Robotic Right Hemicolectomy with Complete Mesocolic Excision and Intracorporeal Anastomosis: A Video Vignette

Abstract

Introduction:

Minimally invasive approaches to right colon resection are associated with improved patient and similar oncologic outcomes compared with open surgery. ^1,2 The intrinsic advantages of the robotic platform include better observation, intra-abdominal access, and stability. ^3,4 Furthermore, in contrast with a laparoscopic approach to a right hemicolectomy, robotic approaches are associated with lower anastomotic complications, increased lymph node harvest, reduced length of stay, lower conversion to open surgery, and comparable morbidity and 30-day mortality. ⁵ This video shows a superior mesenteric vein (SMV) first approach for a robotic right hemicolectomy (RRH) with complete mesocolic excision (CME) and intracorporeal anastomosis. The video also demonstrates ectasia of the middle colic artery. Lastly, data are presented comparing RRH with CME and conventional RRH (without CME).

Methods:

An 83-year-old female presented with symptomatic anemia secondary to a circumferential proximal ascending moderately differentiated adenocarcinoma. Staging scans revealed cecal thickening and multiple right-sided liver lesions without evidence of distant metastases elsewhere. Upfront surgery was offered because of the symptomatic anemia. The SMV-first approach for the vascular dissection began anterior to the anteromedial aspect of the SMV, inferior to the ileocolic pedicle. The dissection continued superiorly along the SMV to sequentially expose the ileocolic pedicle (divided), the trunk of Henle (colic branch divided), and the right branch of an ectatic middle colic artery (divided). The omentum was dissected from the transverse mesocolon and lesser sac entered. The dissection continued laterally to complete the mobilization of the ascending colon and hepatic flexure. The terminal ileum and transverse colon were transected. The use of indocyanine green fluorescence confirmed bowel perfusion. Finally, an intracorporeal isoperistaltic anastomosis was created.

Results:

Total operative time was 180 minutes. The patient was discharged on day 8 postoperatively without complication. Histopathology showed a T3N2a moderately to poorly differentiated adenocarcinoma with 5 out of 33 lymph nodes positive. At our institution, short-term postoperative outcomes and tumor characteristics for 51 patients who underwent RRH with CME (n = 25) and conventional RRH (n = 26) were compared. The mean lymph node harvest was significantly higher in the CME group 37.7 (standard deviation [SD] 12.9; interquartile range [IQR] 30–46) compared with the conventional group 21.8 (SD 7.5; IQR 16.3–25; p < 0.001). There were no other significant differences for short-term postoperative complications and tumor characteristics.

Conclusion:

While illustrating the inherent advantages of the robotic platform, this case also highlights the safety and efficacy of the SMV-first approach for RRH with CME. Furthermore, in our institution, patients who underwent RRH with CME were associated with higher lymph node yield. Although evidence is conflicting, an increased lymph node harvest in CME may be associated with more accurate staging, reduced tumor recurrence, and improved longer term outcomes. ⁶

No competing financial interests exist.

Source of work:

The video was sourced from the Epworth Freemason Hospital, East Melbourne, Australia. There are no associated conflicts of interest or obligations resulting from the source of work.

Runtime of video: 10 mins 30 secs