Robot-Assisted Right Hemicolectomy with a Page-Turning Approach

Abstract

Introduction:

The no-touch isolation, which involves ligating and dissecting the blood vessels prior to touching the tumor, along with complete mesocolic excision (CME), ensures oncologic resection and contributes to improved long-term prognosis. ¹ For right-sided colon cancer, right hemicolectomy has two central vascular ligation sites, the ileocolic artery (ICA) and middle colic artery (MCA), demanding a no-touch isolation technique. Although several approaches for right hemicolectomy are reported, discussion from the perspective of no-touch isolation is lacking. ^2,3 Minimally invasive surgery using robotic assistance is increasingly common, although concerns abound about tissue damage due to the lack of tactile feedback. ⁴ Therefore, in robot-assisted right hemicolectomy, vascular control should be performed before mobilization of the mesocolon. In laparoscopic surgery, the “page-turning approach” is used for no-touch isolation by performing vascular treatment before mesocolon mobilization. ^5,6 This video illustrates a “page-turning” robot-assisted right hemicolectomy using the da Vinci Xi system (Intuitive Surgical Inc.).

Materials and Methods:

A 65-year-old female presented with ascending colon cancer, T4aN1bM0 Stage IIIB. The ports were arranged in an inverted L-shape. First, the omental bursa was opened, the transverse mesocolon was dissected along the right edge of the left branch of the MCA, and the transverse colon was divided intracorporeally. Following a cranial-to-caudal approach, mesocolon dissection continued to the root of the MCA, exposing the superior mesenteric artery and superior mesenteric vein. After dissecting the MCA, dissection was continued caudally to clear the surgical trunk and dissect the ICA and ileocolic vein. The anterosuperior pancreaticoduodenal vein branching independently of the superior mesenteric vein, was exposed and preserved, and the accessory right colic vein, branching from the gastrocolic trunk, was dissected. The transverse mesocolon was fully mobilized distally to the right gastroepiploic vein. After vascular dissection was performed, mobilization of the ascending mesocolon was performed from the inside out, as in “page-turning,” and the distal ileum was resected. Mobilization of the ascending colon from the inside completed the CME. The anastomosis was performed extracorporeally.

Results:

The operative time was 174 minutes, and blood loss was 2 mL. The postoperative course was uneventful with no complications, and the patient was discharged on postoperative day seven. This procedure has been performed on four patients, including the present case. The results were as follows: median age was 71 years (65–75), BMI was 25.6 kg/m² (18.1–31.9), operation time was 220 minutes (174–244), median blood loss was 2 mL (2–37), and postoperative hospital stay was 7 days (7–14). No postoperative complications of Clavien–Dindo grade III or higher were observed.

Conclusions:

Our robot-assisted right hemicolectomy was safely performed using a page-turning approach. Further accumulation of cases and investigation of long-term outcomes are required.

Copyright information:

The artwork of the video’s background has been cited from the following article by He et al.: He Z, Zhang S, Xue P, et al. Completely medial access by page-turning approach for laparoscopic right hemi-colectomy: 6-year-experience in single center. Surg Endosc. 2019;33(3):959–965. doi:10.1007/s00464-018-6525-1. We have obtained copyright permission from the publisher, Springer Nature (license number: 5907701444136, license date: Nov 14, 2024).

No competing financial interests exist.

Runtime of video: 6 mins 55 secs.