HOW I DO IT
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Robotic left colectomy with double indocyanine green guidance and intracorporeal anastomoses
Jan Grosek, Aleš Tomažic
Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
|Date of Submission||09-Sep-2020|
|Date of Decision||18-Nov-2020|
|Date of Acceptance||25-Nov-2020|
|Date of Web Publication||09-Apr-2021|
Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana
Source of Support: None, Conflict of Interest: None
Radical surgery is the mainstay of treatment of colon cancer. Lymphatic drainage of splenic flexure colon cancer is variable, and the exact site of lymphatic dissection is uncertain. Hence, a true consensus of what kind of colectomy should be performed for tumours of the splenic flexure is lacking. Segmental left colectomy (splenic flexure colectomy) (extended), left colectomy as well as subtotal colectomy (extended right colectomy) all have their proponents. Robotic colectomy addresses the limitations of straight laparoscopic colon resections. We report our technique of single-docking totally robotic left hemicolectomy for splenic flexure adenocarcinoma using Da Vinci Xi® Surgical System (Intuitive Surgical, USA) with indocyanine green near-infrared fluorescence for the assessment of both the lymph nodes and intestinal blood flow in real time.
Keywords: Da Vinci Xi system, indocyanine green fluorescence, left hemicolectomy, splenic flexure cancer
| ¤ Introduction|| |
Robotic platform offers many advantages over standard laparoscopy, including better visualisation (stable three-dimensional view, magnification), precise dissection and tissue manipulation, as well as improved ergonomics, potentially reducing fatigue of the operating surgeon.
Near-infrared indocyanine green (ICG) fluorescence can be a very valuable tool for intraoperative decision-making in minimally invasive surgeries. Firefly technology integrated with the Da Vinci Xi systems enables intraoperative ICG fluorescence, and we use it routinely for the assessment of bowel perfusion in all robotic colorectal resections. Moreover, real-time visualisation of lymph flow (lymphatic mapping) was proven as feasible, potentially helping the surgeon with very important visual cues to identify appropriate vessels as well as to determine an appropriate mesenteric/Mesocolic dissection line, thus removing the mesocolon, draining the tumour. Apart from better lymphadenectomy, this could also influence a decision regarding the adjuvant therapy. The validity of ICG fluorescent lymphangiography was asserted by two systematic reviews, done by Van der Zaag et al. and Emile et al., The concept of visualisation of both the lymph nodes and the blood flow can really augment the robotic approach to colectomies, as is adequately shown in a paper by Kobiela et al., describing the technical details of their innovative approach to robotic right colectomy.
Tumours of the splenic flexure lie just between the superior and inferior mesenteric arterial system, thus there is no true consensus in the surgical community regarding the type of colectomy that is best for patients. Segmental left colectomy (splenic flexure colectomy), subtotal colectomy (extended right colectomy) and left colectomy all have their proponents.
Left colectomy, ligating the left colic artery and left branch of the middle colic artery as well, is a standard of care in our clinical practice, regardless of approach.
| ¤ Pre-Operative Preparation|| |
Patients undergo standard pre-operative work-up and preparation, which is the same as for conventional laparoscopic or even open colectomy, according to our institutional practice. This includes full colonoscopy (partial in the case of obstructive carcinoma) and contrast-enhanced computed tomography (CT) of the chest and the abdomen. Every patient is discussed at the multidisciplinary tumour team board. Full mechanical bowel preparation is employed as per standard for all left-sided resections. Tumour marking is performed with India ink under colonoscopic vision >48 h before surgery.
| ¤ Positioning Of Patients and Ports|| |
The efficiency of all robotic resections relies on correct patient set-up and positioning, coupled with proper port set-up. The patient is secured on a special non-slip foam in a modified lithotomy position, with arms tucked at the side. It is of utmost importance to prevent any unnecessary patient movement.
A nasogastric tube is placed for gastric decompression and Foley catheter for urinary bladder decompression. The robotic cart is docked at the left side of the patient, which is positioned in right-sided tilt and slight Trendelenburg. Four 8-mm robotic ports (DV 8 mm) are placed diagonally, preferably all of them lying on an imaginary linear line. We employ configuration of two left-handed instruments and one right-handed instrument. A tip-up fenestrated grasper, a fenestrated bipolar forceps and a monopolar curved scissors are placed into the robotic ports 1, 2 and 4, respectively. The endoscope (30° optics) is placed in the robotic port 3. Scissors in the robotic port 4 is exchanged for energy device (Da Vinci® Vessel Sealer Extend- Intuitive Surgical, Sunnyvale, CA, USA) for mesolonic transection.
An additional 12-mm port Airseal® System (CON-MED, Utica, NY, USA) is inserted in the right lower quadrant. Its valve-less trocar design provides high-flow insufflation and facilitates smoke evacuation. Airseal® port allows the assistant unimpeded introduction of laparoscopic instruments, used for grasping, suction as well as introduction and removal of clips, needles, sutures and endoscopic stapler (Echelon Flex™ GST System 60-mm Powered Plus; Ethicon, Bridgewater, NJ, USA) [Figure 1].
| ¤ Operative Steps|| |
Pre-operative antibiotics are given to cover the intestinal flora, and the abdomen is prepped in a standard sterile fashion. A Verres needle is typically used for insufflation. Laparoscopy is done at first, sweeping the small bowel away from the target anatomy, which is facilitated by tilting the operating table. Under standard white light, the tumour is localised [Figure 2]. Thereafter, ICG (2.5 mg/1 ml) is injected by the bed-side assistant (through the Airseal port) into the sub-serosal/sub-mucosal layer on the distal and the proximal sides of the tumour [Figure 3]. Once the robot is docked and all the instruments are inserted, a medial-to-lateral approach is utilised and central vascular ligation of the left colic artery and the left branch of the middle colic artery is performed, while the inferior mesenteric vein is dissected just below the pancreatic body. Firefly technology is used for ICG fluorescence three times during the operation. At first, the lymphatic system containing ICG is elucidated. The fluorescence lymphatic mapping helps determine an appropriate separation line in the transverse and descending mesocolon [Figure 4]. Thereafter, ICG is administered intravenously to objectively assess bowel perfusion both before [Figure 5] and after the stapled side-to-side intracorporeal anastomosis.
|Figure 4: Visualisation of blood supply to the colon descendens (green colour) after intraoperative intravenous injection of indocyanine green|
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|Figure 5: Demonstration of the mesocolonic lymphatic channels associated with a colon tumour using indocyanine green fluorescence imaging|
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A small Pfannenstiel incision is made, incorporating incision of robotic port (DV) 1 and a wound protector is inserted. This allows for a safe extraction of the colonic specimen. Subsequently, laparoscopy is performed, confirming haemostasis and proper positioning of the drainage tube.
| ¤ Post-Operative Care and Results|| |
Early and frequent mobility is encouraged, and venous thromboembolism prophylaxis is started approximately 12 h after the operation. The nasogastric tube is removed prior to the end of the operation, while the drainage tube and Foley catheter are removed on post-operative day 1. Patients are offered clear liquids in the evening on the day of the operation. In the absence of nausea, vomiting or abdominal discomfort, they are quickly advanced from liquid to regular diet. In general, patients are discharged on post-operative day 5 or 6.
To date, the technique reported here has proven to be very successful. There have been no major complications or arm collisions related to this technique and also no non-recoverable faults with this technique of docking, port positioning or instrument placement. This year, we performed 62 robotic colorectal resections: 17 cases for benign pathology (diverticulosis, inflammatory bowel disease) and 45 for colorectal malignancy. In the latter group, the median lymph node yield was 24 (range 12–41 nodes) and the median positive lymph nodes was 0 (range 0–7 nodes). Final pathological staging was 22% in Stage I (n = 10), 40% in Stage II (n = 18) and 38% in Stage III (n = 17). There were no positive resection margins or intraoperative and injection-related adverse events.
| ¤ Conclusions|| |
Robotic surgery is an upgrade of laparoscopic surgery, offering several advantages. However, there are some key differences in the set-up and positioning, which may affect anaesthetic protocols. Hence, anaesthesiologists should be involved in the planning process.
The Da Vinci Xi robotic platform enables multi-quadrant surgery and, through integrated Firefly technology and fluorescence, delivers very important visual cues regarding bowel perfusion, thus helping the surgeon to determine where to transect the bowel wall. Moreover, injecting the ICG in the near vicinity of the tumour allows the assessment of lymph flow in real time, which may guide the surgeon to find the appropriate mesenteric line, providing for adequate lymphadenectomy and staging, which is especially important for flexure colon tumours.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]