Steps of Robotic Right Hemicolectomy
Robotic right hemicolectomy involves a systematic approach with specific steps for optimal oncologic outcomes while minimizing morbidity and mortality. The procedure combines principles of conventional right hemicolectomy with the advantages of robotic technology.
Preoperative Preparation
- Bowel preparation with hypertonic solution combined with low-residue diet
- Intravenous broad-spectrum antibiotic administration
- Marking of potential stoma sites (if applicable)
- Patient positioning: supine with right hemithorax elevated 30 degrees
- Appropriate placement of defibrillator pads outside the operative field
Port Placement and Robot Docking
- Camera port placement (typically 12mm) at umbilicus or slightly lateral
- Working ports (8mm) placed in an arc formation around the right upper and lower quadrants
- Assistant port (12mm) for stapling and specimen retrieval
- Careful port positioning to avoid arm collision and maximize workspace
- Robot docking from the patient's right side
Initial Steps and Exploration
- Thorough exploration of the peritoneal cavity, documenting extent of disease and adhesions 1
- Examination of the liver for potential metastases
- Assessment of the right colon, terminal ileum, and regional lymph nodes
- Mobilization of the right colon by incising the lateral peritoneal reflection
Vascular Control and Lymphadenectomy
- Identification of the ileocolic vessels at their origin from superior mesenteric vessels
- Careful dissection and ligation of ileocolic vessels at their base (central vascular ligation)
- Identification and ligation of right colic vessels (if present)
- Dissection and ligation of right branch of middle colic vessels
- Complete mesocolic excision with preservation of the mesocolic fascia intact 1
Mobilization of the Right Colon
- Medial-to-lateral dissection along the embryologic plane
- Careful separation of the right mesocolon from the retroperitoneum
- Mobilization of hepatic flexure with preservation of the duodenum
- Complete mobilization of the terminal ileum and transverse colon
Specimen Extraction and Anastomosis
- Extension of one of the port sites (typically periumbilical) for specimen extraction
- Extracorporeal resection of the specimen with adequate proximal and distal margins
- Extracorporeal or intracorporeal anastomosis (stapled side-to-side, end-to-side, or hand-sewn) 2
- For extracorporeal anastomosis: delivery of bowel ends through extraction site
- For intracorporeal anastomosis: complete anastomosis within the abdomen using robotic instruments
Closure and Final Steps
- Inspection of the anastomosis for integrity and hemostasis
- Irrigation of the peritoneal cavity
- Closure of mesenteric defects to prevent internal herniation
- Removal of all instruments under direct visualization
- Closure of port sites with appropriate sutures
Technical Considerations and Pitfalls
- Ensure adequate vascular supply to the anastomosis to prevent leakage 1
- Avoid excessive traction on mesentery to prevent vascular injury
- Careful identification of ureters and duodenum to prevent injury
- Complete mesocolic excision with central vascular ligation improves oncologic outcomes 3
- Retrieve at least 15 lymph nodes for adequate staging 4
Robotic right hemicolectomy offers several advantages over conventional approaches, including enhanced visualization, improved dexterity, and potentially more precise lymph node dissection. Studies have shown that robotic approaches can result in less blood loss and more consistent lymph node retrieval compared to open surgery 4, though operative times are typically longer. The choice between stapled and hand-sewn anastomosis should be based on surgeon preference, as both techniques show comparable leak rates 2.