Robotic sigmoidectomy as a feasible option in advanced colorectal tumors

We present an 81-year-old patient, with no known drug allergies, with a history of a labial neoplasm and a childhood TB who currently has a sigmoid colon neoplasm. Due to alterations in the depositional rhythm, a colonoscopy was performed that reported a large tumor 20 cm from the anal verge, whose pathological anatomy was compatible for adenocarcinoma.

A complete study was performed, with the CT Scan showing a large neoproliferative lesion in the rectum-sigma junction that extended to the mesosigma and fistulized and infiltrated a segment of the proximal sigma. It also presented tumor implants in mesosigma and inflammatory changes by fistulization with two adjacent collections. Given the findings, it was decided to perform a Robotic Sigmoidectomy.

After doing the docking and placing the auxiliary trocar in the usual way, the procedure started. The large tumor was attached to the bladder, as we suspected from previous imaging tests. We carefully began the dissection trying to separate the tumor from the bladder but taking into account that we should not go too close so as not perforate the tumor.

Given the significant fixation of the tumor to the pelvis we decided to release part of the parietocolic and subsequently also access medially so as to gradually surround the large mass. For the medial approach, we proceeded to open the peritoneum from the oncological plane to approach the artery and the inferior mesenteric vein.

Once dissected we carried out the section of both of them by means of clips and the Harmonic device used through the auxiliary trocar. Once the vessels were sectioned, after visualizing and preserving the left ureter, we went back to a lateral approach.

Throughout the procedure, we changed the approach so as to be able to surround the tumor and release it from the area where it was most closely attached. All these maneuvers are facilitated by the wide range of mobility of the robotic instruments, the stable camera, and 3D vision that helps in difficult dissections like this case.

Again we returned to the medial area, approaching the tumor from the back with good vision thanks to the 30º robotic camera. Edema and fibrosis caused by the tumor make dissection difficult, so care must be taken to avoid lesions to vascular structures or the ureter, or perforation of the colon or the tumor itself. Once the bladder was separated and the vessels were sectioned, we decided to change our strategy in order to release the most problematic area of the tumor. Therefore, we proceeded to section the mesocolon and the proximal colon, so that we could retract it and have a better view of the area closely attached to the left parietocolic. Using a mechanical suture device, we sectioned the colon through the auxiliary trocar. In this way we were able to pull the colon and perform a safer dissection.

We can see how edema makes it difficult to differentiate a good plane. The surgical assistant’s work is very important here to keep the surgical field clean, improving vision and facilitating dissection.

Through the electrocautery and the Harmonic device, we released the parietocolic area of the tumor, making sure not to injure any important structure. At this time we can see the ureter, which continues its path without being affected by the tumor and that we left aside to the left, without injuring it and keeping it in mind at all times to avoid potential inadvertent injuries.

Gradually we released the colon and thus accessed the pelvis, going into the distal colon, finding the area where we could perform the rectum section. Once the tumor was passed, we proceeded to perform the circumference section of the mesorrectum using the electrocautery and the Harmonic device, already preparing the rectum for its section.

Finally, we introduced the endo stapler through the auxiliary trocar and sectioned the distal rectum, checking that the colon and the tumor were completely released. After that, we completed the release of the left parietocolic to ensure correct mobilization of the proximal colon and perform an anastomosis with no tension.

The next step is to check vascularization of the sectioned colon by means of indocyanine green, with correct perfusion of the proximal colon, except for the last 2 cm that would be subsequently sectioned, and thus placed the anvil of the mechanical suture and performed the anastomosis.

At this moment the robotic surgery ended. The specimen was extracted through a Pfannenstiel incision and the anvil was placed in the proximal colon, to later finish the procedure with laparoscopic instruments. The end to end colorectal anastomosis was completed by means of a circular mechanical suture and the procedure ended with the placement of an intra-abdominal drainage.

Outcomes

The surgery took 185 minutes. 

Oral intake was initiated 4h after surgery following our ERAS protocol. 

The patient was discharged on the 2nd postoperative day with no complications. 

The pathology revealed a pT4N0 colon adenocarcinoma.