Descending Colon Cancer Resection Using the da Vinci SP with an Access Port kit: World's First Case

Abstract

In Japan, pharmaceutical approval for the use of the da Vinci SP (dV SP) Surgical System in colorectal cancer surgery was obtained in September 2022. This system has an operating arm with three instruments and one scope to be manipulated through a single incision in colorectal cancer surgery. An 88-year-old female presented to our hospital with melena and was diagnosed with cStage IIa descending colon cancer (cT3N0M0). The patient underwent left hemicolectomy with the dV SP using an Access Port kit. The Access Port kit was inserted into a 3-cm vertical skin incision at the umbilicus. With only this surgical wound, mobilization from the rectum to the colon, and lymph node dissection were performed. Herein, we report the world's first descending colon cancer resection with the dV SP using an Access Port kit.

Introduction

Minimally invasive surgery has become the dominant surgical technique in colorectal cancer surgery, and the number of robotic surgeries is increasing[1]. In a study comparing laparoscopic and robotic surgery for colon cancer, it was reported that robotic surgery is superior in the short-term, while the long-term outcomes are equivalent[2,3]. Despite the absence of large-scale randomized controlled trials, the efficacy of colon cancer has been demonstrated. In Japan, robotic surgery was covered by insurance in 2018 for rectal cancer and 2022 for colon cancer; thus, the number of robotic surgeries is expected to continue increasing in the future.

Until recently, robotic surgery was limited to the da Vinci (dV SP) Surgical System (Intuitive Surgical, Sunnyvale, California, USA). With the advancement of robotic technology, various robots - such as the hinotori™ Surgical Robot (Medicaroid, Kobe, Japan) and Hugo RAS (Medtronic, Dublin, Ireland) systems - have been developed and are now in clinical use[4,5]. Robots provide some advantages unique to robotic surgery - such as hand-shake prevention, articulating instruments, and motion scale function - that enable more delicate and precise manipulation than laparoscopic surgery.

Current robotic systems are multiport, which may result in more wounds than laparoscopic surgery in some cases and may be a disadvantage in terms of cosmetic outcomes[6]. Regarding the surgical wound, single-port laparoscopic surgery is considered superior; however, it has some difficulties, such as interference between the forceps and the scope, and creating the surgical field with a single surgeon's forceps[7].

The dV SP was introduced in the USA in 2018, and has been covered by insurance in Japan since September 2022. Previously, the use of stapler, as well as a wound extension or additional port, was sometimes required for gauze delivery using the dV SP[8]; thus, an Access Port kit was developed to overcome these issues. Hence, we report the first surgery for descending colon cancer using an Access Port kit with the dV SP.

Case Report

All procedures in this study were performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments, or comparable ethical standards. Informed consent was obtained from the patient for the publication of this case report. Colorectal cancer surgery using the dV SP was approved by the Institutional Review Board of Sapporo Medical University (approval number 342-219).

An 88-year-old female with a body mass index of 23.7 kg/m² presented to our hospital with melena. Colonoscopy revealed type 2 advanced cancer extending to the semicircle of the descending colon. Histological examination indicated a well-differentiated adenocarcinoma. Computed tomography revealed a thickened wall in the descending colon, consistent with the location of the tumor detected on colonoscopy, without significant swelling of the lymph nodes or distant metastasis (Figure 1). The patient was diagnosed with cStage IIa descending colon cancer (cT3N0M0) according to the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma: The Third English Edition[9]. Consequently, she underwent left hemicolectomy using the dV SP. The surgeon (I.T.) had extensive experience in robotic surgery and underwent operator training as defined by the developing company (Intuitive Surgical).

Figure 1.

Imaging findings of the present tumor.

(a) Colonoscopy revealing type 2 advanced cancer located on descending colon.

(b) Computed tomography coronal section indicating advanced cancer in the descending colon (arrowhead).

(c) Colonography indicating a tumor in the descending colon (arrowhead).

(d) Colonography indicating the arteries (red), veins (blue) and tumor (arrowhead).

A 3-cm vertical skin incision was made in the umbilicus; thereafter, a large Access Port kit (Intuitive Surgical) was fitted into the incision. The head of the patient was positioned 12° downward and 12° right downward. The assistant inserted the forceps and scope into Access Port kit (Figure 2a, b, c), and the small intestine was positioned on the right cephalic side to secure the operative field in the abdominal cavity. Thereafter, to avoid intraoperative drooping of the left colon, the head of the patient was positioned 12° downward and 5° left downward. The dV SP was positioned and docked over the patient's left side. Arm 1 contained bipolar fenestrated forceps during the entire surgical procedure; the scope position, arm 2, and arm 3 were appropriately adjusted depending on the situation. As the surgical field was shifted, the position of the arm was rotated in the “relocate mode” as necessary; in “relocate mode,” attention should be paid to the interference of the arm with the abdominal wall the assistant adjusted the arm to avoid this interference.

Figure 2.

View of an assistant inserting a device via the Access Port kit.

(a) A suction tube is inserted.

(b) An ultrasonically activated device is inserted.

(c) Forceps were inserted.

The medial approach was performed first, with the scope positioned above, arm 2 holding monopolar curved scissors, and arm 3 holding a round tooth retractor (Figure 3a). Thereafter, during peri-inferior mesenteric artery (IMA) manipulation, the scope position was changed to below, arm 2 held the round tooth retractor, and arm 3 held the monopolar curved scissors. The root of the IMA was identified, surrounding lymph nodes were dissected, and the artery was clipped and ligated (Figure 3b). Mobilization of the colon was performed up to the inferior border of the pancreas (Figure 3c); the scope position was changed to above, arm 2 held the monopolar curved scissors, and arm 3 held the round tooth retractor. The inferior mesenteric vein was ligated on the left side of the IMA (Figure 3d). Lateral mobilization of the descending colon was performed up to the splenic flexure vicinity (Figure 3e), and the head of the patient was positioned 12° downward and 5° left downward. The bursa was opened by resecting the omentum at the attachment of the transverse colon using assistant's ultrasonically activated device. The peritoneum was incised at the inferior border of the pancreas, and the splenic flexure mobilization was completed. The patient's head was lowered by 15°, and the left was lowered by 5°.

Figure 3.

Surgical field.

(a) Right side of the rectum.

(b) IMA was clipped and ligated.

(c) Mobilization of the colon at the inferior border of the pancreas.

(d) IMV was clipped and ligated.

(e) Lateral mobilization of the descending colon.

(f) Left side of the rectum.

(g) Rectal dissection.

(h) Pelvis after specimen removal.

IMA: Inferior mesenteric artery, IMV: Inferior mesenteric vein

After mobilization of the left side of the rectum (Figure 3f), the assistant inserted ultrasonically activated device through Access Port kit and mesorectal transection was performed. In rectal transection, the second arm instruction was removed, and the assistant inserted the staplar from the Access Port kit (Figure 3g, h). After removing the operation unit, the colon section was pulled out through the umbilical wound. Although, there was no obvious vascular injury during the intra- and extra- corporeal procedure, indocyanine green fluorescence revealed a poor blood-flow region on the oral side of the colon. It is assumed that the marginal vessel was injured or spasm had occurred during the procedure, therefore, transverse colon mobilization was added with redocking of the dV SP. The transaction was performed in a good perfusion zone, and the specimen was excised (Figure 4a, b). The intestine was then anastomosed using the double-stapling technique, and a drain was inserted through the umbilical wound (Figure 5b). Excluding additional transverse colon mobilization, the console time was 150 min. Console time of additional mobilization was 37 minutes, and total operative time was 295 minutes. The patient was discharged from our institution 8 days postoperatively without any complications. There were no postoperative issues with the wound 30 days postoperatively, and the scar was less visually noticeable compared with preoperative conditions (Figure 5a, c)

Figure 4.

Resected specimen.

(a) Specimen before opening the intestinal tract.

(b) Specimen with intestine opened and fixed.

Figure 5.

Surface image of the body.

(a) Before surgery.

(b) At the end of surgery.

(c) 30 days after surgery.

Discussion

This is the first procedure globally to use an Access Port kit with the dV SP to perform a surgery for descending colon cancer. The dV SP allows for three instruments and one scope to be manipulated through a single incision. DV SP-specific instruments offer a wider and more comfortable range of motion than the human hand, and are equipped with two joints - the “elbow” and “wrist” - for flexible intracorporeal manipulation[10]. A working space of up to 6.5 cm can be secured between instruments, allowing for smooth intra-abdominal manipulation and providing sufficient surgical field expansion.

Single-site laparoscopic surgery is not always easy as it requires the development of a unique field of view, and no assistant traction is available; therefore, development of a more appropriate operative field is required. However, compared with single-port laparoscopic surgery, an additional pair of forceps is used in the dV SP; this makes it easier to apply countertraction, and less interference with the forceps results in a dramatic improvement of operability. In this case, the operation was also much smoother than for single-port laparoscopic surgery, with a good field of view.

The scope incorporates a “cobra” function that enables the operator to flexibly control the angle and direction; it provides a bird's-eye view of the surgical field, with no interference between forceps. This is a significant advantage over the linear scope used in laparoscopic surgery. Additionally, the holographic navigation system enables viewing of the spatial positioning of the forceps, hence reducing interference to a minimum. This case required extensive manipulation from the rectum to the colon; however, it was possible to perform the surgery to create a triangulation without interference at any point in the procedure.

The dV SP is docked at one location on the Access Port kit; thus, the docking time is much shorter than with multiport systems. The instrument is inserted parallel to the scope, and all instruments are inserted in the same field of view, making it safer and quicker to complete[11]. In this case, the duration from docking to the start of dissection was only 5 minutes.

The dV SP has a “relocate mode” that enables the arm to rotate 360 degrees, allowing access in all directions without redocking. Colon cancer surgery requires extensive horizontal transfer. With the Boom-type robot, when splenic flexure transfer is required - as in this case - retargeting is necessary, and an additional port may be required. Additionally, the multiport robot can be very limited in operation due to interference between forceps if the ports are not properly positioned. Conversely, the dV SP has almost no forceps restrictions, allowing the procedure to be performed with only a single wound in the umbilical site. Furthermore, the relocate mode allows for smooth movement of the surgical field; this is a significant advantage as there is no need to consider port placement.

Still, there is the concern that robotic sealing devices and stapler instruments cannot be used. In a previous study reporting descending colon cancer surgery treated using the dV SP, a multichannel instrument was used to solve this problem, and a 4 cm transverse incision was made below the right umbilicus. This method can only accommodate the left-sided colon, in addition to requiring a larger wound. We used an Access Port kit that allowed surgery with a wound of only 3 cm at the umbilical site; this included gauze exchange, suction and hemostatic tubes, an ultrasonically activated device, and staplers, and resulted in a smaller wound. As the surgery was performed in the umbilical wound, access to all areas of the abdominal cavity was also possible; therefore, the use of the Access Port kit seemed to be very effective.

Despite the comparison of outcomes in single-port and multiport surgery reported in laparoscopy, the short- and long-term outcomes are considered comparable and superior regarding cosmetology[7,12-14]. Although, the operative time in this case was longer than in other similar general robotic operations, there are some possible reasons. The first, blood flow in the oral side of the intestine was revealed to be poor, thus additional resection of the intestine and mobilization were required. Second, this case was the first procedure for descending colon cancer using the Access Port kit in the dV SP. There are still some issues to be improved, such as the manipulation method. As these aspects are addressed, it is sufficiently expected to reduce the operation time. There are few reports on the dV SP, and there is a possibility that there is still potential for improvement in the positions and settings. Moreover, despite issues such as energy devices, there is sufficient room for improvement with modifications in the future. Further evidence for surgery using the dV SP is desired as more cases are accumulated in the future; however, considering reports of laparoscopy, we believe that the effectiveness of the dV SP is highly desirable.

Conclusion

Left hemicolectomy using the dV SP and Access Port kit was safely performed. In the future, development of devices and clinical trials will be required to verify efficacy.

Conflicts of Interest

There are no conflicts of interest.

Author Contributions

All authors made substantial contributions to the study and agree with the content of the manuscript.

Approval by Institutional Review Board (IRB)

This study was approved by Institutional Review Board of Sapporo Medical University (approval number 342-219).

Disclaimer

Ichiro Takemasa is one of the Associate Editors of Journal of the Anus, Rectum and Colon and on the journal's Editorial Board. He was not involved in the editorial evaluation or decision to accept this article for publication at all.