robotic right hemicolectomy with d3 lymphadenectomy and

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Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

FOR CITATION PURPOSES: Mathew R , Kim SH . Robotic right hemicolectomy with D3 lymphadenectomy and completemesocolic excision: technical detail. OA Robotic Surgery 2013 Jun 01;1(1):6.

Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail

R Mathew * , SH Kim

Abstract Introduction Since the 1990’s, the surgical treat-ment for colorectal cancers has seen substantial developments over the years, particularly following the introduction of minimally invasive surgical concept by the way of lapa-roscopic surgery. This minimally invasive surgical modality has seen further progress since the advent of robotic surgery. Although robotic right hemicolectomy, performed in the standard fashion, has been performed safely for right colon cancers, there seems to be debate about the added advantages of robotic approach over a laparoscopic approach. However, a robotic right hemicolectomy with D3 lymphad-enectomy and complete mesocolic excision potentially might offer addi-tional benefits. Methodology We report here a detailed opera-tive technique and feasibility for performing a robotic right hemicolec-tomy with D3 lymphadenectomy and complete mesocolic excision and using intracorporeal anastomosis. Conclusion We believe that robotic right hemi-colectomy with D3 lymphadenec-tomy, with complete mesocolic excision, is a realistic and feasible operation for right colon cancers.

Introduction The right colon cancers have been traditionally treated with a standard open right hemicolectomy, and over

the last two decades this has been similarly performed by a laparo-scopic approach. Since the advent of robotic colorectal surgery, first reported by Weber et al. in 2002 1 for robot-assisted colectomy, there has been an increasing trend for the use of robotic surgery in colorectal cancer resections over the years.

Robotic right hemicolectomy has been shown to be feasible and safe, especially from an oncological point of view in several studies 2–4 . The main areas of debate surround around longer operative times and higher cost involved in robotic surgery compared to laparoscopic surgery. These comparative studies and evidence have been primarily, when a standard right hemicolec-tomy was undertaken. The concept of D3 lymphadenectomy as intro-duced by the Japanese surgeons 5,6 , and a similar concept of complete mesocolic excision (CME) 7 proposed by European surgeons provides increased radicality in oncological resections and hence, potentially offer the possibility of better onco-logical advantage 8–10 .

Although there have been well-documented reports of D3 lymphad-enectomy or CME performed laparo-scopically, there are only very limited reports in the published literature regarding this undertaken, roboti-cally. We describe technical aspects of our operative approach to perform a totally robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis.

Methodology Operative techniques for robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis

We used the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA).

Patient position, port placement, cart placement and Robert docking Once general anaesthesia is induced, patient is supine positioned over bean bags that are used as anti-sliding restrainers. Prior to start of opera-tion, we use standard pre-operative measures of antibiotics prophylaxis, urethral catheterisation, anti-embolic compression stockings and pneumatic calf-muscle pumps. It is also advisable to place some cotton roll/gel padding between left shoulder of the patient and bean bag to prevent undue pres-sure on patient shoulder from the vacuum-hardened bean bags.

We use five ports as standard for our robotic right hemicolectomy procedures as follows (Figure 1): Camera port in the left spinoumbilical line (SUL, line jo ining left anterior superior iliac spine and umbilicus) at a position 2–3 cm medial to left mid-clavicular line (MCL). We use a balloon of 12 mm camera port in obese patients. The robotic arm 1 port is placed on the left MCL, around 8 cm below the costal margin. The robotic arm 2 is placed in the midline, in the suprapubic area, with distance to symphysis pubis of 3 cm. The robotic arm 3 is placed on right SUL and 2 cm lateral to right MCL. Apart from the 12 mm camera robotic port, rest of the robotic arm ports are 8 mm in size. A final 5th port is inserted for the assis-tant, which is a 5 mm port placed in the left iliac fossa, just lateral to left MCL. The assistant port is primarily used for suction and can also be used for gentle bowel retraction.

Once all the ports are inserted, with the optical port inserted first under direct vision using open Hassan’s technique, the patient is placed in a 15°–30° Trendelenburg tilt and a 15°

Genera

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* Corresponding authorEmail: [email protected]

Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital,Anam-dong 5-Ga, Seongbuk-gu, Seoul 136-705, Korea

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Figure 2: Dissection of ileocolic vein.

Figure 1: Site for port positions for robotic right hemicolectomy.

right side tilt upwards. Pneumoperi-toneum is initially set at 12 mm Hg. Visual inspection of abdominal cavity and pelvis is performed to assess any obvious evidence of distant meta-static disease. The greater omentum is retracted over and above trans-verse colon, which is then subse-quently pushed up superiorly. The small bowel (SB) is retracted medi-ally so as to place the SB on the left side of patient’s abdominal cavity. 10x10 cm gauze is used to help retain medial SB retraction. This manoeuvre helps visualisation of root of ileocolic pedicle, and also helps during the D3 lymphadenectomy and CME. Finally,

pneumoperitoneum is reduced to8 mm Hg.

The robotic cart is then brought at an angle over the right shoulder of patient. The ports are then docked to the robot—optical zero degree robotic camera, monopolar curved scissors for surgeon’s right arm (robotic arm 1), Cadiere grasper is used as surgeon’s second left arm (robotic arm 2) and Maryland bipolar forceps for use as surgeon’s first left hand (robotic arm 3).

The full insertion of the three working instruments is to be performed under direct vision. Prior to start of next stage of operation

of undertaking robotic surgery, it is important to ensure that there is adequate space between all the robotic arms, particularly the shoulder and elbows. Also, once docked, the positions of the patient should not be changed without undocking completely. The diathermy settings are set as follows: Bipolar settings at 30 (standard), and Monop-olar settings at 25 Cutting (pure) and 25 Coagulation (fulgurate).

Operative part The ileocolic pedicle is identified and then lifted up using Cadiere grasper. The dissection then starts around the origin of ileocolic pedicle. During the dissection process, duodenum is identified and dissected free from ileocolic pedicle. The ileocolic vein and ileocolic artery are identified at its origin from superior mesenteric vein (SMV) and superior mesen-teric artery (SMA). The ileocolic vein (Figure 2) and ileocolic artery (Figure 3) is then divided after ligating near its origin, using 5 mm robotic Hem-O-Lok clips (Weck Closure Systems, Research Triangle Park, NC), with two clips placed prox-imally on patient’s side.

The next step is to dissect along the central vasculature of SMV and SMA axes towards the cephalad direc-tion, dissecting out the entire right colonic mesocolic tissues. During this dissection process along the central vasculature, the right colic, if present is ligated using the Hem-O-Lok clips near its origin (Figure 4) and is then divided. Further dissection of ceph-alad reveals the middle colic vessels and then the right branch of middle colic artery (Figure 5) and vein are clearly identified, and ligated indi-vidually near its origin and then divided. For the ligation of all named major vessels, two Hem-O-Lok clips are placed proximally on patient’s side prior to division. Care is taken to dissect out the entire right colon mesocolic tissues up to the root of the middle colic vessels. The medial to lateral dissection is then completed over the Gerota’s fascia, taking care to

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Figure 3: Dissection of ileocolic artery.

Figure 4: Dissection of right colic artery. SMA, superior mesenteric artery.

Figure 5: Dissection of right branch of middle colic artery.

Figure 6: Stapler transection of transversecolon.

identify and preserve the duodenum, right ureter and gonadal vessels.

The next step of operation is to dissect off the greater omentum, in the avascular plane, from the distal third of transverse colon and works proximally. However, if the

tumour is situated at hepatic flexure or proximal transverse colon, we divide the right half of greater omentum so as to include with the final resection specimen. The supe-rior mobilisation of transverse colon is then completed over the hepatic

flexure. The lateral dissection is then completed, dissecting off the lateral attachments of the right colon. The terminal ileal mesentry is also dissected free.

The transverse colon is then tran-sected (Figure 6) using ‘Echelon FLEX™ 60 blue cartridge’ stapler (Ethicon Endo-Surgery, Inc.). The terminal ileum is also stapler transected (Figure 7) in a similar fashion. In order, to introduce the stapler, the third robotic arm port, in the suprapubic site, is tempo-rarily undocked and then this site is enlarged to insert a 12 mm port so as to accommodate the stapler. (Also to be noted is that this site eventually becomes the specimen extraction site). The specimen is then placed in a retrieval bag (Figure 8) and the bag is closed around its purse-string.

The terminal ileum and distal transverse colon resected ends are placed adjacent to each other, after ensuring that there is no mesenteric twist, and a stay suture is applied (Figure 9) to aid the approximation of the bowel segments and to use as a traction during stapler insertion. An enterotomy and colostomy are made to aid the insertion of ‘Echelon FLEX™ 60 blue cartridge’ stapler and a side-side; iso-peristaltic, stapled anastomosis is then created intracor-poreally (Figure 10). The enterotomy and colostomy stapler insertion site is then closed with continuous stitches using intracorporeal robotic suturing (Figure 11). Prior to anas-tomosis, checks are made to ensure a tension-free anastomosis with good blood supply. Following anastomosis, staple lines and enterotomy closure sites are inspected to ensure integrity of closure and that the anastomosis is healthy and patent.

The specimen bag is then grasped with a grasper from the assistant port and then the robotic arms are undocked. Haemostasis is ensured prior to undocking, and following undocking, haemostasis is ensured of the port sites. The suprapubic port site is area, which is enlarged

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Figure 7: Stapler transection of terminalileum.

Figure 8: Resected specimen insertion into retrieval bag.

Figure 9: Placement of stay suture prior to stapler anastomosis.

Figure 10: Stapler anastomosis, ileo-transverse colic, side-side, iso-peristaltic. Figure 11: Intracorporeal suturing of

stapler entry enterotomy site.

to 3–4 cm, and a wound protector system (Alexis) is inserted and the specimen is extracted and sent for histology.

The extraction site is then washed out and fascia is closed in layers using ‘0’ Vicryl stitches, and the remainder port sites’ fascia is closed with ‘2.0’ Vicryl stitches. The skin is closed with subcuticular absorbable stitches.

Discussion Robotic colonic surgery has gained some interest in recent times following the first reported robot-assisted colectomy in 2002 1 . Compar-isons of robotic colonic surgery to laparoscopic surgery have shown comparable outcomes 11 , and further studies have shown acceptable safety and oncological outcomes for robotic right colonic surgery 2–4 . However, there are disadvantages for robotic surgery with longer operating times 2,12 and increased costs.

The concept of CME, with central vascular ligation, where the tumour

along with the entire associated mesocolon is dissected along the embryological planes and resected after ligation near the origin of central vascular tree, has been getting some increased prominence following better oncological outcomes 7,8 . The Japanese surgeons as per their national colorectal society advo-cate a similar approach in their D3 lymphadenectomy for their advanced colon cancers 5,6 and with a simi-larly better outcome. There are very limited reports regarding under-taking a robotic colonic surgery utilising the D3 lymphadenectomy and CME approach, and we describe here the operative technique for undertaking this procedure.

In our opinion, totally robotic right hemicolectomy, with intracorporeal anastomosis may offer some addi-tional benefits, including need for less dissection of distal transverse colon, which is usually required for a tension-free anastomosis when an extracorporeal anastomosis is

undertaken. Also, in complete robotic approach, the site of specimen extraction site can be cited anywhere to aid cosmesis. We believe that smaller extraction sites, as a result of not requiring extracorporeal anasto-mosis, may help reduce pulmonary morbidity, especially if the incision sites are also much lower on the abdominal wall. In our opinion, the Pfannenstiel approach may be the best, as it also offers better cosmesis. It has been shown in other studies that Pfannenstiel offers better cosmesis, with low incisional hernias of 0%–2% 13–15 compared to up to 24% for midline extraction sites in laparoscopic-assisted surgery 16,17 . Finally, it still remains to be seen whether robotic right hemicolectomy with D3 lymphadenectomy and CME offers any additional benefits over laparoscopic or even conventional open operations. There is no existing current data regarding this and there is a requirement for further studies to evaluate this. Till that time, consid-ering the longer operating times and increased costs, the true beneficial role of robotic surgery remains yet to be fully established, particularly from an oncological point of view.

Conclusion We believe that robotic right hemi-colectomy with D3 lymphadenec-tomy with CME is a realistic and feasible operation for right colon cancers. However, considering the lack of available comprehensive comparative data, it is not possible at

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the current time to have a true overall picture and conclusively establish any benefits of robotic approach over a laparoscopic or conventional-open operation.

Abbreviations list CME, complete mesocolic excision; MCL, mid-clavicular line; SB, small bowel; SMA, superior mesenteric artery; SMV, superior mesenteric vein; SUL, spinoumbilical line.

Acknowledgement The photos used as figures in this article were captured from an edited video authored by Ker Kan Ta n, Charles B Tsang, Seon Hahn Kim and Dean C Koh, of the Division of Colo-rectal Surgery, University Surgical Cluster, National University Health System, Singapore.

References 1. Weber PA, Merola S, Wasielewski A, Ballantyne GH. Telerobot-assisted lapa-roscopic right and sigmoid colectomies for benign disease. Dis Colon Rectum. 2002 Dec;45(12):1689–94. 2. deSouza AL, Prasad LM, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic assistance in right hemicolec-tomy: is there a role? Dis Colon Rectum. 2010 Jul;53(7):1000–6. 3. Zimmern A, Prasad L, Desouza A, Marecik S, Park J, Abcarian H. Robotic colon and rectal surgery: a series of 131 cases. World J Surg. 2010 Aug;34(8):1954–8.

4. D’Annibale A, Pernazza G, Morpurgo E, Monsellato I, Pende V, Lucandri G, et al. Robotic right colon resection: evalu-ation of first 50 consecutive cases for malignant disease. Ann Surg Oncol. 2010 Nov;17(11):2856–62. 5. Sugihara K, editor. Japanese Society for Cancer of the Colon and Rectum: Japa-nese classification of colorectal carci-noma. 2nd ed. Tokyo, Japan: Kanehara; 2009.p27–8. 6. Okuno K. Surgical treatment for diges-tive cancer. current issues - colon cancer. Dig Surg. 2007 May;24(2):108–14. 7. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome. Colorectal Dis. 2009 May;11(4):354–64. 8. West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P. Complete mesocolic excision with central vascular ligation produces an oncologically supe-rior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol. 2010 Jan;28(2):272–8. 9. Higuchi T, Sugihara K. Complete meso-colic excision (CME) with central vascular ligation (CVL) as standardised surgical technique for colonic cancer: a Japanese multicentre study. Dis Colon Rectum. 2010;53:646. 10. West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, et al. Understanding optimal colonic cancer surgery: comparison of Japa-nese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol. 2012 May;30(15):1763–9.

11. Rawlings AL, Woodland JH, Vegunta RK, Crawford DL. Robotic versus lapa-roscopic colectomy. Surg Endosc. 2007 Oct;21(10):1701–8. 12. Rawlings AL, Woodland JH, Craw-ford DL. Telerobotic surgery for right and sigmoid colectomies: 30 consecutive cases. Surg Endosc. 2006 Nov;20(11):1713–8. 13. DeSouza A, Domajnko B, Park J, Marecik S, Prasad L, Abcarian H. Inci-sional hernia, midline versus low trans-verse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy? Surg Endosc. 2011 Apr;25(4):1031–6. 14. Kisielinski K, Conze J, Murken AH, Lenzen NN, Klinge U, Schumpelick V. The Pfannenstiel or so called ‘‘bikini cut’’: still effective more than 100 years after first description. Hernia. 2004 Aug;8(3):177–81. 15. Orcutt ST, Balentine CJ, Marshall CL, Robinson CN, Anaya DA, Artinyan A, et al. Use of a Pfannenstiel incision in minimally invasive colorectal cancer surgery is associated with a lower risk of wound complications. Tech Coloproctol. 2012 Apr;16(2):127–32. 16. Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM. Wound complications of laparoscopic vs open colectomy. Surg Endosc. 2002 Oct;16(10):1420–5. 17. Singh R, Omiccioli A, Hegge S, McKinle C. Does the extraction-site loca-tion in laparoscopic colorectal surgery have an impact on incisional hernia rates? Surg Endosc. 2008 Dec;22(12):2596–600.

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