pedicles was doneinitially with transection of vessels (using robotic hem-o-lock clip applicator, using hem-o lock clips) after nodaldissection. This was followed by standard medial to lateraldissection preserving ureter and gonadal vessels upto

Figure 1. Port positions: central 8 mm supra-umbilical roboticport for camera. Three more 8 mm robotic ports in straight linefrom ASIS to left hypochondrium with average distance of 6 cmin between. Farthest ports are at least 2 cm away from bonylandmarks

2 A. Sunil et al.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2016.DOI: 10.1002/rcs

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

lateral peritoneal reflection. Sigmoid mobilization wascompleted laterally.

A complete splenic flexure mobilization was requiredin five patients and was completed without any signifi-cant difficulty in the same docked position. The ‘flip ma-neuver’ in the Xi system is an advantage so as to pointthe camera and instrument upward in the same positionto detach the colon from the stomach completely undervision.

The colonic phase was followed by pelvic dissection.We continued in the same docked position formesorectal dissection. In the first few cases, whilechanging from the colonic to pelvic phase, we usedretargeting for better alignment of robotic arms for pel-vic dissection. However, after the first few cases, we re-alized this was not required; hence, we have phrased itas ‘single-docking single-phase technique.’ During thepelvic dissection, Arm 4 acted as surgeon’s third arm

most of the time and was instrumental in providing pre-cise and tireless retraction. We used tape around therecto sigmoid junction to allow additional traction bythe assistant through the air-seal port. Total mesorectalexcision was completely satisfactorily. Visualization ofautonomic nerves was excellent with the 3D camera,and they were safeguarded in all patients. Air-sealmode was instrumental in avoiding fogging of the cam-era and blurring of vision. It was also useful in savinginsufflation gas.

For transection of the rectum, the robotic arms wereused to guide the stapler through the assistant port (highstapling). However, for low stapling, the fourth port wasreplaced with a 12-mm laparoscopic port. Specimen ex-traction and anvil placement for the stapled anastomosiswere performed through left iliac fossa incision. Hand-sewn coloanal anastomosis was performed in patients re-quiring intersphincteric resection. Visualization of theintersphincteric space was better with robotic than ourprior laparoscopic experiences.

Results

The demographic profile of the cohort is shown inTable T11. Among the cohort, 28 of 36 cases were givenpreoperative chemoradiotherapy as they showed clinico-radiologically locally advanced disease (Stage III) atinitial evaluation. One case of rectosigmoid carcinoma

Figure 2. Laser pointer centered at the camera port

Figure 3. Targeting function

Table 1. Demographic details and clinic-pathological outcome

Parameter Result

Total number 36Age (Median)(years) 51 (23–75)Sex (Male:Female) 1.76:1 (23:13)BMI (Median) 22.7 (15–30.1)Surgery TypeAPR 13ISR 5AR 18Docking time (Median, Min) 9 (4–14)Robotic procedure time (Median, Min) 280 (100–380)Blood loss (Median, mL) 100 (100–600)Distance from AV (Median,cm) 4.5 (0.5–15)LocationUpper 3rd 5Middle 3rd 8Lower 3rd 23Lymph node yield (Median) 10 (8–52)Distal resection margin (Median,cm) 2.5 (0.8–8)Circumferential resection margin (CRM,mm) 1/36 (2.77%)Quality of mesorectal excisionComplete 35/36 (97.2%)Incomplete 1/36 (2.8%)Post-operative stay (Days) 7 (3–26)

BMI: body-mass index, APR: abdomino-perineal resection,ISR: intersphincteric resection, AR: anterior resection

Total robotic rectal surgery with da Vinci Xi system 3

Copyright © 2016 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2016.DOI: 10.1002/rcs

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

needed conversion to open approach (locally advanced)as it had invaded ureter and presacral fascia. Other de-mographic and clinical parameters are illustrated inTable 1. One patient showed post-operative ileus. Onepatient, who was converted to open approach due tolocally advanced disease, died owing to pulmonarythrombo-embolism. This patient had involved circum-ferential resection margin (CRM). CRM and longitudi-nal resection margins (LRM) were not involved in allthe other patients. Median distances of tumor fromproximal and distal resection margins were 14 and 2.5 cmrespectively. The median lymph node yield was 10. Themedian post-operative stay was 7 days.

Discussion

Laparoscopy has proven its value over the open techniquefor rectal cancer surgery in terms of better short-term out-comes (1,2). However, it is fraught with certain problemssuch as lack of 3D vision, poor ergonomics, limited dexter-ity, restricted degrees of movements (only four) and am-plification of physiologic tremor. This significantlyhampers the performance of surgeons, especially in smallconfined spaces such as the narrow male pelvis or in thosepatients with a high body mass index (BMI). Laparoscopicsurgery has been shown to have a longer learning curvethan robotic surgery (12,13). The development of roboticsystems such as the da Vinci has made it possible to over-come these difficulties (14).

Robotic technology has evolved over a period of time. Itstarted with a hybrid technique of laparoscopic colonicmobilization and robotic pelvic dissection. Later, total ro-botic techniques evolved. But, they required dual dockingand involved cumbersome changes of position of the pa-tient cart (11). Single docking and dual phase techniquewas described with the Da Vinci S version. However, it re-quired multiquadrant port placement and port hopping(change of ports for instruments) (15). Fortunately, therecently developed Xi system empowers the surgeon toperform the whole robotic multiquadrant procedure witha single docking and single phase mode, thereby avoidingthe requirement for port hopping or alteration of the oper-ating arms.

The new Da Vinci Xi system

The Xi system has particular advantages over its prior ver-sions. The advancement in the design of the overheadboom provides greater liberty for accessing organs fromall positions. The facility of a rotating boom in the patientcart has made multiquadrant surgery possible without the

need for re-docking of the robot. In addition, a laserpointer present in the cart centers the camera portenabling optimal positioning of the arms. The system’spreset organ-centered settings enable targeting and align-ment. While prior systems warranted a 90° angle at theproximal joints, a more compact positioning is adoptedby the robotic arms. This positioning of proximal joint pro-vides better patient clearance and makes the surgery saferfor the patient and aids in avoiding recurrent dockings forpatient clearance. This system makes docking userfriendly for less experienced users. A similar decrease indocking time using the new Xi system was seen in theurology department when less experienced nurses weredocking (16). The automatic alignment of arms decreasesarm collisions. The arms are enabled with yellow and graytrackers for active and inactive instruments. This helps infinding instruments in the restricted field easier and safer.For a novice, losing sight of the robotic arms inside the ab-domen can cause potential bowel injuries and this newtracking feature can avoid such mishaps. Placement ofall ports along a straight line reduces external collisionsof arms and aids in smoother multiquadrant surgery.The endoscopic digital architecture is revised to create amore compact design with better visual definition andclarity. An endoscope can be attached to any of the roboticarms. This provides flexibility for visualization of the sur-gical site. The arms are smaller and thinner with newlydesigned FLEX joints that provide a wider range of motionthan the earlier versions and make the multiquadrant pro-cedures easier. Instrument shafts are longer than beforefor greater operative reach. The new system is also com-patible with Intuitive Surgical’s Firefly™ FluorescenceImaging System. It provides the surgeon with additionalvisual information in the assessment of vessels, bile ductsand tissue perfusion.

We did not have any untoward complications intra-operatively. But on a few occasions we faced difficulty inhandling redundant sigmoid colon owing to a narrowerfield of vision. Operative time in our series is comparablewith the world literature and series of hybrid technique(217–383 min) (17–20). We needed splenic flexure mobi-lization in only five patients. In other patients, we did notrequire it as sigmoid colon was quite redundant andhence, reach of the colon for anastomosis was not a con-cern. Similar findings have been noted in Asian patientsin other studies (21–23). This extra length of sigmoid co-lon makes the routine splenic flexure mobilization unnec-essary. This makes multiquadrant colonic surgery lesscumbersome. The number of lymph nodes retrieved wason the low side (10) in our study. But, this may be dueto the majority of patients being offered neoadjuvant che-moradiotherapy. Retrospective studies have shown thatthe number of nodes retrieved tends to lose prognosticsignificance after neoadjuvant chemoradiation. Tumor

4 A. Sunil et al.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2016.DOI: 10.1002/rcs

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

regression grade and lymph node status aremore prognosticthan the number of nodes retrieved after chemoradiation(24,25). Our perioperative outcomes were comparable withprevious robotic series (15,17,26). Our results show that to-tal robotic surgery for rectal cancer is technically feasibleand oncologically safe.

Robotic rectal surgery using the Da Vinci Xi systemenables single docking, single phase rectal resectionwith fewer ports compared with the Si system. At thesame time, the learning curve for the new system maybe lower than anticipated owing to its surgeon-friendlynature.

Conclusion

The latest Da Vinci Xi (Intuitive Surgical) system hasmade total robotic rectal surgeries feasible in a singledocking and single phase without changing the roboticarms. This technology may facilitate minimal access co-lorectal surgery by eliminating the problem of multipledocking steps. The port positions used by us have mademultiquadrant dissections and all varieties of rectal sur-geries possible. Four-arm total robotic rectal surgeriesmay replace the hybrid technique of laparoscopic androbotic surgery for rectal malignancies in the near fu-ture in the wake of the new da Vinci Xi system. Thelearning curve for the new system appears to be shorterthan anticipated. Early perioperative and oncologicaloutcomes of total robotic rectal surgery with the newsystem are promising. Our technique will improve fur-ther as we gather more experience in this field.

Acknowledgements

Department of Gastro-Intestinal Surgery and SurgicalOncology, Tata Memorial Center, Mumbai, India.

Conflicts of Interest

The authors have stated explicitly that there are noconflict of interest in connection with this article.

Funding Information

No specific funding.

References

1. Jayne DG, Thorpe HC, Copeland J, et al. Five-year follow-up ofthe Medical Research Council CLASICC trial of laparoscopicallyassisted versus open surgery for colorectal cancer. Br J Surg2010; 97: 1638–1645.

2. van der Pas MH, Haglind E, Cuesta MA, et al. Colorectal cancerlaparoscopic or open resection ii (color ii) study group.Laparo-scopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol2013; 14: 210–218.

3. Weber PA, Merola S, Wasielewski A, Ballantyne GH. Telerobotic-assisted laparoscopic right and sigmoid colectomies for benigndisease. Dis Colon Rectum 2002; 45: 1689–1694.

4. Patel CB, Ragupathi M, Ramos-Valadez DI, Haas EM. Athree-arm (laparoscopic, hand-assisted, and robotic) matched-caseanalysis of intraoperative and postoperative outcomes in minimallyinvasive colorectal surgery. Dis Colon Rectum 2011; 54: 144–150.

5. Pigazzi A, Ellenhorn JD, BallantyneGH PIB. Robotic-assisted lap-aroscopic low anterior resection with total mesorectal excisionfor rectal cancer. Surg Endosc 2006; 20: 1521–1525.

6. Kwon DS, Chang GJ. The role of minimally invasive surgery andoutcomes in colorectal cancer. Perm J 2011; 15: 61–66.

7. Baek JH, McKenzie S, Garcia-Aguilar J, Pigazzi A. Oncologic out-comes of robotic-assisted total mesorectal excision for the treat-ment of rectal cancer. Ann Surg 2010; 251: 882–886.

8. Memon S, Heriot AG, Murphy DG, et al. Robotic versus laparo-scopic proctectomy for rectal cancer: a meta-analysis. Ann SurgOncol 2012; 19: 2095–2101.

9. Trastulli S, Farinella E, Cirocchi R, et al. Robotic resection com-pared with laparoscopic rectal resection for cancer: systematicreview and meta-analysis of short-term outcome. Colorectal Dis2012; 14: 134–156.

10. Lin S, Jiang HG, Chen ZH, et al.Meta-analysis of robotic and lap-aroscopic surgery for treatment of rectal cancer. World JGastroenterol 2011; 17: 5214–5220.

11. D’Annibale A, Morpurgo E, Fiscon V, et al. Robotic and laparo-scopic surgery for treatment of colorectal diseases. Dis ColonRectum 2004; 47: 2162–2168.

12. Bokhari MB, Patel CB, Ramos-Valadez DI, et al. Learning curvefor robotic-assisted laparoscopic colorectal surgery. Surg Endosc2011; 25: 855–860.

13. Mirnezami AH, Mirnezami R, Venkatasubramaniam AK, et al.Robotic colorectal surgery: hype or new hope? A systematicreview of robotics in colorectal surgery. Colorectal Dis 2010;12: 1084–1093.

14. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic sur-gery: a current perspective. Ann Surg 2004; 239: 14–21.

15. Hellan M, Stein H, Pigazzi A. Totally robotic low anterior resec-tion with total mesorectal excision and splenic flexure mobiliza-tion. Surg Endosc 2009; 23: 447–451.

16. Guo F, Zhang C, Wang HQ, et al. Application of a laser-guideddocking system in robot-assisted urologic surgery. Int J MedRobot 2015 Jun 20; [Epub ahead of print]. Q2

17. Choi DJ, Kim SH, Lee PJ, et al. Single-stage totally robotic dis-section for rectal cancer surgery: technique and short-termoutcome in 50 consecutive patients. Dis Colon Rectum 2009;52: 1824–1830.

18. Baik SH, Ko YT, Kang CM, et al. Robotic tumor-specificmesorectalexcision of rectal cancer: short-term outcome of apilotrandomized trial. Surg Endosc 2008; 22: 1601–1608.

19. Hellan M, Anderson C, Ellenhorn JD, et al. Short term outcomesafter robotic-assisted total mesorectalexcisionfor rectal cancer.Ann Surg Oncol 2007; 14: 3168–3173.

20. Spinoglio G, Summa M, Priora F, et al. Robotic colorectalsurgery: first 50 cases experience. Dis Colon Rectum 2008;51: 1627–1632.

21. Bhatnagar BN, Sharma CL, Gupta SN, et al. Study on the ana-tomical dimensions of the human sigmoid colon. Clin Anat2004; 17: 236–243.

Total robotic rectal surgery with da Vinci Xi system 5

Copyright © 2016 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2016.DOI: 10.1002/rcs

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

22. Kim J, Choi DJ, Kim SH. Laparoscopic rectal resection with-out splenic flexure mobilization: a prospective studyassessing anastomotic safety. Hepatogastroenterology 2009;56: 1354–1358.

23. Brennan DJ, Moynagh M, Brannigan AE, et al. Routine mobiliza-tion of the splenic flexure is not necessary during anterior resec-tion for rectal cancer. Dis Colon Rectum 2007; 50: 302–307.

24. Persiani R, Biondi A, Gambacorta MA, et al. Prognostic implica-tions of the lymph node count after neoadjuvant treatment forrectal cancer. Br J Surg 2014; 101: 133–142.

25. Ishihara S, Fukushima Y, Akahane T, et al. Number of lymphnodes in rectal cancer is correlated with response to preopera-tive chemoradiotherapy but is not associated with patient sur-vival. Hepatogastroenterology 2014; 61: 1000–1007.

26. Park YA, Kim JM, Kim SA, et al. Totally robotic surgery for rectalcancer: from splenic flexure to pelvic floor in one setup. SurgEndosc 2010; 24: 715–720.

6 A. Sunil et al.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2016.DOI: 10.1002/rcs

1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162

66676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127

Author Query Form

Journal: The International Journal of Medical Robotics and Computer Assisted Surgery

Article: rcs_1734

Dear Author,

During the copyediting of your paper, the following queries arose. Please respond to these by annotating your proofs withthe necessary changes/additions.• If you intend to annotate your proof electronically, please refer to the E-annotation guidelines.• If you intend to annotate your proof by means of hard-copy mark-up, please use the standard proofing marks. If man-ually writing corrections on your proof and returning it by fax, do not write too close to the edge of the paper. Pleaseremember that illegible mark-ups may delay publication.

Whether you opt for hard-copy or electronic annotation of your proofs, we recommend that you provide additional clar-ification of answers to queries by entering your answers on the query sheet, in addition to the text mark-up.

Query No. Query Remark

Q1 AUTHOR: Please confirm that given names (red) and surnames/family names(green) have been identified correctly.

Q2 AUTHOR: Latest publishing info required.

USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION

Required software to e-Annotate PDFs: Adobe Acrobat Professional or Adobe Reader (version 7.0 or above). (Note that this document uses screenshots from Adobe Reader X) The latest version of Acrobat Reader can be downloaded for free at: http://get.adobe.com/uk/reader/

Once you have Acrobat Reader open on your computer, click on the Comment tab at the right of the toolbar:

1. Replace (Ins) Tool – for replacing text.

Strikes a line through text and opens up a text box where replacement text can be entered.

How to use it

Highlight a word or sentence.

Click on the Replace (Ins) icon in the Annotations section.

Type the replacement text into the blue box that appears.

This will open up a panel down the right side of the document. The majority of tools you will use for annotating your proof will be in the Annotations section, pictured opposite. We’ve picked out some of these tools below:

2. Strikethrough (Del) Tool – for deleting text.

Strikes a red line through text that is to be deleted.

How to use it

Highlight a word or sentence.

Click on the Strikethrough (Del) icon in the Annotations section.

3. Add note to text Tool – for highlighting a section to be changed to bold or italic.

Highlights text in yellow and opens up a text box where comments can be entered.

How to use it

Highlight the relevant section of text.

Click on the Add note to text icon in the Annotations section.

Type instruction on what should be changed regarding the text into the yellow box that appears.

4. Add sticky note Tool – for making notes at specific points in the text.

Marks a point in the proof where a comment needs to be highlighted.

How to use it

Click on the Add sticky note icon in the Annotations section.

Click at the point in the proof where the comment should be inserted.

Type the comment into the yellow box that appears.

USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION

For further information on how to annotate proofs, click on the Help menu to reveal a list of further options:

5. Attach File Tool – for inserting large amounts of text or replacement figures.

Inserts an icon linking to the attached file in the appropriate pace in the text.

How to use it

Click on the Attach File icon in the Annotations section.

Click on the proof to where you’d like the attached file to be linked.

Select the file to be attached from your computer or network.

Select the colour and type of icon that will appear in the proof. Click OK.

6. Add stamp Tool – for approving a proof if no corrections are required.

Inserts a selected stamp onto an appropriate place in the proof.

How to use it

Click on the Add stamp icon in the Annotations section.

Select the stamp you want to use. (The Approved stamp is usually available directly in the menu that appears).

Click on the proof where you’d like the stamp to appear. (Where a proof is to be approved as it is, this would normally be on the first page).

7. Drawing Markups Tools – for drawing shapes, lines and freeform annotations on proofs and commenting on these marks.

Allows shapes, lines and freeform annotations to be drawn on proofs and for comment to be made on these marks..

How to use it

Click on one of the shapes in the Drawing Markups section.

Click on the proof at the relevant point and draw the selected shape with the cursor.

To add a comment to the drawn shape, move the cursor over the shape until an arrowhead appears.

Double click on the shape and type any text in the red box that appears.