Experience with Laparoscopic and Robotic Colon Surgery Together with Other Major Minimally Invasive Procedures for Unrelated Pathologies

Introduction

Laparoscopy has been accepted for treatment of a wide range of abdominal pathologies including diseases of the large intestine and robotic surgery further revolutionized this predicament.^1–4 Multiple studies have documented superiority of minimally invasive colectomy when compared to the open approach.^4,5

In subsets of patients, more than one surgical problem needs to be addressed simultaneously. Injuries to neighboring organs occurring during colon surgery such as a tear in the spleen during splenic flexure mobilization warrant repair and laparoscopy may have advantages. ⁶ During emergent situations such as following abdominal trauma, colon repair, or resection together with other procedures may be necessary, which in the stable trauma patient may be performed safely using laparoscopy. ⁷ Also, if oncologic patients require combined colon resections together with other procedures, minimally invasive technique may be superior to the open approach.^8–10 Combined laparoscopic colectomy together with partial hepatectomy for colorectal cancer with liver metastases has been shown to be feasible and safe.^11,12 Piccoli et al. demonstrated excellent results after robotic-assisted multivisceral resections in the setting of endometriosis or locally advanced colorectal cancer. ⁸

A limited number of combined minimally invasive elective major colon surgeries together with another procedure done for unrelated pathology including nephrectomies has been reported with good results.^13–17 Kim et al. demonstrated that combining laparoscopic colectomies for colon cancer with other laparoscopic interventions for unrelated pathologies did not increase the risk for complications including anastomotic leakage. ¹⁸ The most common 2nd procedure in this large series was cholecystectomy.

We present a series of patients undergoing combined laparoscopic or robotic-assisted major colon surgeries and had a second minimally invasive procedure done for an unrelated pathology.

Patients and Methods

This is a retrospective cohort study. The case database of a single surgeon with minimally invasive surgical fellowship training from two institutions during a 10-year period was queried for combined colectomies together with other interventions.

The study was approved by the ethics committees. Data were obtained from electronic medical records (Meditech, EPIC), and a database was created using MS Excel. Data are displayed as a percentage for the population for discreet parameters and median with range for continuous parameters. Statistical analysis was performed using MS Excel.

All open cases, combined cases performed for one pathology and laparoscopic colectomies together with a minor procedure were excluded. Lysis of adhesions even if extensive was not considered an inclusion criterion. Only cases in which both procedures could be finalized using a minimally invasive approach were included.

Results

All cases of laparoscopic colectomy together with removal of skin lesions (4), IVC filter placement (3) or closure of small ventral hernias (8) were excluded. Two patients who had laparoscopic right colectomy with another colectomy (sigmoid colectomy for combined volvulus, segmental left colectomy for synchronous colon cancer) were not considered. Two patients who had a colectomy followed by a second laparoscopic procedure (cholecystectomy, fundoplication) within a month were also excluded.

The final study group consisted of 6 men and 7 women with a median age of 64.4 (range 42.7–75.4) years. Demographic and clinical data are shown in Table 1 and Fig. 1a–c. Right (5) and sigmoid (4) colectomies were the most common large bowel procedures; there was one colostomy reversal and rectopexy each. Colorectal cancer (4), diverticulitis (3), and volvulus (3) were the most common indications. Additional procedures included two splenectomies (sarcoidosis, ITP), PEH repairs (4), cholecystectomies (2), right diaphragmatic repairs (3), and one appendectomy for acute appendicitis, one duodenal wedge resection for carcinoid, and one reversal of a gastric bypass for a Roux limb stricture. Seven cases were done laparoscopic and six with robotic assistance. Three cases were done with 3 ports, six with 4 ports, and four with 5 trocars. Port placement was planned preoperatively and adaption during surgery to obtain best view for both procedures. Synergistic steps of the two procedures such as mobilization of the splenic flexure together with opening of the lesser sack and dividing of the gastrocolic ligament (fundoplications and splenectomies), and mobilization of right colon and Kocherization of duodenum were done without repositioning of the patient or instruments. Median operative time was 4.3 (range 2.5 to 6.6) hours. Figure 2 shows computed tomography scan of a patient with a PEH and sigmoid diverticulitis.

OPEN IN VIEWER

FIG. 1.

(a) Distribution of colonic procedures. (b) Distribution of underlying colonic disorders. (c) Distribution of secondary minimally invasive procedures.

OPEN IN VIEWER

FIG. 2.

Abdominal CT-scan (a: coronal, b: axial) demonstrating sizeable paraesophageal hernia (arrow) and sigmoid diverticulitis (arrows). CT, computed tomography.

In one case, a staged approach was chosen with resection of the strictured Roux limb and the dilated sigmoid colon due to volvulus. During second look operation after 48 hours, a partial gastrectomy and gastro-gastrostomy were done together with creation of a colostomy. For the right hemicolectomies, in 4 cases a stapled extracorporeal anastomosis was done through a 5 cm periumbilical incision and in one case, a robotic-assisted intracorporeal sewn anastomosis (2 layers) was created. Three left colon anastomosis were stapled (EEA), and two were done using a robotic-assisted sutured technique.

Three patients were well and alive when lost to FU at 4, 2.5 and 2 years after surgery. Two patients died within 6 months related to their comorbid conditions and cancer progression, and eight patients are well and alive after median 1.3 (range 0.5–5.5) years. There was not a single anastomotic breakdown. Complications (Table 1) included ileus (1) and small bowel obstruction (1), the latter unrelated to the surgery but required re-intervention. One patient has ongoing chronic abdominal pain associated with enteroparesis. One patient has ongoing GERD after repair of her recurrent PEH and another patient required a balloon dilatation after the fundoplication. There was one superficial surgical site infection and one had a minor bleed at the extraction site.

Discussion

Combining minimally invasive colectomy and other major abdominal surgeries can be safely done and in this series did not increase morbidity or mortality confirming previously published data.^10,14,18,19 The approach prevents delay in treatment and saves the patient a second operation. Many of our patients underwent procedures never described before. Patient selection and good preoperative planning are crucial and port placement may need to be altered to achieve good exposure for both procedures.

During the first 5 years only three cases were done, but the volume increased in 2018 and 2019 with more experience, institutional support, and availability of the robotic platform. Our first case had the longest operative time with almost 400 minutes; however, more than 1 hour was spent locating a duodenal carcinoid with endoscopic guidance. All other cases were finished within 150 to 300 minutes, which is comparable to the series of Kim. ¹⁸ The combined splenectomy (sarcoidosis) and sigmoid colectomy (perforated diverticultis) were the first such reported case and helped refining the technique. ¹³ The 2nd such case was done in 2018 (bleeding transverse colon cancer and refractory idiopathic thrombocytopenic with a platelet count of 5 K/L). Laparoscopic colectomy with splenectomy for splenic metastases or locally advanced cancer has been shown feasible and safe.^20,21

In 2019, our 1st of four combined colon surgeries together with PEH repair was successfully performed (Fig. 1). Mackowsky et al. reported a combined right hemicolectomy for colon cancer together with PEH repair. ¹⁴ Neither sigmoid colectomy nor colostomy reversal nor rectopexy together with PEH repair have been previously reported. Addressing diverticular disease and rectal prolapse and PEH simultaneously may be beneficial as PEH repair only would leave the diseased colon in place potentially causing intraabdominal pressure elevation, which could jeopardizing the PEH repair. Due to the risk for ileus and difficulties placing a nasogatsric tube through the fundoplication, gastrostomy tube placement is advisable.

During the COVID19 epidemic (2020–2021), no additional cases were done. With the acquisition of the robotic platform at the hospital, the program was restarted and expanded in 2023 with four additional cases. This confirms data by Dwyer et al., who reported that the robotic approach was helpful in patients with combined colectomy and liver resection for colorectal cancer metastases. ²² Two of our patients underwent robotic plication of the right diaphragm due to eventration together with right hemicolectomy and both patients experienced significant improvement in their shortness of breath following the procedure. ²³

Appropriate patient selection is one important aspect, and if significant comorbidities are present, a staged approach may still be a better option to keep operative time shorter. If any intraoperative complications occur, it may also be advisable to finish one procedure and bring the patient back after recovery for the 2nd part. To avoid unnecessary placement of an excess number of trocars, compromises are necessary—the majority of our cases was done with four ports only. Timing of docking and re-docking of the robot needs to be well planned especially when operating in the pelvis and the epigastrium. Lysis of adhesions was in all cases done laparoscopically, which seems to safe significant time.

To summarize, our data support the concept of combining major laparoscopic procedures; however, indications for independent pathologies are limited. ¹⁸ Cochetti et al. summarized 15 cases of combined minimally invasive colectomy with nephrectomy and in general reported good outcomes.^15,16 Due to specialization, coordination, and reimbursement issues, surgeons may not be willing to combine these surgeries. Whereas removing a gallbladder during right hemicolectomy is a rather simple addition,^11,18,24 combining a colectomy with a fundoplication or splenectomy is much more complex.^14,25

In the academic setting, a team of two specialized surgeons may be required, which raises multiple issues such as who is the primary surgeon, what is the best patient positioning, what is the most effective trocar placement, what procedure will be done first, and who will be responsible for postoperative care including advancement of diet. This should though be able to be sorted out and surgical teams should be encouraged to work together for the benefit for the patient as shown by Kaida et al. and Kojima et al..^17,19 In the community setting, if surgeons with broad spectrum minimal experience are available, these combined procedures may be more commonly done but a significant number of cases like ours may never get published.