Robotic Assisted Right Hemicolectomy with Intracorporeal Anastomosis

The cadiere grasper, a fenestrated bipolar grasper, and a hook electrocautery were placed in the robotic ports. The ileocolic vessel was lifted and plane underneath was developed, with a pocket created above the duodenum. The ileocolic was divided using the vessel sealer. The dissection was continued up to the level of the transverse colon and again up over the duodenum. This was done in order to free up the transverse colon so it could be completely mobilized. The colon was retracted medially and the lateral attachments of the ascending colon and the terminal ileum were freed to allow mobilization. This was continued up and around the hepatic flexure, to ensure full tension free mobilization of the transverse colon. The ileum was elevated and a GIA stapling device was used to come across the small bowel. The vessel sealer was used to divide the mesentery of the small bowel. Next the proximal transverse colon was elevated and a GIA stapling device was used to come across the bowel. Vessel sealer was again used to divide the mesentery. At this point, Firefly was used to ensure good perfusion of both the small and large bowel. An intentional enterotomy was created in the small bowel and an intentional colotomy was made in the colon, the GIA stapler was placed through each limb of the bowel. These two ends were lined up and then the GIA stapler was deployed. A second firing of the stapler was then deployed by extending the stapler into the crotch of the previous staple line. The common enterotomy suture was placed at the end and a running Vicryl suture was used to close the common enterotomy. A second Vicryl suture was used from the bottom up and the two Vicryl sutures were then tied in the middle. This was then oversewn using a running V-Loc suture. The robot at this point was undocked. The camera port was upsized to allow the collection bag to be placed into the abdominal cavity to collect the colon. An Alexis wound protector was placed while the specimen was placed into an endocatch bag, and delivered through the midline. The incision was copiously irrigated and hemostasis was obtained. Leak test was performed under direct vision via insufflation from a colonoscope advanced to the sigmoid colon. There were no signs of bubbling or leak. Abdomen was irrigated. Hemostasis was obtained. Omentum was brought down near the anastomosis and midline incision closed with two #1 PDS sutures. Port sites were closed with Monocryl suture. The patient was discharged home from the hospital on POD #2, final pathology showed tubulovillous adenoma with focal surface of high grade dysplasia. Margins with no abnormalities. Twelve lymph nodes were negative for metastatic disease. Patient is doing well postoperatively.

Indications to proceed with colorectal surgery include various benign and malignant causes. Patients may present to the office or to the hospital and there are different elective vs emergent reasons to intervene surgically in patients. In this particular case, the patient presented electively for tumor removal, which was biopsy proven adenocarcinoma of the colon

There are few absolute contraindications to colon resection and there should be an active discussion between the patient and the doctor about risks/benefits and all available treatment options. Indications for minimally invasive surgery have expanded and issues previously considered contraindication to a minimally invasive approach, such as morbid obesity, palpable mass, bowel obstruction and patients who have had multiple previous abdominal surgeries would not be candidate for minimally invasive procedures; however, recent studies have called these issues into question, and many surgeons are offering minimally invasive procedures to these patients. The majority of surgeons will still perform open operations instead of minimally invasive surgery in an unstable patient, patients with toxic megacolon, and for fecal peritonitis.

Patient was taken to the OR, urology performed cystoscopy with right ureteral stent insertion. Patient was positioned in lithotomy with careful attention to positioning. Lithotomy is preferred to allow additional assistant positioning. Veress needle was placed in RUQ and used to insufflate the abdomen. Once insufflated, a trocar was placed at the level just superior to the umbilicus and diagnostic laparoscopy was performed. The tattooed area of the colon was identified in the proximal ascending colon. It was decided at this point to proceed with robotic procedure. Three more trocars were placed, all in the midclavicular line under direct vision. The robot was docked over the patient�s right shoulder.

Preoperative evaluation begins with a thorough history and physical, paying attention to the number and type of previous abdominal surgeries. Based on the patient's age and previous medical history, the patient should have an EKG, a CXR, and appropriate blood work including nutrition labs. Cardiology and/or pulmonary consultation may be needed as well, again, depending on patient's age and history. Patients who have been diagnosed with colorectal cancer must undergo staging workup, which includes computed tomography (CT) scans and colonoscopy to rule out synchronous colonic lesions. Minimally invasive surgery adds a new twist to the surgical procedure. Previously, during an open procedure, a mass/lesion could be palpated and removed by palpating the colon; however, when performing minimally invasive surgery this is not possible. Various techniques have been developed to help localize the lesions. If the lesions are not marked properly, the surgeon may wind up removing the wrong segment of colon. Options available for preoperative localization include barium enema, CT colonography, colonoscopy with India ink injection or placement of metallic clips, and intraoperative endoscopy.

Important anatomy to be aware of is where the duodenum is located in regards to the right colon and the ileocolic vessels. Care must be taken when dissecting the colon and its mesentery to mobilize and free the ileocolic vessels.

Prior to agreeing to surgery, the surgeon must discuss risks and benefits of the procedure to the patient. The benefits of minimally invasive colorectal cancer includes decreased morbidity, shorter hospital time, less opioid analgesic use, quicker return to work, and less blood loss. Again, discussions between the patient and the surgeon should discuss all risks and benefits, and the decision for which type of surgery should be determined together.

Risks of any surgical procedure include bleeding, infection, risk to nearby organs, possible cardiac event, and even death. With minimally invasive surgery, there are some additional risks including port site hernias, gas embolus, decreased venous return causing cardiovascular collapse, and inadequate removal of tumor due to misidentification.

Risks of any surgical procedure include bleeding, infection, risk to nearby organs, possible cardiac event, and even death. With minimally invasive surgery, there are some additional risks including port site hernias, gas embolus, decreased venous return causing cardiovascular collapse, and inadequate removal of tumor due to misidentification.

Thank you to Dr. Maloney Patel for her help and guidance

http://www.uptodate.com/contents/overview-of-colon-resection, http://link.springer.com/chapter/10.1007%2F978-1-4939-1581-1_4, http://link.springer.com/book/10.1007%2F978-1-4899-7531-7