End-to-End Handsewn Anastomosis

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14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction

Fig. 14.16 Side-to-end

handsewn anastomosis: opening of both transverse colon and ileum, after having started the rst bite of the second running suture for the anterior layer. (Copyright © Giovanni Dapri. Illustration by M.Crespi)

Fig. 14.17 Side-to-end

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closed end against the lateral side of the transverse colon. A continuous running suture is placed aligning the ileum to the colon, using absorbable material (e.g., PDS 2/0) (Fig.14.18). The rest of the anastomosis is created as described previously (Figs.14.19 and 14.20).

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Fig. 14.18 End-to-side

Fig. 14.19 End-to-side

G. Dapri and M. Montorsi

End-to-End Handsewn Anastomosis

This type of isoperistaltic anastomosis is useful in cases of intestinal obstruction and consequent small bowel dilatation when the ileal diameter is of similar size to the colon. The two linear staple lines, on the ileal end and on the transverse colon end, are placed in front of each other. A posterior running suture is performed from

14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction

Fig. 14.20 End-to-side

Fig. 14.21 End-to-end

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one corner of each limb to the opposite corners (Fig.14.21). Then, a new running suture (anterior layer) is initiated at one end of the anastomotic apex. After taking the rst bite, the colon and ileum can either be opened along the staple line (Fig.14.22). The anterior layer of the anastomosis is completed as described previously (Fig.14.23).

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Fig. 14.22 End-to-end

Fig. 14.23 End-to-end

G. Dapri and M. Montorsi

Pitfalls andTroubleshooting

Twisting oftheAnastomosis

With ICA, the choice of anastomotic conguration can be decided upon by observing the natural positioning of the viscera after their transection. Additionally, by being

14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction

able to fully visualize the abdominal cavity, bowel, and mesentery, twisting and tension are avoided. When an ECA is being constructed, care must be taken during extraction and after bowel transection to avoid twisting. It can often be difcult to visualize the mesentery through the extraction incision. If there is any doubt about twisting prior to performing the anastomosis, the recommendation is to view the mesentery. This can be done while keeping the bowel limbs extracorporeally and placing the camera in one of the lateral ports to visualize the bowel and mesentery.

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Operative Time

Although ICA can initially take longer to perform, as the surgeon gains experience, the time needed to create it can eventually equal that of ECA.In addition, there are several facts that will help reduce operative time during ICA: (1) There is less need for full transverse colon and ileal mobilization with ICA as the bowel does not need to be pulled up through the abdominal wall for extraction. This is particularly helpful in obese patients or in patients with prior surgeries where adhesions are a ratelimiting step. (2) Place all sutures required for anastomosis creation/enterocolotomy closure within the abdomen after specimen’s transection to minimize the need to keep placing and removing sutures. (3) Stapled closure of the common channel will avoid the need for any suturing. (4) Using clips and barbed sutures or creating a loop at the end of the suture avoids the need to tie knots.

Spillage

During ECA creation, a wound protector is commonly placed prior to specimen’s extraction. A sterile eld can be created around the bowel prior to making an enterotomy/colotomy. With enough length of bowel mobilized and extracted extracorporeally, non-crushing bowel clamps can be placed on both bowel limbs to prevent enteric ow during enterotomy creation or enterotomy closure. During ICA, there is minimal leakage of intestinal contents because of the pressure generated by the pneumoperitoneum. As discussed earlier, the use of a mechanical bowel preparation can also reduce the possibility of spillage during anastomotic creation. During intracorporeal stapled anastomosis, one must be prepared to handle the contaminated stapler after completion of the stapled anastomosis. A gauze can be inserted into the abdomen (before stapling) and used to cover the stapler upon removal through the trocar. In this way, the fecal contamination of the trocar can be avoided or at least minimized.

Alignment/Ergonomics

Often times after bowel division and aligning the bowel in preparation for ICA, the surgeon realizes that the trocar position is not optimized for ICA.This can either be

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G. Dapri and M. Montorsi

secondary to suboptimal position of the camera or suboptimal trocar positioning. There are several maneuvers that can help in this scenario:

1. Place a stay suture on the far side of the planned anastomosis, and have the assis-

tant hold it upward toward the abdominal wall, or use a suture passer through the

abdominal wall to retract it. This allows for improved traction on the bowel

which remains in stable and optimized position for the surgeon. In addition, by

pulling up on the bowel in this manner, there is less risk of fecal spillage after

enterotomy or during the anastomosis.

2. Although many surgeons prefer to staple through the suprapubic port site as this

is the incision that will be upsized for specimen extraction, sometimes it can be

challenging to get a good angle to staple the anastomosis from this location. In

these cases, stapling from an alternative port (e.g., umbilical port) is

recommended.

3. When the ports are found to be too challenging for safe anastomotic creation, the

placement of even one additional 5mm port can solve the problem.

4. If the bowel continues to lay in a position that makes it challenging to safely cre-

ate an ICA, additional mobilization of the transverse colon and root of ileal mes-

entery can be done to gain mobility and to optimize positioning.

5. Lastly, when all of the above maneuvers fail, one can always perform an ECA.

Outcomes

Five recent systematic reviews and meta-analyses have compared outcomes of laparoscopic right hemicolectomy performed with extracorporeal versus intracorporeal anastomosis [3, 7–9, 12] (Tables 14.1). None of the meta-analyses demonstrated statistically signicant differences in operative time, and only one describes a lower mortality rate [12]. Cirocchi and colleagues [12] reported also less blood loss during ICA, while van Oostendorp and colleagues [3] and Ricci and colleagues [7] demonstrated a reduced short-term morbidity after ICA, including signicant reduction in wound infection rates. Wu and colleagues [8], Feroci and colleagues [9], and Cirocchi and colleagues [12] showed a shorter time to rst defecation. Ricci and associates [7], Wu and associates [8], and Feroci and associates [9] showed reduced time to rst oral intake. The use of analgesics was evaluated by Feroci and coauthors [9] and Cirocchi and coauthors [12], and the ICA was associated to a decreased use. The length of hospital stay was signicantly shorter with ICA [3, 7–9]. Cosmetic outcomes were evaluated by Wu and associates [8] and Cirocchi and associates [12], with superior results after ICA.Most notable, ICA was also associated with signicantly lower rate of incisional hernia [7] with overall rates 2.3% vs. 13.7% following ICA vs. ECA across 14 matched studies.

14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction

Table 14.1 Overview of results from meta-analyses comparing laparoscopic right hemicolec-

tomy performed with intracorporeal versus extracorporeal anastomosis

Study Ricci et al. [7] 864 853 ICA associated with lower:

Wu et al. [8] 994 963 ICA associated with lower:

Van Oostendorp et al. [3]

Cirocchi et al. [12]

Feroci et al. [9]

ICA intracorporeal anastomosis, ECA extracorporeal anastomosis, WMD weighted mean difference, CI condence interval, OR odds ratio

763 729 ICA associated with lower:

945 total ICA associated with lower:

202 223 ICA associated with signicantly decreased:

ResultsICA ECA

Overall complication rate (27.6% vs 38.4%, P=0.01). Time to rst oral intake (WMD −1; 95% CI=−1.59 to −0.41). Length of stay (WMD −1.13; 95% CI=−1.90 to −0.35). Wound infection (4.9% vs 8.9%, P=0.03). Incisional hernia (2.3% vs 13.7%, P=0.02). No differences in anastomotic leak (3.4% vs 4.6%, P=0.12), OR time, blood loss, conversion, reoperation, mortality, analgesia required

Length of stay (WMD −1.03, 95% CI −1.57 to −0.48). Time to rst bowel movement (WMD −0.65, 95% CI −0.97 to

−0.32). Time to liquid diet (WMD −0.87, 95% CI −1.41 to −0.33). No signicant differences in intraoperative (OR=0.75, 95% CI

0.21–2.74) and postoperative complications (OR=0.74, 95% CI

0.49–1.12), mortality (RR=0.59, 95% CI 0.19–1.86), and anastomotic leak (OR=0.77, 95% CI 0.45–1.31)

Short-term morbidity (OR 0.68, 95% CI 0.49–0.93). Length of stay (WMD −0.77, 95% CI −1.46 to −0.07). Surgical site infection (OR 0.56, 95% CI 0.35–0.88). No signicant difference in mortality (OR 0.36, 95% CI 0.09–

1.46), anastomotic leak (OR 0.77, 95% CI 0.39–1.49), ileus (OR

0.94, 95% CI 0.57–1.57).

Mortality rate (0.34% vs 1.32%, OR 0.52; 95% CI 0.09–3.10),

though not statistically signicant. No signicant difference in anastomotic leak (1.13% vs 1.84%, OR 0.90, 95% CI 0.24–3.10) and intraoperative complications (OR 0.54; 95% CI 0.09–3.24). A meta-analysis of postoperative morbidity was not possible because the data reported in the included studies were too heterogenous

Time to rst atus (OR=-0.48, 95% CI −0.78 to −0.18). Time to solid diet (OR=-1.00, 95% CI −1.33 to −0.67). Use of analgesics (OR=-1.00, 95% CI −1.34 to −0.66). Length of stay (OR=−0.93, 95% CI −1.79 to −0.07). No signicant difference in intraoperative complications (OR

0.84; 95% CI −0.14–5.20), mortality (OR 0.75; 95% CI 0.10–

5.93), nonsurgical site complications (OR=0.79, 95% CI

0.20–3.13), surgical site complications (OR=0.44, 95% CI

0.14–1.39)

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G. Dapri and M. Montorsi

Conclusions

The choice of the anastomotic technique during laparoscopic right colectomy depends on the surgeon’s preference, as well as patient’s anatomy and intraoperative ndings. While the literature does not suggest any major differences in outcomes related to these various anastomotic techniques, many suggest decreased woundrelated morbidity, better cosmesis, decreased postoperative pain, and incisional hernia rate with ICA.

References

1. Jacobs M, Verdeja JC, Goldstein HS.Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc. 1991;1(3):144–50.

2. Stein SA, Bergamaschi R.Extracorporeal versus intracorporeal anastomosis. Tech Coloproctol. 2013;17(Suppl 1):S35–9.

3. van Oostendorp S, Elfrink A, Borstlap W, Schoonmade L, Sietses C, Meijerink J, et al. Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta-analysis. Surg Endosc. 2017;31(1):64–77.

4. Lipski D, Dapri G, Himpens J.Completely staple-free hand-sewn laparoscopic anastomosis in colorectal surgery. J Laparoendosc Adv Surg Tech A. 2008;18(2):282–5.

5. Dapri G, Carandina S, Mathonet P, Himpens J, Cadière GB.Suprapubic single-incision laparoscopic right hemicolectomy with intracorporeal anastomosis. Surg Innov. 2013;20:484–92.

6. D’Annibale A, Pernazza G, Morpurgo E, Monsellato I, Pende V, Lucandri G, et al. Robotic right colon resection: evaluation of rst 50 consecutive cases for malignant disease. Ann Surg Oncol. 2010;17(11):2856–62.

7. Ricci C, Casadei R, Alagna V, Zani E, Taffurelli G, Pacilio CA, etal. A critical and comprehensive systematic review and meta-analysis of studies comparing intracorporeal and extracorporeal anastomosis in laparoscopic right hemicolectomy. Langenbeck’s Arch Surg. 2017;402(3):417–27.

8. Wu Q, Jin C, Hu T, Wei M, Wang Z.Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A. 2017;27(4):348–57.

9. Feroci F, Lenzi E, Garzi A, Vannucchi A, Cantao S, Scatizzi M.Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis. Int J Color Dis. 2013;28(9):1177–86.

10. Tiefenthal M, Asklid D, Hjern F, Matthiessen P, Gustafsson UO.Laparoscopic and open rightsided colonic resection in daily routine practice. A prospective multicentre study within an Enhanced Recovery After Surgery (ERAS) protocol. Color Dis. 2016;18(2):187–94.

11. Moghadamyeghaneh Z, Hanna MH, Carmichael JC, Mills SD, Pigazzi A, Nguyen NT, etal. Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg. 2015;220(5):912–20.

12. Cirocchi R, Trastulli S, Farinella E, Guarino S, Desiderio J, Boselli C, etal. Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy– systematic review and meta-analysis. Surg Oncol. 2013;22(1):1–13.

Robotic Right-Sided Colon Resection: Unique Considerations andOptimal

Setup

KonstantinUmanskiy

Introduction andRationale

Laparoscopic right colectomy is a commonly performed procedure. While some general surgeons steadfastly reject minimally invasive approach to right colectomy, most general and colorectal surgeons are quite comfortable performing laparoscopic (hand-assist or pure) right hemicolectomy. Below are a few reasons to consider the robotic approach:

1. Gaining experience with robotic colon surgery. Right colectomy is often referred

to as a “gateway procedure” because it allows the surgeons who are learning minimally invasive surgery to begin with procedures that are considered “less challenging” [1]. Once surgeons ascend the learning curve, they may expand their clinical portfolio to other, more complex procedures such as left colectomy, low anterior resection, and abdominoperineal resection.

2. Complete mesocolic excision (CME). There is a growing body of literature sug-

gesting that extensive excision of mesocolon at the time of right colectomy, similar to total mesorectal excision of the rectum, can improve lymph node yield and lead to improved oncologic outcomes [2–4]. The CME involves central vascular ligation with complete exposure and lymphadenectomy along the superior mesenteric vessels. This increases the technical demand of minimally invasive surgery in right colon cancer and adds the potential of worsened vascular complications compared to standard right hemicolectomy. Even in the hands of experienced laparoscopists, mastering laparoscopic CME technique has proven to be quite challenging. Robotic surgery may potentially overcome the limitations of straight laparoscopic instruments in CME given its technical features

K. Umanskiy (*) University of Chicago, Department of Surgery, Chicago, IL, USA e-mail: kumanskiy@surgery.bsd.uchicago.edu

https://doi.org/10.1007/978-3-030-24812-3_15

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such as instrument stability, enhanced dexterity of wristed instruments, and improved 3D visualization.

3. Intracorporeal anastomosis (ICA) is a compelling reason to adopt the robotic

technique for right colectomy [5]. With its advantages of wristed instruments and easier intracorporeal suturing, intracorporeal robotic anastomosis may become easier to perform and may gain popularity. With adoption of ICA, surgeons are able to move the specimen extraction site away from periumbilical midline region and toward the pubis using a small muscle-splitting Pfannenstiel incision. This likely contributes to decreased pain, lower rates of wound complications, and incisional hernia that have been reported in some comparative studies of laparoscopic right colectomy performed with intracorporeal vs. extracorporeal anastomosis [6, 7].

4. With popularization of da Vinci Xi® (Intuitive Surgical, Sunnyvale, CA, USA)

surgical robot, which is capable of rotating its base, single docking total abdominal colectomy is now feasible [8]. Learning the technical steps of right colectomy could enable surgeons to seamlessly incorporate right colectomy into total abdominal colectomy or other multiquadrant procedures [9].

K. Umanskiy

Indications andContraindications

Any patient who is a candidate for minimally invasive procedure could be considered for robotic colectomy. Morbid obesity, a relative contraindication to laparoscopic approach, could be one of the reasons to consider robotic approach instead of conventional laparoscopy. During conventional laparoscopy in morbidly obese individuals, the thick abdominal wall may cause signicant torqueing of the instruments, reduce precision and accuracy of movements, and lead to instrument malfunction or even breakage. Robotic platform is uniquely suited to overcome these disadvantages and reduce physical and psychological strain on the surgeon [10]. The remote center on the ports reduces trocar site torque and instrument strain. The robotic approach also allows smooth, controlled movements with variable degree of scaling and built-in tremor reduction. Furthermore, construction of robotic intracorporeal anastomosis could eliminate the need for additional dissection to exteriorize the bowel for anastomosis. This, thereby, would reduce unnecessary traction on the tissue and minimize the length of the incision. Absolute contraindications to robotic surgery are similar to those of laparoscopy and include surgical scenarios resulting hemodynamic compromise and inability to tolerate pneumoperitoneum. Relative contraindications to robotic right colectomy include intestinal obstruction, signicant intra-abdominal adhesions, large lesions, or stulizing lesions.

Principles andQuality Benchmarks

Most of the principles of the robotic right colectomy for benign and malignant disease are based on the well-established laparoscopic approach [11] and are described in detail in chapters on laparoscopic right colectomy for benign (Chap. 2) and malignant

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