Suprapubic approach for robotic complete mesocolic excision in right colectomy: Oncologic safety and short-term outcomes of an original technique

https://doi.org/10.1016/j.ejso.2017.07.020Get rights and content

Abstract

Introduction

Right-sided colon cancer has a worse prognosis than left-sided colon cancer. Complete mesocolic excision (CME) with central vessels ligation (CVL) reduces local recurrence, but is technically demanding, particularly with a laparoscopic approach.

Aim of this study is to describe a new robotic approach to right colectomy with CME and CVL and to report oncologic safety and short term outcomes.

Methods

Twenty consecutive patients were included. All patients had a right colon adenocarcinoma and underwent right colectomy with a suprapubic approach. Surgery was realized with the Da Vinci Xi® system and all trocars were placed along a horizontal line 3–6 cm above the pubis. CME with CVL was realized in all the patients.

Data analysed were: duration of surgery, conversions to open surgery, intraoperative and postoperative complication by Clavien Dindo classification, margins of resections, length of specimen and number of lymph nodes retrieved.

Results

Patients median age was 69 years, median body mass index was 27 kg/m2. Median operative time was 249 min, blood loss was negligible, no conversions to open or laparoscopic surgery occurred. Median hospital stay was six days; two postoperative grade IIIa Clavien–Dindo complications occurred, no 30-days postoperative death was registered. Resection margins were negative in all patients; median tumour diameter was 3.6 cm, median specimen length was 40 cm, median number of harvested lymph nodes was 40.

Conclusions

Robotic right colectomy with CME using a suprapubic approach is a feasible and safe technique that allows for an extended lymphadenectomy and provides high quality surgical specimens.

Introduction

Oncologic outcomes in right-sided colon cancers are worse than in left-sided ones [1], [2], and oncologic adequacy of surgery is a determinant factor [3].

In 2008, West et al.[4] demonstrated a significant 15% survival benefit in patients who had surgery for colon cancer with a surgical specimen that had a bulky and intact mesocolon rather than a mesocolon with little bulk and deep tears up to the muscularis propria.

In 2009 Hohenberger et al.[5] provided evidences that, in addition to mesocolon integrity, central vessel ligation (CVL) and adequate specimen length would be of paramount importance for obtaining oncologically adequate colon resection, by increasing the number of lymph nodes retrieved.

Since its description, the adoption of CME in colon cancer surgery has repeatedly shown to provide better oncologic results when compared to standard colectomy [6], [7], [8], [9], [10], [11].

Nevertheless, right colectomy with CME is still not widely adopted, both with open and even more with a minimally invasive approach, mainly due to its technical challenges [12] and a potential increase of complications [13].

The short-term advantages of minimally-invasive surgery have been clearly demonstrated, and a minimally-invasive approach should be the treatment of choice for patients with right colon cancer [14], [15], [16].

Robotic surgery has been conceived to overcome some of the technical limitations of standard laparoscopy: its potential benefits appear mostly exploitable in complex surgical procedures requiring, in particular, precise vascular dissection and extended lymphadenectomy, as in right colectomy with CME and CVL.

Furthermore, the last Da Vinci Xi® robotic system may present some additional advantages in colorectal procedures in comparison with previous versions, such as a simpler docking, the possibility to position the optical system in any of the arms, and thinner robotic arms easier to move.

The aim of this study is to present a preliminary experience of robotic right colectomy with CME and CVL with a new technique of extensive posterior dissection using a suprapubic approach and trocar layout.

Section snippets

Patients and methods

Twenty consecutive patients with a histologically-proven diagnosis of adenocarcinoma of the caecum, ascending or proximal transverse colon without evidence of distant metastases who received a robotic right colectomy with Xi® system at two different centres (European Institute of Oncology, Milan, Italy and Misericordia Hospital, Grosseto, Italy) were analysed from prospectively collected institutional databases. The study was conducted according to the Helsinki declaration guidelines.

Surgical technique

The patient is positioned in supine position, with arms and legs adducted; hips are lifted and thighs lowered in order to avoid any collision with the robotic arms. The operative table is in slight Trendelenburg position (10°) and rotated to the left (10°).

After creation of pneumoperitoneum using a Veress needle placed in the left hypochondrium, four robotic trocars are inserted along a horizontal suprapubic line, 3–6 cm above the pubis; an accessory 10 mm trocar for the assistant is inserted

Results

From July to December 2016, 20 patients underwent robotic right colectomy with the Xi® robotic system and suprapubic approach.

Study population comprises 10 males and 10 females with a median age of 69 years (range 57–89) and a median body mass index of 27 kg/m2 (range 19–40).

Tumour was located in the caecum in 6 cases (30%), in the ascending colon in 7 cases (35%), and at the hepatic flexure or proximal transverse colon in the remaining 7 cases (35%).

Seven patients (35%) had previous abdominal

Discussion

Recent reviews [1], [2] confirmed that right-sided colon cancers have a worse prognosis than left-sided ones; this difference in outcomes is reported to be related not only to a different biology of the disease, but also to the adequacy of surgery.

Surgery is the mainstay of cure for colon cancer, therefore oncological adequacy of resection is of paramount importance in providing patients with an effective treatment [3].

It has been clearly demonstrated that minimally-invasive surgery can achieve

Funding source

No funding was obtained for paper drafting and completion.

Conflict of interest

Giuseppe Spinoglio and Paolo Pietro Bianchi are proctor for Intuitive Surgical.

References (41)

  • E. Storli et al.

    Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II

    Tech Coloproctol

    (2014)
  • N.P. West et al.

    Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon

    J Clin Oncol

    (2010)
  • C.F. Chow et al.

    Laparoscopic complete mesocolic excision: West meets East

    World J Gastroenterol

    (2014)
  • C.A. Bertelsen et al.

    Short-term outcomes after complete mesocolic excision compared with ‘conventional’ colonic cancer surgery

    Br J Surg

    (2016)
  • J. Fleshman et al.

    Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST study group trial

    Ann Surg

    (2007)
  • The Colon Cancer Laparoscopic or Open Resection Study Group et al.

    Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial

    Lancet Oncol

    (2009)
  • B.L. Green et al.

    Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

    Br J Surg

    (2013)
  • D. Dindo et al.

    Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey

    Ann Surg

    (2004)
  • M.S. Cho et al.

    Modified complete mesocolic excision with central vascular ligation for the treatment of right-sided colon cancer: long-term outcomes and prognostic factors

    Ann Surg

    (2015)
  • M. Milone et al.

    Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers

    Surg Endosc

    (2015)
  • Cited by (32)

    View all citing articles on Scopus
    View full text