Title: Robotic Complete Mesocolic Excision for Right-sided Colon Cancer

VideoScript

  1. An 84-year-old male patient was admitted to our clinic with the complaints of easy fatigue and loss of energy. Pallor was noted on physical examination. Laboratory tests were normal except for a low hemoglobin level.
  2. Colonoscopy revealed a tumoral mass located in the hepatic flexure and the diagnosis of adenocarcinoma was made by endoscopic biopsy.
  3. Computed tomography scan showed a tumoral mass in the right colon with no distant metastasis.
  4. Trocar placement is shown here.
  5. The robotic chart is docked from the right side of the patient.
  6. The peritoneum overlying the ileocolic vascular pedicle was gently lifted up and then scored using robotic scissors.
  7. In this case, there is an anatomical variation with the superior mesenteric artery running lateral to the superior mesenteric vein.
  8. First, the ileocolic artery is isolated, clipped with hem-o-lock clips near its origin from the superior mesenteric artery and divided.
  9. Then, the right colic artery is dissected, clipped and divided.
  10. The ileocolic vein is dissected, clipped and divided.
  11. Here is shown the dissection of the middle colic artery. This artery is divided in the same fashion.
  12. Cephalad dissection along the ventral side of the superior mesenteric vein permits a complete dissection of the gastrocolic trunk of Henle.
  13. Here is shown the gastrocolic trunk of Henle.
  14. The branches of the gastrocolic trunk are isolated, clipped and divided individually.
  15. The video now shows the dissection of the right gastroepiploic artery.
  16. This artery is clipped and divided.
  17. Mesenteric dissection is performed via medial-to-lateral approach staying between the embryological planes just anterior to the Toldt’s fasciae and duodenum.
  18. After mesenteric dissection is completed, the terminal ileum is prepared for transection.
  19. An endo-linear staple is used for ileal transection.
  1. The video now shows the entire ligated vascular structures.
  2. With caudal traction of the transverse colon, the bursa omentalis is entered and the gastrocolic tissue is divided from left to the right, completing the right colon mobilization.
  3. Hem-o-lok clips can be used for vascular control during this dissection.
  4. In order to choose the point of transection at an optimally perfused area of the transverse colon, we use the near-infrared fluorescence imaging system.
  5. This helps identify intravascular fluorescence signals in real time.
  6. Then, the transverse colon is transected using an endolinear staple.
  7. For bowel anastomosis, first, the ileum is approximated to the transverse colon with a 3/0 silk suture.
  8. A 1-cm opening was created in the ileum and transverse colon
  9. A side-to-side ileotransversostomy anastomosis is created intracorporeally.
  10. The opening in the anastomosis is closed with a 3/0 V-lock suture.
  11. The specimen is placed in an endobag and extracted through the suprapubic incision extended from the suprapubic trocar site.
  12. The specimen is inspected for macroscopic intactness of the fascial mesocolic envelope
  13. The distance between the tumor and high vascular tie is measured.
  14. The operative time in this case was 310 minutes, and operative blood loss was 25 ml.Final histopathologic examinationrevealed a T3, moderately differentiated adenocarcinoma with no metastasis in the 61 lymph nodes retrieved.

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