Get an inside look at a robotic right hemicolectomy for ascending colon cancer, performed by Puja Shah Berry, MD , colorectal and general surgeon at WellSpan Health. In this operative walkthrough, Dr. Berry highlights key technical considerations and oncologic principles, including dissection along embryologic planes, central vascular ligation and lymph node harvest, assessment of bowel perfusion using indocyanine green (ICG) fluorescence, and creation of a tension-free ileocolic anastomosis.
Follow the procedure step-by-step as Dr. Berry shares her approach to navigating complex anatomy, preserving critical structures and achieving an appropriate oncologic resection using robotic-assisted techniques.
My name is Doctor Pooja Bri. I'm a colorectal and general surgeon for Wellspan Health in New York, Pennsylvania, and this is my video doing a robotic right hemicolectomy for an ascending colon cancer. What you're seeing here now is the insertion of the camera into the abdominal cavity. I have already placed ports. Those are the silver tubes that you see on the screen, and my assistant is now placing the instruments that I need to do the procedure. Here, I am clearing off the ileocolic pedicle, which is what I need to do in order to do the oncologic part of the operation. I'm moving the small bowel out of the way. This patient's BMI is about 30, but as you can see, there's a little bit of excessive intraabdominal adipocity, which does make some of the parts of this case a little bit harder. Here, I am now getting into the embryonic plane between the mesocolon and the retroperitoneum. And you will see me continuing to push the retroperitoneum down as I work my way towards the hepatic flexure. So those thin fibers there are what separate one plane from another. And I'm just checking that I'm keeping the duodenum safe, as that is one structure that can get injured during this part of the case. I'm continuing to just work my way slowly through this dissection, and here to the right of the screen, you can see the duodenum, that's the pink structure. And here shortly, I will approach the hepatic flexure. I'm just cutting down the duodenal attachments to the meso colon. The black stuff that you can see here is the tattoo from the endoscopist, and I have just popped through the hepatocolic ligament, and the liver is what you're seeing in the background, and I'm just opening up that window. The instrument that I'm using is my vessel sealer, and this cuts, this burns, and then cuts at the same time. Below us you can also see the kidney. The next part of this is taking the iliocholic artery or pedicle, and I typically do this with a stapler, although there are multiple ways to take this vessel. And we do this in what we call a high fashion, so we do it right at the origin off of the superior mesenteric artery. And we have an automatic stapler that staples and then cuts. Once I complete this, the primary oncologic part of the operation is done. The lymph nodes that are important to harvest live along this vessel, and that's why we take it as close to the origin as possible. Now, I'm going to continue to take the mesentery of the transverse colon up to my distal dissection point. I'm now working on the lateral attachments. This patient has some embryologic adhesions that I am taking down, and as I take down the lateral attachments, I will meet that prior dissection window that I created earlier in the hepatic flexure. At this point, I'm taking the mesentery of the small intestine, and because this is an ascending colon cancer, I'm taking about 5 centimeters of the ileum with me. And I'm using the vessel sealer to transect the mesentery and all of the arterial blood flow with it. And I'm just continuing to work here. This is called the ICG function. We give the patient ICG through the IV, and that allows me to check the blood flow in the conduit of the colon and the ileum. And I'm now going to staple the mid transverse colon, which is going to be my distal transection point. And you can see here I'm checking and I'm being extra cautious that the mesentery comes right up to the staple line to ensure that I have adequate blood flow to heal the anastomosis. I am double checking the blood flow with my ICG function. And the stapler does not always go all the way across the colon. So, in a moment you will see me getting a second staple load to finish stapling off the distal transection point. I'm, you can see I'm kind of looking at it closer to decide if I can just cut it with a scissor or if I need another staple load. And for safety, I opted to get another staple load. So you'll see that come in and complete. The transsection of the transverse colon here in a moment. And my assistant is at the bedside the whole time. Doing the instrument exchanges for me. As you can see, the colon conduit that will make the anastomosis has a little bit of bleeding. This is actually quite good because it means this is a healthy, well-perfused piece of bowel. But in the corner there, you can see there is a very small vessel that is spurting. I grabbed it just to control it. I'll cauterize it here in a second, and I ultimately ended up suturing it just to control the blood flow, but that has been done off screen as this video was edited for brevity. Next, I am assessing the profusion to the small intestine, and I'm going to staple that. I am, again, triple checking that I have enough length on the ileum. I want to get at least 5 centimeters of it in the specimen, and I'm making sure that the mesentery comes right up to the staple line. So, those are the little micro adjustments you see me doing here. Now, the entire specimen is free. This was a pretty bulky ascending colon tumor. You can see the tattoo, which is just distal to the tumor, and I place it above the liver while I make the anastomosis. Here I am making a colotomy with my scissor. And this will be used to make the anastomosis. I'm just dilating it up here so that it can take the stapler. My assistant is ready on standby with the suction in case the patient's bowel prep was not adequate. In this case, we can see there was not much left in the colon. Now, I'm going to make an enterotomy. Similarly, I will need to dilate this up. There's almost always a little bit more enteric fluid. My assistant is suctioning that out, just so that we have a clean staple line when we make the anastomosis. My assistant is now going to give me another staple load. This stapler is really the key to making the anastomosis. It will both staple and cut, and so, the new anastomosis will be the length of the bowel that is on the stapler. So, I'm using the stapler to dilate the colotomy. And usually we put the bigger portion in the colon. And then I'll put the thinner portion into the small intestine. Sometimes it takes a little bit of maneuvering to really line everything up so that I'm happy and that we can make a tension-free, well-perfused anastomosis. So here you can see I'm trying to pull as much bowel onto this as I can, just to make the anastomosis at least 3 centimeters, which would be considered standard for an anastomosis in this location. Now the stapler is firing and the patient now has a new ileocholic connection. While excluding the entire portion that we resected earlier. The last part of this case involves me closing what we call the common channel. This part I will suit your clothes. And it's very important that we do not leave any holes during this part of the case in the anastomosis because this is where a patient can leak. So I personally will do a two-layered closure, which you'll see in a little bit, and I'm making sure to get a full thickness bite of the entire colon and small bowel. In order to make sure that this heals appropriately. This particular suture is barbed, meaning we do not need to tie a knot in it, and that's what you just saw there. I was threading it through the eye of the suture. And I'll just continue closing the colon to the small bowel, full thickness. Here, I'm at the end of it. I've closed most of it. I'm just taking my last few bites. And then I'm gonna go backwards for my double layer closure just to really make sure this is. As robust as it can be in terms of common channel closure. And these bites I'm really aiming more for serom muscular rather than full thickness. And what you'll see here in a second, that the needle driver does have a cutting function, which is nice, and what you'll see here in a second now is I'm going to check and make sure this has come together really nicely and that there's no leak on the bottom side, which is where it's most likely to leak. I'm handing the specimen to my assistant. So that we can extract it from the body, which will happen off screen. I do make a slightly bigger incision through one of my port sites. And the very last thing I'm doing here is I'm going to take some momentum. I'm going to cover up the anastomosis, so that if in case there is some sort of leak in a week or a couple of weeks, ideally the omentum would act as a pseudogram patch and seal that up. Fortunately leaks from right colon resections are fairly low. And now I'm gonna hand the staple line to my assistant for extraction. This patient ultimately ended up having a stage two colon cancer. No lymph nodes were involved. Therefore, this patient did not need any chemotherapy and surgery was considered curative. Thank you very much for watching my video and I hope you have a great day.
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