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

Abstract

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.

Robotische Hemikolektomie rechts mit kompletter mesokolischer Exzision (CME): Das suprapubische Bottom-to-up-Prinzip mit fluoreszenzangiografiegesteuerter Darmtranssektion und intrakorporaler Ileotransversostomie – eine Videovignette

“…Wir konnten kürzlich das Potenzial der robotischen HKR mit CME und ZGL in Bottomto-up-Strategie bez. Verbesserung der mittleren Anzahl an im Rahmen der Lymphadenektomie resezierten Lymphknoten demonstrieren [11]. Das Video in diesem Beitrag illustriert alle essenziellen Schritte des Verfahrens und fasst diese zusammen.…”

Minimally invasive right colectomy - from conventional laparoscopic resection to robotic-assisted surgery: a narrative review

“…This approach has been increasingly used [ Figure 2, blue points]. The trocars are positioned on a horizontal line 3-4 cm above the pubic symphysis, separated by 6.5-7.5 cm [23,32,38,39] . The unconventional viewpoint is a potential barrier against its widespread use.…”

“…Scotton et al [28] Xi Diagonal MtL 253 Y Y Y Johnson et al [29] Xi 149 Y Y Spinoglio et al [30] S and Si 279 Y Y Y Park et al [31] Si 195 Y Y Y Schulte et al [32] Xi Suprapubic MtL 285 19] 0 0 D'Annibale et al [20] 0 1 (2) 0 1 (2) 0…”

“…Schulte et al [32] 0 9 (29) 2 (6.4) 0 0 0 robotic assistance [55,56] . EA may require an extensive mobilization of the transverse colon for reaching the specimen extraction incision [54,57] .…”

“…The present narrative review aims to describe the main technical aspects of robotic right colectomy (RRC) and compare the learning curve, the short-and longterm outcomes, and the costs between LRC and RRC. A literature search was performed in MEDLINE database (PubMed); articles published in English between 2000 and 2019 using the following terms were screened: "MIS", "RC/colon resection", "robotic surgery", AND "laparoscopic surgery" [Tables 1-3] [17,[19][20][21][22][23][24][25][26][27][28][29][30][31][32] .…”