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POSTOPERATIVEMANAGEMENT
Ourunitcurrentlyusesanaggressiveenhancedrecoveryprotocolthat stressesoutambulationandearlyfeeding.Thepatient,afterashortstay intherecoveryroom,istransferredtothesurgicalfloorwherewithin2–4 hoursheorsheismobilizedandambulated.Theambulationiscontinued onpostoperativeday1withwalksinthehallsatleastsixtimesdaily.
Softdietisgiventothepatientthenightoftheprocedure.Routine medications,eitheroralorintravenous,fornauseaareprescribedsuchas ondansetronandpromethazine.Onlyifthepatienthasrepeatedepisodes ofnauseaorvomitingthedietisstopped.Theindividual’shome medicationsarealsostartedthatsamenightunlesscontraindicatedby suchanticoagulants.
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Paincontrolisthemainissue,especiallyinaculturewhereopiatesare common.Ourinstitutioncurrentlyhasseveralprotocolsforpreemptive anesthesiathatincludetransversusabdominalplaneblocksinthe preoperativeareaandforhigh-riskpatients,suchasthosewith inflammatoryboweldisease,whohavebeenonopiates.Wecurrently haveacontinuousinfusionofketaminethatgetsstartedonabolusdose givenbytheanesthesiologistintraoperativelyandcontinued postoperativelyuntilday3or4unlessthepatientisreadyfordischarge earlier.
Oralacetaminophenisgiventothepatientevery6hoursaroundthe clock,unlesscontraindicated.Oralorintravenousopiatesareprescribed onlyforseverepainonapainscore8–10andbreakthrough,butoverall theyarediscouragedandthenursingstaffisinstructedtotrytoavoid them.Allpatientswillbegivenalvimopan12mgevery12hoursfromthe preoperativeareauntilthedayofdischargeasaperipherallyactingμ­opioidreceptorantagonist.
RoutineandstrictDVTprophylaxisisfollowedusingheparin5,000 unitssubcutaneouslyevery8or12hoursdependingonsurgeon’s preferenceorenoxaparin40mgdaily.Incertainhigh-riskpatientswith potentialforlowmobilityupondischarge,anextendedDVTprophylaxis protocolisusedfor21dayspostoperatively.
Routinenursingcareofthepatientisfairlystraightforward,the incisionshavebeenclosedwithasubcuticularsutureandDermabond Advanced(Ethicon,Cincinnati,OH),andwithin24hoursofthesurgery thepatientmayshower.Theintravesicalcatheterisremovedonthe
morningofpostoperativeday1;andinpatientswithpotentialurinary retention,suchasbenignprostatichypertrophy,aroutinebladder scanningandstraightcatheterizationareimplementedifunableto urinate.
Thepatientwillrunaninfusionof5%dextroseandlactatedRinger’s solutionpostoperativelythatwillbestoppedandheparinlockgiven intravenouslyonpostoperativeday1.Dextrosesolutionisavoidedin diabeticstoavoidhyperglycemiainthepostoperativeperiod.
Ourcurrentlengthofhospitalstayis3days;bythattimethenursing casemanageranddischargeplannerhavealreadyassessedtheneedsof thepatientathomeandsafetyincasethatoccupationalandphysical therapyconsultshavetobeplacedfordischargetoanursingfacility.

RESULTS

Minimallyinvasiverightcolectomysurgeryissafeandfeasible. Applicationofrobotictechnologyinthesettingofasegmentalcolectomy hasconsistentlyfailedtoshowanysignificantadvantages.Thelearning curveforroboticsseemstobefasterthanthatforlaparoscopictechnique, possiblyduetothe7degreesoffreedom,superiorvisualization,and stablethirdarmretractionoftherobot.Ourcurrentapproachtodecrease thecostisbasicallytargetedattheinstrumentationuse.Thebasiccostof roboticandpatientdraping,sutures,anddisposablematerialsusedinthe operationarefairlystandardizedandfixed.TheuseofHem-o-lock (Teleflex,Morrisville,NC,USA)clipsinsteadofanydiathermydevicealso isalargecostsavingsintheprocedure.Reductioninfiringreloadsof roboticstaplerscanbeachievedbydissectionofthemesenteryofthe colonandterminalileumtodecreasethewidthofthetissue.
Significantdebatehasexistedabouttherelativemeritsofastapled versushand-sewnileocolicanastomosis.ACochranereviewof1,125 anastomosesbyChoyetal.indicatedthatstapledfunctionalend-to-end ileocolicanastomosisisassociatedwithfewerleaksthanhand-sewn anastomosis.Currently,controversyexistsovertheperformanceofintra­orextracorporealanastomosis.Theincidenceofherniaafteraroboticor laparoscopicresectionhasbeendescribed(17.4%and22.2%, respectively)inalargereviewfromWidmaretal.Therefore,thepotential toreducethesequelaeofthiscomplicationexistswiththeperformanceof anintracorporealanastomosiswithsubsequentspecimenextraction usingaPfannenstielincision.
Theperformanceofintracorporealanastomosisroboticor laparoscopicallymaydecreasethelengthofhospitalstayandrecovery despitethelongeroperativetime.AretrospectivereviewofNational QualityImprovementProgrambyMilleretal.included17,774 colectomies(11,267laparoscopicvs.653robotic).Althoughtheoperative timeintheroboticgroupwashigher,thehospitallengthofstaywas significantlydecreasedby1dayintheroboticgroup.Thatdifferencewas maintainedintherightorleftresections.Nocostcomparisonwasmade inthisstudy.
Roboticsingleincisionorsingleportrightcolectomy(SPRC)hasbeen reportedandwehaveexperienceinthetechnique.Weconsiderthis techniqueasanadvancedapplicationofrobotictechnologyandonly selectedcentershavehadexperiencewithit.Juoetal.reported59right colectomiesandconcludedthatthetechniqueissafeandfeasibletobe used.Duringthisadvancedroboticprocedure,theoperatorwillcrossthe armsatthefascialeveluponinsertionofthesingleport.Retractionis
limitedanditrequiressignificantuseof“wristing”maneuversto accomplishthedissection.Ourexperiencefor3yearsinSPRC(16 patients)comparedtomultiportroboticright(25patients)offeredlower operativetimesof82versus110minutesfavoringtheSPRC(probably relatedtothefactthatweperformedextracorporealanastomosis)with similarlengthofhospitalstay(4.2vs.4days)andcomplications(25%vs. 36%)(unpublisheddata).
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Inthecurrenteraofcostcontainmentandcapitationpercase,the surgeonmustbeawareoftheexpensesincurredintheOR.Our institutioncurrentlyhasimplementedasystemwherethesurgeon receivesascorecardwiththetotalitemizedcostoftheprocedureandthe operativetime.Theuseofequipmenthasbeenreducedandaconstant efforttodecreasethepricehasyieldedasignificantdecreasefromour averageoriginalcostof$3,927perroboticcolectomy;thecostis$1,813. Asperthelaparoscopiccounterpartscorecardin2011,thecostofa laparoscopiccolectomyhasdecreasedfrom$1,870to$1,326in2015.Our institutionaldataclearlyshowsthattheinvolvementofthesurgeon improvesthesavingsinaroboticprogram.

CONCLUSIONS

Theapplicationofrobotictechnologyinrightcolectomyisstillinits infancybecauseofmultifactorialreasonsthatincludeadoption,learning curve,andcost.Preliminarydataindicatesafetyandfeasibilityequivalent tothelaparoscopictechnique.Furtherinvestigationisneededintheuse ofintracorporealorextracorporealanastomotictechniquesbecausethe earlydataindicateimprovedshort-termoutcomes.
RECOMMENDEDREFERENCESAND READINGS
ChoyPY,BissettIP,DochertyJG,ParryBR,MerrieA,FitzgeraldA.Stapledversushandsewn
methodsforileocolicanastomoses.CochraneDatabaseSystRev2011;(9):CD004320.
doi:10.1002/14651858.CD004320.pub3. de’AngelisN,LizziV,AzoulayD,BrunettiF.Roboticversuslaparoscopicrightcolectomyforcolon
cancer:analysisoftheinitialsimultaneouslearningcurveofasurgicalfellow.JLaparoendosc
AdvSurgTechA2016;26:882–92. GramsJ,TongW,GreensteinAJ,SalkyB.Comparisonofintracorporealversusextracorporeal
anastomosisinlaparoscopic-assistedhemicolectomy.SurgEndosc2010;24(8):1886–91.
doi:10.1007/s00464-009-0865-9. JuoYY,AgarwalS,LukaS,SateyS,ObiasV.Single-incisionroboticcolectomy(SIRC)caseseries:
initialexperienceatasinglecenter.SurgEndosc2015;29(7):1976–81. Lagares-GarciaJ,O’ConnellA,FirilasA,RobinsonCC,DumasBP,HagenME.Theinfluenceof
bodymassindexonclinicalshort-termoutcomesinroboticcolorectalsurgery.IntJMedRobot
2016;12:680–5.doi:10.1002/rcs.1695. MatsudaA,MiyashitaM,MatsumotoS,etal.Isoperistalticversusantiperistalticstapledside-to-
sideanastomosisforcoloncancersurgery:arandomizedcontrolledtrial.JSurgRes
2015;196(1):107–12. MillerPE,DaoH,PaluvoiN,etal.Comparisonof30-daypostoperativeoutcomesafter
laparoscopicvsroboticcolectomy.JAmCollSurg2016;223(2):369–73.
doi:10.1016/j.jamcollsurg.2016.03.041. 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.JLaparoendoscAdvSurgTechA
2013;23(5):414–7.doi:10.1089/lap.2012.0404. TrastulliS,CorattiA,GuarinoS,etal.Roboticrightcolectomywithintracorporealanastomosis
comparedwithlaparoscopicrightcolectomywithextracorporealandintracorporeal
anastomosis:aretrospectivemulticentrestudy.SurgEndosc2015;29(6):1512–21.
doi:10.1007/s00464-014-3835-9. vanOostendorpS,ElfrinkA,BorstlapW,etal.Intracorporealversusextracorporealanastomosis
inrighthemicolectomy:asystematicreviewandmeta-analysis.SurgEndosc2017;31:64–77. WidmarM,KeskinM,BeltranP,etal.Incisionalherniasafterlaparoscopicandroboticright
colectomy.Hernia2016;20(5):723–8.doi:10.1007/s10029-016-1518-2.
Chapter6
Hand-AssistedLaparoscopic RightColectomy
BrianT.Valerian

INDICATIONS/CONTRAINDICATIONS

Indications
Theindicationsforhand-assistedlaparoscopic(HAL)right hemicolectomyarepredominantlythesameasthoseforlaparoscopicand openrighthemicolectomy:benignandmalignantprocessesthatinvolve thedistalterminalileum,cecum,ascendingcolon,hepaticflexure,and proximaltransversecolon.HALofferssurgeonsthebenefitsof laparoscopicsurgeryincludingsmallerincisions,lesspostoperativepain, shorterhospitallengthofstay,andmorerapidreturnofbowelfunction whilestillallowingthesurgeontactilefeedbackprovidedwithopen surgery.UtilizingHAL,thehandcanretractorgans,dissect,andrapidly controlbleeding.
HALismorefrequentlyusedforlefthemicolectomyortotalcolectomy andtotalproctocolectomy;itstilloffersadvantagesincertainsituations forright-sidedcolectomies.Inflammationorfriabletissuesfrom inflammatoryboweldisease,orthickenedmesenterysuchasseenwith Crohn’sdiseaseareexamples.Aphlegmonfromdiverticulardiseaseor inflammatoryboweldiseaseorlargebulkytumorsormassesareother examples.Morbidobesitycanmakelaparoscopicsurgerychallenging,but HALcanoftenallowforsuccessfulminimallyinvasivesurgerytobe performed.Thehandcaneasilyretractthecolonormesenteryinan obesepatientoraidwithexposurethatlaparoscopicinstrumentsmaynot beabletoprovide.HALalsoallowspalpationofaneoplasmwithinthe colon,whichmaynotbeidentifiedvisually.Thepatientsandprocedures thatgainthemostbenefitfromHALarethosethatrequireanextraction siteormini-laparotomy.
SpecificindicationsforHALrighthemicolectomyincluderefractory Crohn’sdisease,right-sideddiverticulardisease,colonpolypsnot amenabletoendoscopicremoval,malignanciesandneoplasms,volvulus orcecalbascule,andarteriovenousmalformationsorotherbleeding lesions.
Contraindications
Contraindicationstypicallyfallintotwobroadclassifications—absolute andrelativecontraindications.Absolutecontraindicationsarethose generalmedicalconditionsthatwouldprecludeaminimallyinvasive approachthatrequirespneumoperitoneumsuchaschronicobstructive pulmonarydisease,severecardiacdiseaseforwhichdecreasedvenous returncanbedetrimental,inabilitytotolerateTrendelenburgposition, hepaticdisease,coagulopathy,andamoribundpatient.Relative contraindicationshavedecreasedassurgeonexperienceandskillhave increased.Morbidobesity,previousabdominalsurgery,adhesions,and phlegmonsareallrelativecontraindications,butskilledlaparoscopic surgeonscanoftenutilizeminimallyinvasivetechniquestosafely completeoperationsinthesepatients.Earlyreportsofportsite metastasisinminimallyinvasivesurgeryformalignancyhavebeen disproven,andmultiplestudieshaveshownthatbothHALand laparoscopicsurgeryaresafeandeffectiveinpatientswithmalignancies. Therearecertainotherconditionsthatremainabsoluteorrelative contraindicationsincludingbowelobstructionwithmassivelydilated bowelandbowelperforation.
PREOPERATIVEPLANNING
Apatientundergoinganycolonsurgeryrequiresacompleteevaluation. Patientsbeingconsideredforminimallyinvasivetechniquesalsorequire additionalevaluationsbecausetheabilitytopalpateallabdominal structuressuchastheliverandperitonealsurfacesmaybelimited. Determiningextentofdiseaseinvolvementandlocalizationoflesions, masses,andtumorsfacilitatessurgery.Colonoscopyallowsidentification ofpolyps,tumors,masses,andlesions.Tattooingofsmallerpolypsand tumorsorofflatlesionsallowsforvisualidentificationatthetimeof surgery.Indiainkcanbeeasilyutilizedtotattoolesionsbyinjectingin threeorfourquadrantsaroundthelesionforfutureidentification. Colonoscopyalsoensurestherearenoothersynchronouslesions throughouttheremainingcolon.
Preoperativeimagingwithcomputerizedtomographyallowsfor evaluationoflocalextentofdiseaseandpossiblemetastaticspreadto otherorgansandstructuresinmalignantlesions.Inaddition,itcanhelp determineresectabilityandensurethereisnodirectextensionoflesions orinvasiontoadjacentstructures,notonlyinmalignantconditionsbut alsoinconditionssuchasCrohn’sdisease.
Inpreparationforsurgery,apatient’ssuitabilityforsurgeryis determined.IfthepatienthasanyabsolutecontraindicationstoHAL, opensurgerycanbeoffered.Thepreoperativediscussionandconsent processmustalwaysincludethepossibilityofconversiontoanopen procedureifitcannotbeaccomplishedsafelyutilizingminimallyinvasive techniques.Duringthepreoperativediscussion,perioperativeand postoperativeexpectationscanbeexplainedaswellasrisks,benefits,and alternatives.Managingperioperativeexpectationsisparamounttogood outcomesandpatientsatisfaction.
Standardmechanicalbowelpreparationisrecommendedbecausean emptycoloniseasiertomanipulateandhandleusingminimallyinvasive techniques.Theuseoforalpreoperativeantibioticsisatthediscretionof thesurgeon.Prophylacticintravenousantibioticsatthetimeofsurgery, venousthromboembolismprophylaxis,andperioperativeinitiativesand carearethesameasthoseforanycolectomy.PatientsundergoingHAL colectomyareappropriatecandidatesforenhancedrecoveryprotocolsif thoseareutilized.

SURGERY

Positioning
Thepatientisplacedsupineontheoperatingroomtable.Otherpositions includemodifiedlowlithotomypositionwiththethighsatorslightly belowthelevelofthehiptopreventinterferencewithlaparoscopic instrumentmobility.Splitlegpositionerscanalsobeutilizedbecause thesedevicessupporttheentirelowerextremity,decreasingthechanceof peronealnerveinjuryandofferthesurgeonaccesstostandbetweenthe legsshouldtheneedarise.Theauthor’spreferenceistoplacethepatient insplitlegposition.Arestraintdevicecanbeplacedacrossthepatient’s chesttohelppreventslippageontheoperatingroomtableduring manipulationofthetableintraoperativelyforpositioning.Thelegscanbe similarlysecuredifinsplitlegposition.Theleftarmshouldbepadded andtuckedatthepatient’sside.Pneumaticsequentialcompression devicesareplacedtoreducetheriskofdeepveinthrombosis.Abladder catheterisinsertedtodecompressthebladderintraoperatively. Orogastricdecompressioncanbeaccomplishedbytheanesthesiateam. Thesurgeonandassistantstandtothepatient’sleftandmonitorsare placedonthepatient’srightside.Oneormoremonitorscanbeusedif available.Thescrubtechnicianstandstothepatient’srightside(Fig.6-1). Alternatively,thesurgeoncanstandbetweenthepatient’slegswiththe assistanttothepatient’sleftside,whilethescrubcanremainonthe patient’srightside.
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