Suprapubic approach for robotic complete mesocolic excision in right colectomy: Oncologic safety and short-term outcomes of an original technique
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)
- et al.
The worse prognosis of right-sided compared with left-sided colon cancers: a systematic review and meta-analysis
J Gastrointest Surg
(2016) - et al.
Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study
Lancet Oncol
(2008) - et al.
Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study
Lancet Oncol
(2015) - et al.
Improved survival after an educational project on colon cancer management in the county of Stockholm – a population based cohort study
Eur J Surg Oncol
(2015) - et al.
Implementation of complete mesocolic excision at a university hospital in Denmark: an audit of consecutive, prospectively collected colon cancer specimens
Eur J Surg Oncol
(2014) - et al.
Prognostic survival associated with left-sided vs right-sided colon cancer: a systematic review and meta-analysis
JAMA Oncol
(2016) Surgical considerations in patients with cancer of the colon and rectum
Semin Oncol
(1991)- et al.
Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome
Colorectal Dis
(2009) - et al.
Surgical technique and survival in patients having a curative resection for colon cancer
Dis Colon Rectum
(2003) - et al.
Extended lymph node dissection in colorectal cancer surgery. Reliability and reproducibility in assessments of operative reports
Int J Colorectal Dis
(2010)
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
Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon
J Clin Oncol
Laparoscopic complete mesocolic excision: West meets East
World J Gastroenterol
Short-term outcomes after complete mesocolic excision compared with ‘conventional’ colonic cancer surgery
Br J Surg
Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST study group trial
Ann Surg
Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial
Lancet Oncol
Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer
Br J Surg
Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey
Ann Surg
Modified complete mesocolic excision with central vascular ligation for the treatment of right-sided colon cancer: long-term outcomes and prognostic factors
Ann Surg
Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers
Surg Endosc
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