Utility of the da Vinci X robotic system in extramesocolic resections for locally-advanced colon cancer: A video vignette

Abstract

Objective:

To demonstrate the surgical technique for robotic extramesocolic resection using the da Vinci X platform in locally-advanced colon cancer (LACC), highlighting the challenges associated with this approach when the oncological margins of resection extend beyond the mesocolic fascia.

Methods:

This study, designed as a stepwise demonstration of surgical technique with narrated video footage, was conducted at a tertiary cancer center and teaching hospital in India. The patient was an 86-year-old man with Eastern Cooperative Oncology Group (ECOG) performance score of one, a surgical history of having undergone a laparotomy in the past, a significant family history of colon cancer and no comorbidities, who presented with complaints of bleeding per rectum since 3 months and lower abdominal fullness since 1 month, which on physical examination was determined to be a solitary well-circumscribed fixed mass in the left iliac fossa. On further evaluation, the colonic origin of this mass was confirmed, with colonoscopy revealing a circumferential ulceroproliferative growth extending from 35 to 40 cm of the anal verge, the biopsy of which was reported as a well-differentiated adenocarcinoma. On contrast-enhanced CT of the thorax, abdomen and pelvis, transmural thickening of the distal descending and proximal sigmoid colon causing severe luminal narrowing was evident, with infiltration of the left psoas and abdominal wall musculature, and abutting the left ureter and gonadal vessels, suggestive of LACC. Given the stricturing nature of the primary tumor with features suggestive of impending obstruction, and in the absence of significant locoregional lymphadenopathy or distant metastases, the multidisciplinary tumor board recommended primary surgical resection. A robotic approach was offered, considering the patient’s good performance status, the limited extent of extramesocolic disease, and the anticipated favorable postoperative outcomes.

Results:

The patient underwent a robotic anterior resection with extended complete mesocolic or extramesocolic excision. Before the procedure, a staging laparoscopy was performed to exclude peritoneal surface metastases and confirm operability, following which additional robotic ports were inserted, docking performed and the instruments deployed. Early into surgery, contiguous involvement of the retroperitoneal structures seen to abut the tumor on imaging was ruled out, ensuring disease resectability. Despite the lack of haptic feedback, the surgical margins were estimated and an en bloc resection performed based on compensatory visual cues including tissue color and texture, mobility of fascial planes and peritumoral edema, demonstrating the Reverse Braille phenomenon or faux haptic feedback wherein tactile sensation is perceived when vision is greatly enhanced, primarily considered a function of surgeon experience and the acuity of vision in a bloodless field as facilitated by robotic platforms. Intestinal continuity was subsequently restored by performing an intracorporeal stapled colo-colic anastomosis. On histopathological evaluation, the resection margins were negative and the nodal yield adequate. The patient made an uneventful recovery and was discharged from the hospital six days after surgery.

Conclusion:

Robotic extended resections for LACC may be considered oncologically safe and feasible, with satisfactory perioperative outcomes, when performed by experienced surgeons in select patients with good performance status and limited extramesocolic tumor extension following appropriate multidisciplinary evaluation.