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

Surgical outcomes of a prospective, phase 2 trial of robotic surgery for resectable right-sided colon cancer (the ROBOCOLO trial)

Aim

We evaluated the safety of robotic surgery for right-sided colon cancer in Japan.

Methods

This was a prospective, open-label, single-arm phase II trial conducted at two institutions. Patients ≥20 years old with stage I-III right-sided colon cancer and scheduled for radical resection with ≥D2 lymph node dissection were eligible. The criterion for surgeons was experience performing robot-assisted rectal resection in ≥40 cases. The primary endpoint was the postoperative complication rate ≤30 days after surgery.

Results

From August 2021 to February 2023, 42 patients were enrolled; three were excluded, with 39 analyzed as the full analysis set. The median age was 72 years, and the median body mass index was 23.2. The tumor was located in the cecum in 13 cases (33.3%), ascending colon in 20 cases (51.3%), and transverse colon in six cases (15.4%). Ileocolic resection was performed in 17 cases (43.5%) and right hemicolectomy in 22 cases (56.5%), both with D3 lymph node dissection. The median console time was 109 min, and the operative time was 170 min. The mean blood loss was 7.7 mL. Intracorporeal anastomosis was performed in 28 patients (71.8%). There were no conversions and no intraoperative adverse events. The median postoperative stay was 5 days. Postoperative complications occurred in four patients (10.2%; paralytic ileus [n = 3] and pneumonia [n = 1]). All postoperative complications were grade 1 or 2, with no mortalities noted. R0 resection was achieved in all patients.

Conclusions

This study demonstrated the safety and feasibility of robotic surgery for right-sided colon cancer.

Caudal-to-Cranial Approach for Right Colectomy with Complete Mesocolic Excision in Colon Cancer: A Systematic Review and Meta-analysis

BACKGROUND

A newly emerging approach "caudal to cranial" with complete mesenteric excision (CME) has recently been proposed for right colectomy in patients with right colon cancer. To date, only a few studies about this approach have appeared. Our study aims to investigate the safety and efficacy of this new technique.

METHODS

A systematic review of the literature was conducted to evaluate the evidence regarding short- and long-term outcomes after the caudal-to-cranial approach (CCA). Methodological Index for Non-Randomized Studies was used to evaluate methodological quality. The risk of bias was assessed using Robvis tool. Meta-analyses have been conducted for the outcomes of studies comparing CCA with other techniques.

RESULTS

We found six studies from 2017 to 2021 with a total of 594 patients. The postoperative complications and oncological outcomes were acceptable. Two studies comparing CCA to medial-to-lateral approach were included in the meta-analysis. No differences were found between the techniques regarding to operative time, length of hospital stay, overall morbidity, and number of lymph nodes.

CONCLUSION

Although the interpretation of our findings may be restrained by methodological limitations, risk of bias, and the absence of well-designed randomized controlled trials, CCA with CME in right-sided colon cancer may be a feasible and safe procedure.

Macroscopic Evaluation of Colon Cancer Resection Specimens

Colon cancer is a common disease internationally. Outcomes have not improved to the same degree as in rectal cancer, where the focus on total mesorectal excision and pathological feedback has significantly contributed to improved survival and reduced local recurrence. Colon cancer surgery shows significant variation around the world, with differences in mesocolic integrity, height of the vascular ligation and length of the bowel resected. This leads to variation in well-recognised quality measures like lymph node yield. Pathologists are able to assess all of these variables and are ideally placed to provide feedback to surgeons and the wider multidisciplinary team to improve surgical quality over time. With a move towards complete mesocolic excision with central vascular ligation to remove the primary tumour and all mechanisms of spread within an intact package, pathological feedback will be central to improving outcomes for patients with operable colon cancer. This review focusses on the key quality measures and the evidence that underpins them.

Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review

BACKGROUND

Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.

METHODS

PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques.

RESULTS

Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique.

CONCLUSIONS

The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Scarless laparoscopic incisions in Pfannenstiel (slip): the first 50 cases using an innovative approach in pediatric robotic surgery

Incisions in the supra-pubic region have been described robotic-assisted surgery to improve cosmetic results in adults, but seldom in children. We aimed to present an innovative trocar placement in the Pfannenstiel line, named Scarless Laparoscopic Incisions in Pfannenstiel (SLIP), and evaluate its feasibility for various intra-abdominal procedures and its cosmetic results in pediatric robotic surgery. We performed a monocentric prospective study, including children undergoing robotic-assisted surgeries using a SLIP approach (July 2019-September 2021). Data regarding demographics, surgery, and outcome were collected and reported as median (range), or number (percentage). Cosmetic results were evaluated with a questionnaire. A SLIP approach was performed in 50 children (24 cholecystectomies, 12 splenectomies, 2 cholecystectomies and splenectomies, 9 colonic resections, 2 choledochal cyst resections, and 1 pancreatic pseudocyst resection). Median age was 11 years (2-18) and median weight 35 kg (10.5-80). Conversion to laparoscopy occurred in two cases. Post-operative complications occurred in 5 patients (10%), after colectomies [intrabdominal abscess (n = 3), stoma dysfunction (n = 1), parietal abscess (n = 1)], of which 3 (6%) required reintervention (intrabdominal abscess n = 2, stoma dysfunction n = 1). Regarding scars, 68% (n = 28) of parents and patients reported the maximal score of 5/5 for global satisfaction and 63% (n = 26) had all scars hidden by underwear. SLIP approach is versatile and can be used in supra- and infra-mesocolic robotic-assisted procedures. The low complication rate shows its safety in both young children and teenagers and does not increase operative difficulties. It results in high patient satisfaction regarding scars, and a scarless abdomen.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Tunnel versus medial approach in laparoscopic radical right hemicolectomy for right colon cancer: a retrospective cohort study

PURPOSE

This study aimed to explore the feasibility and safety of the tunnel approach in laparoscopic radical right hemicolectomy for colon cancer.

METHODS

From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who underwent laparoscopic radical right hemicolectomy at the Affiliated Cancer Hospital of Zhengzhou University were enrolled. The patients were stratified into either a tunnel approach (TA) (n = 56) group or traditional medial approach (MA) (n = 50) group according to the surgical technique performed. The baseline demographics, perioperative outcomes and oncologic outcomes were compared between the two groups.

RESULTS

The baseline characteristics did not differ between groups. The TA group had significantly less blood loss [20.0 (10.0-40.0) vs. 100 (100.0-150.0) ml, p < 0.001] and a shorter operation time [128.4 ± 16.7 vs. 145.6 ± 20.3 min, p < 0.001] than the MA group. The time to first flatus and postoperative hospital stay were similar [3.0 (2.0-4.0) vs. 3.0 (3-4.0) days, p = 0.329; 10.4 ± 2.6 vs. 10.7 ± 3.0 days, p = 0.506] between the two groups. The conversion to laparotomy and complication rates were similar between groups (0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p = 0.603, respectively). No treatment-related deaths occurred in either group. The TA group did not have significantly better survival outcomes than the MA group (p = 0.372).

CONCLUSIONS

The TA seems to allow for more favourable results in terms of blood loss and operative time than the MA, with similar results regarding time to first flatus, hospital stay, postoperative complication rate, conversion rate and oncologic outcomes; moreover, the TA is easier for beginners to master.

Updates on Robotic CME for Right Colon Cancer: A Qualitative Systematic Review

Background. Complete mesocolic excision (CME) is a surgical technique introduced with the aim of ameliorating the oncologic results of colectomy. Various experiences have demonstrated favorable oncologic results of CME in comparison with standard colectomy, in which the principles of CME are not respected. The majority of the literature refers to open or laparoscopic CME. This review analyses current evidence regarding robotic CME for right colectomy. Methods. An extensive Medline (Pub Med) search for relevant case series, restricted to papers published in English, was performed, censoring video vignettes and case reports. Results. Fourteen studies (ten retrospective, four comparative series of robotic versus laparoscopic CME) were included, with patient numbers ranging from 20 to 202. Four different approaches to CME are described, which also depend on the robotic platform utilized. Intraoperative and early clinical results were good, with a low conversion and anastomotic leak rate and a majority of Clavien–Dindo complications being Grades I and II. Oncologic adequacy of the surgical specimens was found to be good, although a homogeneous histopathologic evaluation was not provided. Conclusions. Further large studies are warranted to define long-term oncologic results of robotic right colectomy with CME and its eventual benefits in comparison to laparoscopy.

Complete mesocolic excision and D3 lymphadenectomy with central vascular ligation in right-sided colon cancer: a systematic review of postoperative outcomes, tumor recurrence and overall survival

BACKGROUND

In right-sided colon cancer surgery, currently there is a great deal of discussion and debate regarding complete mesocolic excision (CME) versus conventional right hemicolectomy (CRH) on postoperative outcomes and oncological results. Our aim was to perform a systematic review of the short- and long-term outcomes of CME to standardize surgical approach in patients with right-sided colon cancer.

METHODS

A systematic review was performed examining available data on randomized and non-randomized studies evaluating the role of CME and D3 lymphadenectomy in the treatment of right-sided colon cancer, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards.

RESULTS

After literature search, 919 studies have been recorded, 110 studies underwent full-text reviews and 30 studies met inclusion criteria. The total number of CME procedures was 5931. Postoperative complications was reported in 28 studies with pooled overall complications of 1.88% for CME surgery. Six studies reported 0% of overall postoperative complications and they demonstrated a low incidence of complications following CME procedure. Anastomotic leak was reported in 27 studies with pooled proportion of 0.92% after CME resections. There were 16 papers reporting overall survival following CME procedure, with a mean of 85% of patients survived at 5 years. Mean 5-year overall survival was 93.05% in stage I patients, 89.76% in stage II patients and 79.65% in stage III patients. Local and distant recurrence were included in 21 studies, reporting tumor recurrence rate of 12.25% following CME. 5-year tumor recurrence was 5.8% in stage I patients, 7.68% in stage II patients and 15.69% in stage III patients.

CONCLUSIONS

CME does not increase the risk of postoperative complications and significantly improves the long-term oncological impact. Prospective multicentre studies results are needed to verify if CME could be considered standard surgery for right colon cancer.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

BACKGROUND

Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region.

MATERIALS AND METHODS

On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed.

RESULTS

Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo).

CONCLUSIONS

In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

Feasibility of robotic right colectomy with complete mesocolic excision and intracorporeal anastomosis: short-term outcomes of 161 consecutive patients

Technical and oncological aspects are still debated when dealing with minimally-invasive right colectomy. Main controversial issues still remain about whether the anastomosis should be performed intra- or extracorporeally and if a complete mesocolic excision (CME) should be carried out. We report the feasibility of robotic right colectomy with CME and intracorporeal anastomosis (IA) for right sided colon cancer. Data from patients who underwent robotic right colectomy with IA and CME from January 2015 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications (minor I-II and major III-IV according to Clavien-Dindo classification), conversion rate, 30-day postoperative outcomes and pathological outcomes were the variables assessed. A total of 161 patients undergoing robotic right colectomy for cancer met the inclusion criteria. Mean operative time was 185 min, no intraoperative complications were observed, and the conversion rate was 3.7% (6 patients requiring elective conversions). Overall, mean postoperative stay was 4.9 days and the overall 30-day complication rate was 16.1%. 20 patients (12.4%) had minor complications, while major postoperative complications occurred in six patients (3.7%). Anastomotic leak was recorded in one patient (0.6%) and the 30-day re-admission rate was 0.6%. Mean number of harvested lymph nodes was 21.9. Patients requiring conversion experienced two minor complications, with a mean length of stay of 7 days. Robotic right colectomy with CME and IA is feasible and it is associated with good intraoperative and short-term postoperative clinical outcomes.

Fluorescence-guided D3 lymphadenectomy in robotic right colectomy with complete mesocolic excision

BACKGROUND

In robotic right hemicolectomy for cancer, appropriate lymphadenectomy is essential. Visualization of draining lymph nodes and blood flow with near-infrared (NIR) fluorescence DaVinci^® imaging system is a recent development. We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) endoscopic submucosal injection to intraoperatively identify tumour lymphatic basin.

METHODS

The day before surgery, in patients scheduled for robotic right colectomy an endoscopic submucosal injection of 3 mg of ICG solution around the tumor is realized. Robotic right hemicolectomy is performed with suprapubic trocars layout and "bottom to up dissection", realizing a CME with central vessel ligation and D3 lymphadenectomy. Site of primary tumor and lymphatic basin are visible with the FireflyTM camera modality.

RESULTS

From July 2016 to July 2020, 85 patients received a robotic right colectomy with CME and D3 lymphadenectomy. In 50 patients, ICG submucosal injection was performed: visualisation of the site of primary tumour and of LN in the D3 area was possible in all cases; in 17/50 patients (34%), LN out from anatomical lymphatic basin were identified. No side effects were observed.

CONCLUSIONS

In this series, submucosal ICG injection showed to be feasible and safe. The accuracy in identification of D3 lymphatic basin was high, thus permitting an image-guided radical lymphadenectomy. Fluorescent technology represents an interesting innovation to ameliorate surgery of colon cancer.

Oncological reasons for performing a complete mesocolic excision: a systematic review and meta-analysis

BACKGROUND

While complete mesocolic excision (CME) has been shown to have an oncological benefit as compared to conventional colonic surgery for colon surgery, this benefit must be weighed up against the risk of major intra-abdominal complications. This paper aimed to assess the comparative oncological benefits of CME.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature until May 2020 was performed. Comparative studies assessing CME versus conventional colonic surgery for colon cancer were compared, and outcomes were pooled.

RESULTS

A total of 700 publications were identified, of which 19 were found to meet the inclusion criteria. A total of 25 886 patients were compared, with 14 431 patients in the CME arm. CME was associated with a significantly higher rate of vascular injury (odds ratio 3, P < 0.001). Rates of local and distant recurrence were lower in the CME group (odds ratio 0.66 and 0.73, respectively, both P < 0.001). CME patients had a significantly higher lymph node yield (P < 0.001). While no significant differences were noted between the two groups in terms of pooled 3- or 5-year disease-free survival, pooled 5-year overall survival was significantly higher in the CME group (relative risk 0.82, P < 0.001).

CONCLUSION

Based on the available evidence, CME is associated with improved oncologic outcomes at the expense of higher complication rates, including vascular injury. The oncological benefits need to weighed up against a multitude of factors including the level of hospital support, surgeon experience, patient age, and associated comorbidities.

Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques

PURPOSE

Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful.

METHODS

We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled.

RESULTS

A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes.

CONCLUSIONS

ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.

Complete mesocolic excision in minimally invasive surgery of colonic cancer: do we need the robot?

Background

Robotic surgery offers favorable prerequisites for complex minimally invasive surgeries which are delivered by higher degrees of freedom, improved instrument stability, and a perfect visualization in 3D which is fully surgeon controlled. In this article we aim to assess its impact on complete mesocolic excision (CME) in colon cancer and to answer the question of whether the current evidence expresses a need for robotic surgery for this indication.

Methods

Retrospective analysis and review of the current literature on complete mesocolic excision for colon cancer comparing the outcome after open, laparoscopic, and robotic approaches.

Results

Complete mesocolic excision results in improved disease-free survival and reduced local recurrence, but turns out to be complex and prone to complications. Introduced in open surgery, the transfer to minimally invasive surgery resulted in comparable results, however, with high conversion rates. In comparison, robotic surgery shows a reduced conversion rate and a tendency toward higher lymph node yield. Data, however, are insufficient and no high-quality studies have been published to date. Almost no oncologic follow-up data are available in the literature.

Conclusion

The current data do not allow for a reliable conclusion on the need of robotic surgery for CME, but show results which hypothesize an equivalence if not superiority to laparoscopy. Due to recently published technical improvements for robotic CME and supplementary features of this method, we suppose that this approach will gain in importance in the future.

A Case-matched Comparative Study of Laparoscopic Versus Open Right Colonic Resection for Colon Cancer: Developing Country Perspectives

BACKGROUND

The open approach to right hemicolectomy remains the most widely adopted, whereas laparoscopic surgery is technically more demanding with possible loss of benefit for lengthy procedures compared with open surgery. The aim of this study is to compare the outcomes of the laparoscopic versus open surgery for right colon cancer resections.

MATERIALS AND METHODS

Patients who underwent an elective and potentially curative right colectomy for colon cancer between 2015 and 2019 were included and those who underwent emergency surgery, palliative resection, or cytoreductive surgery were excluded. Patients were randomly matched on 1:2 basis for age, disease stage, neoadjuvant chemotherapy, and extent of colectomy (right vs. extended right hemicolectomy, and additional major resection). The analysis was conducted on an intention-to-treat basis. The outcomes were reported as median (range) or percent as appropriate.

RESULTS

Among 160 patients, 18 were excluded. The final matching included 69 patients. The were no significant differences between the groups regarding patients' age and sex distribution, tumor size, and preoperative serum albumin and hemoglobin. There were 2 conversions (8.7%) to open surgery. Although the operating time for laparoscopic surgery was longer (200 vs. 140 min, P<0.001), it was associated with less blood loss (50 vs. 100 mL, P=0.001) and shorter primary and total hospital stay (4.1 vs. 6.0 days, P<0.001). There were no differences in the rates of severe complications (0% vs. 13%), reoperations (0% vs. 4.3%), readmissions (13% vs. 8.7%), mortality (0% vs. 2.2%), R0 resections (95.7% vs. 97.8%), and lymph node retrieval rate (28 in each group).

CONCLUSION

The laparoscopic approach to right colon resection for colon cancer is associated with less operative trauma and quicker recovery compared with open surgery and offers an equivalent oncologic resection.

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

Backround

Several studies have demonstrated a direct correlation between lymph node yield and survival after colectomy for cancer. Complete mesocolic excision (CME) in right colectomy (RC) reduces local recurrence but is technically demanding. Here we report our early single center experience with robotic right colectomy comparing our standardized bottom-to-up (BTU) approach of robotic RC with CME and central vessel ligation (CVL) facilitated by a suprapubic access with the “classical” medial-to-lateral (MTL) strategy.

Methods

A 4-step BTU approach of robotic RC guided by embryonal planes in the process of retrocolic mobilization with suprapubic port placement was performed in the BTU-group (n = 24; all with intention to treat cancer). In step 1 CME was initiated with caudolateral mobilization of the right colon guided by the fascia of Toldt across the duodenum and up to the Trunk of Henle. Subsequently, dissection was performed BTU right of the middle supramesenteric vessels with central ileocolic vessel ligation in step 2. Subsequent to separation of the transverse retromesenteric space and completion of mobilization the hepatic flexure in step 3, the transverse mesocolon was then transected right of the middle colic vessels in step 4. An extracorporeal side to side anastomosis was performed. We compared the outcome of the BTU-group with a MTL-group (n = 7).

Results

Patient characteristics like age, gender, BMI, comorbidity (ASA) and M-status were comparable among groups. There was no conversion. Overall complication rate was 35.5%. We experienced no anastomoses insufficiency, grade Dindo/Clavien III/IV complication or mortality in this study. Type I and II complications and surgical characteristics incl. OR-time, ICU- and hospital-stay were comparable between the two groups. However, the lymph node yield was superior in the BTU-group (mean 40.2 ± 17.1) when compared with the MTL-group (16,3 nodes ±8.5; p <  0,001).

Conclusions

Compared to the classical MTL approach, robotic suprapubic BTU RC changes from a search of the layers bordering the oncological dissection to a consequent utilization of the planes as a retro-mesocolic guide during CME. The BTU strategy could bear the potential to increase the lymph node yield. Robotic systems may provide the technical requirements to combine advantages of both open and minimally invasive RC.

Robotic right colectomy with complete mesocolic excision and indocyanine green guidance

BACKGROUND

Robotic complete mesocolic excision (CME) has recently emerged as promising technique to enhance oncologic results in hemicolectomy for cancer. The potential near-infrared (NIR) fluorescence with indocyanine-green (ICG) dye for lymphatic mapping is under investigation and few small case-series are reported.

METHODS

ICG solution was endoscopically injected the day before surgery in patients undergoing robotic right colectomy with CME using the Da Vinci Xi® system and the bottom to up technique. During surgery the ICG was excited by light in the near-infrared (NIR) spectrum of the Firefly™ system, of the Da Vinci Xi® system for image comparison in standard white light and NIR, and real-time visualization of the lymphatic drainage.

RESULTS

Twenty patients affected by right colon cancer underwent robotic right colectomy with the bottom to up technique. No cases converted to open surgery were observed. During surgery, a fluorescent mapping of draining lymph nodes, was visualized in all the 20 patients. In seven patients (35%), lymph nodes outside the standard lymphatic basin were identified and removed.

CONCLUSIONS

The association of robotic right colectomy with the bottom to up technique and ICG-guided lymphadenectomy is a feasible and safe procedure. ICG lymphatic mapping may help to perform a correct CME, although the independent impact of these procedures on oncologic outcome deserves further investigations.

Implementing complete mesocolic excision for colon cancer - mission completed?

The definition of complete mesocolic excision (CME) for colon carcinomas revolutionized the way of colon surgery. This technique conquered the world starting from Erlangen. Nevertheless, currently new developments especially in minimally invasive surgery challenge CME to become settled as a standard of care. To understand the evolution of CME, anatomical details occurring during embryogenesis and their variations have to be considered. This knowledge is indispensable to transfer CME from an open to a minimally invasive setting. Conventional surgery for colon cancer (non-CME) has a morbidity of 12.1–28.5% and a 3.7% mortality risk vs. 12–36.4% morbidity and 2.1–3% mortality for open CME. The morbidity of laparoscopic CME is between 4 and 31% with a mortality of 0.5–0.9%. In robotic assisted surgery, morbidity between 10 and 25% with a mortality of 1% was published. The cancer-related survival after 3 and 5 years for open CME is respectively 91.3–95% and 90% vs. 87% and 74% for non-CME. For laparoscopic CME the 3- and 5-year cancer-related survival is 87.8–97% and 79.5–80.2%. In stage UICC III the 3- and 5-year cancer-related survival is 83.9% and 80.8% in the Erlangen data of open technique vs. 75.4% and 65.5–71.7% for laparoscopic surgery. For stage UICC III the 3- and 5-year local tumor recurrence is 3.8%. The published data and the results from Erlangen demonstrate that CME is safe in experienced hands with no increased morbidity. It offers an obvious survival benefit for the patients which can be achieved solely by surgery. Teaching programs are needed for minimally invasive CME to facilitate this technique in the same quality compared to open surgery. Passing these challenges CME will become the standard of care for patients with colon carcinomas offering all benefits of minimally invasive surgery and oncological outcome.