Right hemicolectomy and transverse colectomy

Introduction

Robot-assisted right and transverse colectomy is rapidly gaining popularity among surgeons as the preferred approach for treatment of ascending and transverse colon cancers. This is partly due to the ease of performing intracorporeal anastomosis, limiting the need for larger extraction incisions, which was common in most laparoscopic approaches due to the utilization of an extracorporeal anastomosis. Studies have reported less estimated blood loss, shorter gastrointestinal recovery, lower rates of postoperative ileus, lower narcotic use, shorter hospital stay, and lower complication and conversion rates when robotic surgery is utilized. ^, Robotic surgery also has been shown to have comparable oncologic outcomes to open and laparoscopic surgery. ^,

KEY OPERATIVE STEPS ( FIG. 49.1 )

1.
Position the patient
2.
Access abdomen, establish pneumoperitoneum, and place ports
3.
Position the small bowel
4.
Identify and preserve the duodenum
5.
Ileocolic pedicle isolation and ligation
6.
Medial to lateral mobilization
7.
Lateral mobilization
8.
Division of the terminal ileal mesentery and terminal ileum
9.
Division of the transverse mesocolon and transverse colon
10.
Ileocolic anastomosis

Fig. 49.1, Key Operative Steps of Robotic Right Hemicolectomy.

Indications and contraindications: Right colectomy and transverse colectomy

Right and transverse colectomy can be performed for both benign and malignant conditions. Benign conditions include adenomatous polyps of the colon that cannot be removed endoscopically, carcinoid tumors, and ileocolic Crohn disease. A right colectomy is indicated for lesions involving the terminal ileum, ascending colon, hepatic flexure, or proximal transverse colon. An extended right colectomy can be considered for those patients with a mid to distal transverse colon lesion. However, patients with a distal transverse colon lesion may be better served with an extended left hemicolectomy.

Preoperative assessment

A thorough history and physical examination must be performed preoperatively. Prior abdominal surgical history and colonoscopy results should be reviewed, and an effort should be made to localize the tumor either with colonoscopy and tattooing or abdominal CT scan or both. Patients should be counseled on the possibility of a stoma and the likelihood of the operation being converted to an open procedure.

Operating room setup and patient positioning

Proper patient positioning is essential for success in robotic surgery. For a robotic right colectomy and transverse colectomy, the patient should be placed in supine position with both arms tucked and with all pressure points padded. A foam nonslip pad is placed underneath the patient, and a padded strap across the chest should be used to prevent sliding. The robot may be docked to whatever side is convenient for the operating room staff.

Port placement

Optimizing port placement is an important step to successful completion of right and transverse colectomies, avoiding external and internal collisions while allowing working room for the bedside assistant. Pneumoperitoneum can be established via any technique. It is the author’s preference to gain access to the abdomen via an optical entry technique in the left upper quadrant 2 cm below the costal margin at the midclavicular line using a 5-mm 0-degree scope and a 5-mm port. After the abdomen is insufflated, robotic trocars are placed in a linear pattern spanning from the pubic symphysis to the left mid-clavicular line ( Fig. 49.2 ). Ideally, the distance between each of the robotic trocars will be between 6 and 10 cm. The 12-mm stapler port is placed halfway between the abdominal midline port and the left subcostal port.

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