We present a case of a seventy-two year old female found on colonoscopy to have multiple polyps and an ascending colon mass that was biopsy proven adenocarcinoma who underwent a robotic assisted right hemicolectomy with intracorporeal anastomosis.
DOI# http://dx.doi.org/10.17797/54hba94993
Editor Recruited by: Vincent Obias
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 The colon was retracted medially and the lateral attachments of the ascending colon and the terminal ileum were freed to allow mobilization.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
Review Robotic Assisted Right Hemicolectomy with Intracorporeal Anastomosis. Cancel reply
Related Videos
Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Robotic Assisted Right Hemicolectomy with Intracorporeal Anastomosis.