Robotic right hemicolectomy with D 3 lymphadenectomy and complete mesocolic excision : technical detail

Introduction Since the 1990’s, the surgical treatment for colorectal cancers has seen substantial developments over the years, particularly following the introduction of minimally invasive surgical concept by the way of laparoscopic surgery. This minimally invasive surgical modality has seen further progress since the advent of robotic surgery. Although robotic right hemicolectomy, performed in the standard fashion, has been performed safely for right colon cancers, there seems to be debate about the added advantages of robotic approach over a laparoscopic approach. However, a robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision potentially might offer additional benefits. Methodology We report here a detailed operative technique and feasibility for performing a robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision and using intracorporeal anastomosis. Conclusion We believe that robotic right hemicolectomy with D3 lymphadenectomy, with complete mesocolic excision, is a realistic and feasible operation for right colon cancers. Introduction The right colon cancers have been traditionally treated with a standard open right hemicolectomy, and over the last two decades this has been similarly performed by a laparoscopic approach. Since the advent of robotic colorectal surgery, first reported by Weber et al. in 2002 1 for robot-assisted colectomy, there has been an increasing trend for the use of robotic surgery in colorectal cancer resections over the years. Robotic right hemicolectomy has been shown to be feasible and safe, especially from an oncological point of view in several studies 2–4 . The main areas of debate surround around longer operative times and higher cost involved in robotic surgery compared to laparoscopic surgery. These comparative studies and evidence have been primarily, when a standard right hemicolectomy was undertaken. The concept of D3 lymphadenectomy as introduced by the Japanese surgeons 5,6 , and a similar concept of complete mesocolic excision (CME) 7 proposed by European surgeons provides increased radicality in oncological resections and hence, potentially offer the possibility of better oncological advantage 8–10 . Although there have been welldocumented reports of D3 lymphadenectomy or CME performed laparoscopically, there are only very limited reports in the published literature regarding this undertaken, robotically. We describe technical aspects of our operative approach to perform a totally robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis. Methodology Operative techniques for robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis We used the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). Patient position, port placement, cart placement and Robert docking Once general anaesthesia is induced, patient is supine positioned over bean bags that are used as anti-sliding restrainers. Prior to start of operation, we use standard pre-operative measures of antibiotics prophylaxis, urethral catheterisation, anti-embolic compression stockings and pneumatic calf-muscle pumps. It is also advisable to place some cotton roll/gel padding between left shoulder of the patient and bean bag to prevent undue pressure on patient shoulder from the vacuum-hardened bean bags. We use five ports as standard for our robotic right hemicolectomy procedures as follows (Figure 1): Camera port in the left spinoumbilical line (SUL, line jo ining left anterior superior iliac spine and umbilicus) at a position 2–3 cm medial to left midclavicular line (MCL). We use a balloon of 12 mm camera port in obese patients. The robotic arm 1 port is placed on the left MCL, around 8 cm below the costal margin. The robotic arm 2 is placed in the midline, in the suprapubic area, with distance to symphysis pubis of 3 cm. The robotic arm 3 is placed on right SUL and 2 cm lateral to right MCL. Apart from the 12 mm camera robotic port, rest of the robotic arm ports are 8 mm in size. A final 5th port is inserted for the assistant, which is a 5 mm port placed in the left iliac fossa, just lateral to left MCL. The assistant port is primarily used for suction and can also be used for gentle bowel retraction. Once all the ports are inserted, with the optical port inserted first under direct vision using open Hassan’s technique, the patient is placed in a 15°–30° Trendelenburg tilt and a 15° Ge ne ra l S ur ge ry * Corresponding author Email: ronniematthews@hotmail.com Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Anam-dong 5-Ga, Seongbuk-gu, Seoul 136705, Korea Methodology Page 2 of 5 Co m pe ti n g in te re st s: n on e de cl ar ed . C on fl i ct o f i nt er es ts : n on e de cl ar ed . A ll au th or s co nt rib ut ed to th e co nc ep ti o n, d es ig n, a nd p re pa ra ti o n of th e m an us cr ip t, a s w el l a s re ad a nd a pp ro ve d th e fi n al m an us cr ip t. A ll au th or s ab id e by th e A ss oc ia ti o n fo r M ed ic al E th ic s (A M E) e th ic al ru le s of d is cl os ur e. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Mathew R , Kim SH . Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail. OA Robotic Surgery 2013 Jun 01;1(1):6. Figure 2: Dissection of ileocolic vein. Figure 1: Site for port positions for robotic right hemicolectomy. right side tilt upwards. Pneumoperitoneum is initially set at 12 mm Hg. Visual inspection of abdominal cavity and pelvis is performed to assess any obvious evidence of distant metastatic disease. The greater omentum is retracted over and above transverse colon, which is then subsequently pushed up superiorly. The small bowel (SB) is retracted medially so as to place the SB on the left side of patient’s abdominal cavity. 10x10 cm gauze is used to help retain medial SB retraction. This manoeuvre helps visualisation of root of ileocolic pedicle, and also helps during the D3 lymphadenectomy and CME. Finally, pneumoperitoneum is reduced to 8 mm Hg. The robotic cart is then brought at an angle over the right shoulder of patient. The ports are then docked to the robot—optical zero degree robotic camera, monopolar curved scissors for surgeon’s right arm (robotic arm 1), Cadiere grasper is used as surgeon’s second left arm (robotic arm 2) and Maryland bipolar forceps for use as surgeon’s first left hand (robotic arm 3). The full insertion of the three working instruments is to be performed under direct vision. Prior to start of next stage of operation of undertaking robotic surgery, it is important to ensure that there is adequate space between all the robotic arms, particularly the shoulder and elbows. Also, once docked, the positions of the patient should not be changed without undocking completely. The diathermy settings are set as follows: Bipolar settings at 30 (standard), and Monopolar settings at 25 Cutting (pure) and 25 Coagulation (fulgurate). Operative part The ileocolic pedicle is identified and then lifted up using Cadiere grasper. The dissection then starts around the origin of ileocolic pedicle. During the dissection process, duodenum is identified and dissected free from ileocolic pedicle. The ileocolic vein and ileocolic artery are identified at its origin from superior mesenteric vein (SMV) and superior mesenteric artery (SMA). The ileocolic vein (Figure 2) and ileocolic artery (Figure 3) is then divided after ligating near its origin, using 5 mm robotic Hem-O-Lok clips (Weck Closure Systems, Research Triangle Park, NC), with two clips placed proximally on patient’s side. The next step is to dissect along the central vasculature of SMV and SMA axes towards the cephalad direction, dissecting out the entire right colonic mesocolic tissues. During this dissection process along the central vasculature, the right colic, if present is ligated using the Hem-O-Lok clips near its origin (Figure 4) and is then divided. Further dissection of cephalad reveals the middle colic vessels and then the right branch of middle colic artery (Figure 5) and vein are clearly identified, and ligated individually near its origin and then divided. For the ligation of all named major vessels, two Hem-O-Lok clips are placed proximally on patient’s side prior to division. Care is taken to dissect out the entire right colon mesocolic tissues up to the root of the middle colic vessels. The medial to lateral dissection is then completed over the Gerota’s fascia, taking care to Methodology Page 3 of 5 Co m pe ti n g in te re st s: n on e de cl ar ed . C on fl i ct o f I nt er es ts : n on e de cl ar ed . A ll au th or s co nt rib ut ed to th e co nc ep ti o n, d es ig n, a nd p re pa ra ti o n of th e m an us cr ip t, a s w el l a s re ad a nd a pp ro ve d th e fi n al m an us cr ip t. A ll au th or s ab id e by th e A ss oc ia ti o n fo r M ed ic al E th ic s (A M E) e th ic al ru le s of d is cl os ur e. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Mathew R , Kim SH . Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail. OA Robotic Surgery 2013 Jun 01;1(1):6. Figure 3: Dissection of ileocolic artery. Figure 4: Dissection of right colic artery. SMA, superior mesenteric artery. Figure 5: Dissection of right branch of middle colic artery. Figure 6: Stapler transection of transverse


Introduction
The right colon cancers have been traditionally treated with a standard open right hemicolectomy, and over the last two decades this has been similarly performed by a laparoscopic approach.Since the advent of robotic colorectal surgery, first reported by Weber et al. in 2002 1 for robot-assisted colectomy, there has been an increasing trend for the use of robotic surgery in colorectal cancer resections over the years.
Robotic right hemicolectomy has been shown to be feasible and safe, especially from an oncological point of view in several studies [2][3][4] .The main areas of debate surround around longer operative times and higher cost involved in robotic surgery compared to laparoscopic surgery.These comparative studies and evidence have been primarily, when a standard right hemicolectomy was undertaken.The concept of D3 lymphadenectomy as introduced by the Japanese surgeons 5,6 , and a similar concept of complete mesocolic excision (CME) 7 proposed by European surgeons provides increased radicality in oncological resections and hence, potentially offer the possibility of better oncological advantage [8][9][10] .
Although there have been welldocumented reports of D3 lymphadenectomy or CME performed laparoscopically, there are only very limited reports in the published literature regarding this undertaken, robotically.We describe technical aspects of our operative approach to perform a totally robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis.

Operative techniques for robotic right hemicolectomy with D3 lymphadenectomy and CME and intracorporeal anastomosis
We used the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA).

Patient position, port placement, cart placement and Robert docking
Once general anaesthesia is induced, patient is supine positioned over bean bags that are used as anti-sliding restrainers.Prior to start of operation, we use standard pre-operative measures of antibiotics prophylaxis, urethral catheterisation, anti-embolic compression stockings and pneumatic calf-muscle pumps.It is also advisable to place some cotton roll/gel padding between left shoulder of the patient and bean bag to prevent undue pressure on patient shoulder from the vacuum-hardened bean bags.
We use five ports as standard for our robotic right hemicolectomy procedures as follows (Figure 1): Camera port in the left spinoumbilical line (SUL, line jo ining left anterior superior iliac spine and umbilicus) at a position 2-3 cm medial to left midclavicular line (MCL).We use a balloon of 12 mm camera port in obese patients.The robotic arm 1 port is placed on the left MCL, around 8 cm below the costal margin.The robotic arm 2 is placed in the midline, in the suprapubic area, with distance to symphysis pubis of 3 cm.The robotic arm 3 is placed on right SUL and 2 cm lateral to right MCL.Apart from the 12 mm camera robotic port, rest of the robotic arm ports are 8 mm in size.A final 5th port is inserted for the assistant, which is a 5 mm port placed in the left iliac fossa, just lateral to left MCL.The assistant port is primarily used for suction and can also be used for gentle bowel retraction.
Once all the ports are inserted, with the optical port inserted first under direct vision using open Hassan's technique, the patient is placed in a 15°-30° Trendelenburg tilt and a 15°   right side tilt upwards.Pneumoperitoneum is initially set at 12 mm Hg.Visual inspection of abdominal cavity and pelvis is performed to assess any obvious evidence of distant metastatic disease.The greater omentum is retracted over and above transverse colon, which is then subsequently pushed up superiorly.The small bowel (SB) is retracted medially so as to place the SB on the left side of patient's abdominal cavity.10x10 cm gauze is used to help retain medial SB retraction.This manoeuvre helps visualisation of root of ileocolic pedicle, and also helps during the D3 lymphadenectomy and CME.Finally, pneumoperitoneum is reduced to 8 mm Hg.
The robotic cart is then brought at an angle over the right shoulder of patient.The ports are then docked to the robot-optical zero degree robotic camera, monopolar curved scissors for surgeon's right arm (robotic arm 1), Cadiere grasper is used as surgeon's second left arm (robotic arm 2) and Maryland bipolar forceps for use as surgeon's first left hand (robotic arm 3).
The full insertion of the three working instruments is to be performed under direct vision.Prior to start of next stage of operation of undertaking robotic surgery, it is important to ensure that there is adequate space between all the robotic arms, particularly the shoulder and elbows.Also, once docked, the positions of the patient should not be changed without undocking completely.The diathermy settings are set as follows: Bipolar settings at 30 (standard), and Monopolar settings at 25 Cutting (pure) and 25 Coagulation (fulgurate).

Operative part
The ileocolic pedicle is identified and then lifted up using Cadiere grasper.The dissection then starts around the origin of ileocolic pedicle.During the dissection process, duodenum is identified and dissected free from ileocolic pedicle.The ileocolic vein and ileocolic artery are identified at its origin from superior mesenteric vein (SMV) and superior mesenteric artery (SMA).The ileocolic vein (Figure 2) and ileocolic artery (Figure 3) is then divided after ligating near its origin, using     identify and preserve the duodenum, right ureter and gonadal vessels.
The next step of operation is to dissect off the greater omentum, in the avascular plane, from the distal third of transverse colon and works proximally.However, if the tumour is situated at hepatic flexure or proximal transverse colon, we divide the right half of greater omentum so as to include with the final resection specimen.The superior mobilisation of transverse colon is then completed over the hepatic flexure.The lateral dissection is then completed, dissecting off the lateral attachments of the right colon.The terminal ileal mesentry is also dissected free.
The transverse colon is then transected (Figure 6) using 'Echelon FLEX™ 60 blue cartridge' stapler (Ethicon Endo-Surgery, Inc.).The terminal ileum is also stapler transected (Figure 7) in a similar fashion.In order, to introduce the stapler, the third robotic arm port, in the suprapubic site, is temporarily undocked and then this site is enlarged to insert a 12 mm port so as to accommodate the stapler.(Also to be noted is that this site eventually becomes the specimen extraction site).The specimen is then placed in a retrieval bag (Figure 8) and the bag is closed around its purse-string.
The terminal ileum and distal transverse colon resected ends are placed adjacent to each other, after ensuring that there is no mesenteric twist, and a stay suture is applied (Figure 9) to aid the approximation of the bowel segments and to use as a traction during stapler insertion.An enterotomy and colostomy are made to aid the insertion of 'Echelon FLEX™ 60 blue cartridge' stapler and a side-side; iso-peristaltic, stapled anastomosis is then created intracorporeally (Figure 10).The enterotomy and colostomy stapler insertion site is then closed with continuous stitches using intracorporeal robotic suturing (Figure 11).Prior to anastomosis, checks are made to ensure a tension-free anastomosis with good blood supply.Following anastomosis, staple lines and enterotomy closure sites are inspected to ensure integrity of closure and that the anastomosis is healthy and patent.
The specimen bag is then grasped with a grasper from the assistant port and then the robotic arms are undocked.Haemostasis is ensured prior to undocking, and following undocking, haemostasis is ensured of the port sites.to 3-4 cm, and a wound protector system (Alexis) is inserted and the specimen is extracted and sent for histology.
The extraction site is then washed out and fascia is closed in layers using '0' Vicryl stitches, and the remainder port sites' fascia is closed with '2.0' Vicryl stitches.The skin is closed with subcuticular absorbable stitches.

Discussion
Robotic colonic surgery has gained some interest in recent times following the first reported robotassisted colectomy in 2002 1 .Comparisons of robotic colonic surgery to laparoscopic surgery have shown comparable outcomes 11 , and further studies have shown acceptable safety and oncological outcomes for robotic right colonic surgery [2][3][4] .However, there are disadvantages for robotic surgery with longer operating times 2,12 and increased costs.
The concept of CME, with central vascular ligation, where the tumour along with the entire associated mesocolon is dissected along the embryological planes and resected after ligation near the origin of central vascular tree, has been getting some increased prominence following better oncological outcomes 7,8 .The Japanese surgeons as per their national colorectal society advocate a similar approach in their D3 lymphadenectomy for their advanced colon cancers 5,6 and with a similarly better outcome.There are very limited reports regarding undertaking a robotic colonic surgery utilising the D3 lymphadenectomy and CME approach, and we describe here the operative technique for undertaking this procedure.
In our opinion, totally robotic right hemicolectomy, with intracorporeal anastomosis may offer some additional benefits, including need for less dissection of distal transverse colon, which is usually required for a tension-free anastomosis when an extracorporeal anastomosis is undertaken.Also, in complete robotic approach, the site of specimen extraction site can be cited anywhere to aid cosmesis.We believe that smaller extraction sites, as a result of not requiring extracorporeal anastomosis, may help reduce pulmonary morbidity, especially if the incision sites are also much lower on the abdominal wall.In our opinion, the Pfannenstiel approach may be the best, as it also offers better cosmesis.It has been shown in other studies that Pfannenstiel offers better cosmesis, with low incisional hernias of 0%-2% [13][14][15] compared to up to 24% for midline extraction sites in laparoscopic-assisted surgery 16,17 .Finally, it still remains to be seen whether robotic right hemicolectomy with D3 lymphadenectomy and CME offers any additional benefits over laparoscopic or even conventional open operations.There is no existing current data regarding this and there is a requirement for further studies to evaluate this.Till that time, considering the longer operating times and increased costs, the true beneficial role of robotic surgery remains yet to be fully established, particularly from an oncological point of view.

Conclusion
We believe that robotic right hemicolectomy with D3 lymphadenectomy with CME is a realistic and feasible operation for right colon cancers.However, considering the lack of available comprehensive comparative data, it is not possible at Email: ronniematthews@hotmail.com Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Anam-dong 5-Ga, Seongbuk-gu, Seoul 136-705, Korea Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Mathew R , Kim SH .Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail.OA Robotic Surgery 2013 Jun 01;1(1):6.

Figure 1 :
Figure 1: Site for port positions for robotic right hemicolectomy.
5 mm robotic Hem-O-Lok clips (Weck Closure Systems, Research Triangle Park, NC), with two clips placed proximally on patient's side.The next step is to dissect along the central vasculature of SMV and SMA axes towards the cephalad direction, dissecting out the entire right colonic mesocolic tissues.During this dissection process along the central vasculature, the right colic, if present is ligated using the Hem-O-Lok clips near its origin (Figure 4) and is then divided.Further dissection of cephalad reveals the middle colic vessels and then the right branch of middle colic artery (Figure 5) and vein are clearly identified, and ligated individually near its origin and then divided.For the ligation of all named major vessels, two Hem-O-Lok clips are placed proximally on patient's side prior to division.Care is taken to dissect out the entire right colon mesocolic tissues up to the root of the middle colic vessels.The medial to lateral dissection is then completed over the Gerota's fascia, taking care to Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Mathew R , Kim SH .Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail.OA Robotic Surgery 2013 Jun 01;1(1):6.

Figure 5 :
Figure 5: Dissection of right branch of middle artery.
The suprapubic port site is area, which is enlarged Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Mathew R , Kim SH .Robotic right hemicolectomy with D3 lymphadenectomy and complete mesocolic excision: technical detail.OA Robotic Surgery 2013 Jun 01;1(1):6.

Figure 9 :
Figure 9: Placement of stay suture prior to stapler anastomosis.