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Robotic Right Hemicolectomy for Tubulovillous Adenoma with High-Grade Dysplasia: Multimedia Analysis of a Contemporary Technique

Abstract

Robotic right hemicolectomy is a minimally invasive technique for right colon resections. The technique utilizes a robotic laparoscopic instrument to perform dissection of the right colon and to perform intracorporeal anastomoses, allowing for smaller abdominal incisions, quicker recovery times, and decreased short- and long-term complications. In this case, a robotic right hemicolectomy was performed to remove an endoscopically unresectable mass at the ileocecal valve. An intracorporeal stapled ileocolic anastomosis was performed and the colon was removed through a trocar insertion site. The robotic-assisted minimally invasive technique allows for clear visualization of the dissection planes and facilitates intracorporeal anastomoses that would otherwise be difficult to perform using traditional laparoscopy.

Case Overview

Background

The incidence of colon polyps increases with age. In men 50 years of age, the prevalence of polyps ranges between 25% and 30% globally, but can be up to 70% in high-risk countries such as the United States.1

Dysplasia of colonic epithelium is defined by architectural and ultrastructural features. By definition, an adenoma is a low-grade dysplastic lesion. Higher-grade dysplasias are characterized by loss of differentiation and increased mitotic features seen on histology. Some adenomas progress to high-grade dysplasia, carcinoma in situ, and invasive carcinoma. Despite the fact that there is no definitive evidence that villous features are associated with progression to invasive disease, there is substantial evidence to suggest that certain features of adenomatous polyps may place the patient at higher risk for malignant transformation.1

Therapeutic endoscopy is usually sufficient to appropriately resect suspect colonic polyps. In cases where the polyp is unresectable via endoscopy, laparoscopic or open partial colectomy may be indicated. Here, we present the case of a patient with a high-risk colonic polyp that was unresectable on endoscopy, indicating robotic-assisted minimally invasive hemicolectomy.

Focused History of the Patient

The patient is a 65-year-old male with a past medical history of type II diabetes, hypertension, and chronic kidney disease (stage 3) who was found to have a complex polyp on the posterior aspect of his ileocecal valve, discovered on screening colonoscopy. On histology, the polyp was a tubulovillous adenoma with high-grade dysplasia. The mass could not be completely removed endoscopically despite several attempts. Surgical resection was recommended given the size of the lesion and the degree of dysplasia. A robotic-assisted laparoscopic approach was offered because of the patient’s body habitus and the ease of facilitating the creation of an intracorporeal anastomosis.

Physical exam

No abnormal findings were found on physical exam. Most colonic neoplasms, benign or malignant, will not produce changes in physical exam findings in their early stages. Patients with large polyps may give rise to hemoccult-positive stool.

Imaging

No additional imaging was indicated for this benign colon polyp; however, if malignancy is identified in the pathology specimen following surgical resection, additional staging evaluation may be warranted.

Natural History

For ethical reasons, it is difficult to design studies examining the rate of malignant transformation among adenomatous polyps. Nevertheless, a registry-based study in Germany found a strong time-dependent increase in the incidence of colorectal cancer in both men and women with adenomatous polyps.2

Options for Treatment

Tubulovillous adenomas with high-grade dysplasia can be treated with endoscopic resection alone. For patients with completely resected high-risk adenomas, colonoscopy within 3 years is recommended.3 Polyps requiring piecemeal excision should have 6 month interval follow-up because of increased risk of development of colorectal cancer. In cases where endoscopic resection is not possible, such as in this patient, partial colectomy is required.4

Rationale for Treatment

Minimally invasive colorectal operations have been associated with decreased lengths of stay, lower rates of conversion, and equivalent survival rates.5 Intracorporeal anastomoses have also been found to result in fewer postoperative complications. Robotic techniques allow for easier completion of intracorporeal anastomosis than is the case for traditional laparoscopy.6 Robotic right hemicolectomy has been shown to result in shorter hospital stays and lower complication rates at the expense of longer operative times.7 Longer operative times are frequently multifactorial and may partially be attributable to intraoperative setup and adjustments of the robotic instrumentation.

Special Considerations

Contraindications for robotic surgery are similar to those for laparoscopic procedures. Inability to tolerate pneumoperitoneum or general anesthesia are the only absolute contraindications. Relative contraindications include a history of multiple intra-abdominal operations, intra-abdominal sepsis, coagulopathy, and severe bowel dilation.8,9

Discussion

This multimedia analysis demonstrates successful performance of a robotic-assisted minimally invasive right hemicolectomy for a tubulovillous adenoma with a high-grade dysplastic polyp. An intracorporeal stapled ileocolic anastomosis was utilized, and the colon was removed through a trocar insertion site. This case is a good example of use of the robotic-assisted minimally invasive technique for treatment of potentially metastatic colonic lesions that were otherwise unresectable endoscopically.

The first laparoscopic procedures were performed in the 1980s.10 Since then, the instruments and techniques have progressed rapidly. In 1993, the first robotic-assisted minimally invasive abdominal procedure was performed. This evolution culminated in the appearance of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) in 2009.

The advantages of robotic-assisted laparoscopic surgery include excellent visualization and substantially increased degrees of freedom. The disadvantages are primarily the expense associated with these systems and longer operative times. A meta-analysis comparing traditional laparoscopic hemicolectomies with robotic-assisted procedures showed that the latter were associated with less blood loss and fewer complications; however, with longer operation times. Recovery of bowel function as well as other perioperative outcomes were comparable between the two approaches.7

As robotic equipment becomes more widely available and adopted, and as surgical techniques continue to improve, we anticipate that operative procedure times will become shorter and outcomes will continue to improve as this technology evolves. Moreover, the learning curve of this procedure is expected to be enhanced by the audiovisual feedback features facilitated by this operative platform.

Equipment

Da Vinci XI robotic surgical system.

Disclosures

The authors have nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgments

None.

Citations

  1. Myers DJ, Arora K. Villous Adenoma. InStatPearls [Internet] 2018 Dec 13. StatPearls Publishing. (Accessed 17 September 2019).
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  3. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. United States Multi-Society Task Force on Colorectal Cancer. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844. doi:10.1053/j.gastro.2012.06.001.
  4. Hassan C, Quintero E, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2013;45:842-64. doi:10.1055/s-0033-1344548.
  5. Sun Z, Kim J, Adam MA, et al. Minimally invasive versus open low anterior resection equivalent survival in a national analysis of 14,033 patients with rectal cancer. Ann Surg. 2016;263.1152-1158. doi:10.1097/SLA.0000000000001388.
  6. Morpurgo E, Contardo T, Molaro R, Zerbinati A, Orsini C, D'Annibale A. Robotic-assisted intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy for cancer: a case control study. J Laparoendosc Adv Surg Tech Part A 2013;23:414-417. doi:10.1089/lap.2012.0404.
  7. Ma S, Chen Y, Chen Y, et al. Short-term outcomes of robotic-assisted right colectomy compared with laparoscopic surgery: A systematic review and meta-analysis. Asian J Surg. 2019;42:589-598. doi:10.1016/j.asjsur.2018.11.002.
  8. Nathaniel J. Soper and Carol E.H. Scott-Conner (eds.) The SAGES Manual 3rd ed. 2012 Volume 1 Basic Laparoscopy and Endoscopy doi:10.1007/978-1-4614-2344-7_1.
  9. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 11e New York, NY: McGraw-Hill.
  10. Spinoglio G, editor. Robotic surgery: current applications and new trends. Springer; 2015 Jan 24.