Robotic right colectomy

Indications

Following its introduction in 1991, multiple reviews in the literature have shown numerous advantages of the minimally invasive laparoscopic approach to colectomy. Although the rates of utilization of minimally invasive techniques have continued to increase over time, more than half of all colon resections are still performed via an open approach decades after the introduction of laparoscopic colon resection. Limited visibility, poor exposure, the need to access multiple quadrants of the abdominal cavity, poor ergonomics, and a protracted learning curve are frequently used as explanations for this slow adoption. Improved 3D visualization, comfortable positioning with improved ergonomics for the surgeon, the stable wristed instrumentation offered by a robotic platform, and computer simulation for surgical skills development address many of these early concerns and may allow an increasing number of patients who require colon resection to obtain the benefits of a minimally invasive procedure.

The most common indications for resection of the right colon are benign and malignant neoplasms. Less common indications include inflammatory bowel disease, colonic volvulus, intussusception, trauma, tumors of the appendix, and ischemia. While all indications may be amenable to a robotic approach, patient selection early in a surgeon’s experience is particularly critical. Patients with benign disease or incurable metastatic disease may be preferable while progressing along the learning curve. Disease in the cecum or appendix may also be preferable, limiting the extent of mobilization of the transverse colon and exposure of the middle colic vessels which can be particularly challenging. In addition, patients with a lower body mass index and no prior abdominal procedures are better candidates early in a surgeon’s experience. Procedures early in a surgeon’s experience will likely require longer operative times, so overall patient health and comorbidities are important considerations as well.

Patient preparation

Complete medical risk assessment is appropriate for all patients undergoing right colon resection. Many of these patients are elderly, and identification and optimization of all comorbidities are keys to a successful outcome. Endoscopic evaluation and preoperative imaging will help plan the appropriate procedure. Ink marking of intraluminal pathology to aid in intraoperative identification should be considered, particularly when smaller lesions are being resected. Radiographic imaging as indicated by the presenting pathology should be reviewed.

Enhanced recovery after surgery (ERAS) protocols have been shown to reduce overall morbidity and length of stay without increasing readmission rates. Aerobic exercise and incentive spirometry daily for 7–10 days prior to the surgery may recruit alveoli, reducing the risk of perioperative pulmonary complications. Smokers are encouraged to quit 4 weeks prior to their operation. We allow patients to consume clear liquids until 2 hours prior to surgery to minimize the risk of dehydration. A carbohydrate-rich beverage 2 hours before surgery is recommended.

Traditional bowel preparation with preoperative lavage and oral antibiotics has been the source of great debate over the past decade. Recent reviews of the National Surgical Quality Improvement Program colectomy database have shown that mechanical bowel preparation with the addition of oral antibiotics reduces the risk of surgical site infection, wound dehiscence, anastomotic leak, and organ space infection. This improvement was noted in comparison to patients receiving mechanical preparation alone or no preoperative preparation. ^, The day prior to surgery, polyethylene glycol is commonly used for mechanical bowel preparation. Three oral doses of neomycin and either an erythromycin base or metronidazole over 10 hours follow the mechanical lavage. Patients are encouraged to consume additional liquids during and following the preparation. A second-generation cephalosporin, such as cefoxitin or cefotetan, is commonly used. A first-generation cephalosporin such as cefazolin may be combined with metronidazole in hospitals where E. coli resistance to second-generation cephalosporins is a concern.