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

摘要

Introduction Since the 1990’s, the surgical treatment for colorectal cancers has seen substantial developments over the years, particularly following the introduction of minimally invasive surgical concept by the way of laparoscopic 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 lymphadenectomy and complete mesocolic excision potentially might offer additional benefits. Methodology We report here a detailed operative technique and feasibility for performing a robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision and using intracorporeal anastomosis. Conclusion We believe that robotic right hemicolectomy with D3 lymphadenectomy, 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 laparoscopic 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 hemicolectomy was undertaken. The concept of D3 lymphadenectomy as introduced 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 oncological advantage 8–10 . Although there have been welldocumented reports of D3 lymphadenectomy or CME performed laparoscopically, there are only very limited reports in the published literature regarding this undertaken, robotically. 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 operation, 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 pressure 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 midclavicular 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.