Robotic complete mesocolic excision using indocyanine fluorescence imaging in colorectal cancer: A case study and technical approach.

INTRODUCTION: Colorectal cancer is the second most common malignancy in developed countries and accurate staging is vital for determining the most appropriate management plan, in particular, whether adjuvant chemotherapy is recommended in addition to surgical resection. There is currently no consensus regarding standard practice for lymph node resection in colorectal cancer although there is increasing evidence to support the use of sentinel lymph node mapping to target lymph node sampling and facilitate ultra-staging of nodes. PRESENTATION OF CASE: We present the case of a 49 year old female who underwent a robotic right hemicolectomy and complete mesocolic excision for caecal adenocarcinoma using indocyanine fluorescence imaging (ICG FI) to guide nodal dissection. DISCUSSION: ICG FI may be useful for sentinel lymph node mapping in colorectal cancer. This technique can assist to identify the first draining lymph nodes and permit ultra-staging of lymph nodes. CONCLUSION: While there is still limited evidence to support ICG FI, the current body of literature suggests that it is likely to be a feasible and sensitive technique for guiding sentinel lymph node sampling in colorectal cancer.

Robotic-assisted complete mesocolic excision, central vascular ligation and para-aortic lymph node dissection in multifocal carcinoid: A case report and technical description.

INTRODUCTION: Neuroendocrine tumours are the most common type of primary small bowel neoplasm. Consensus guidelines recommend a multimodal approach to treatment of such tumours, with aggressive surgical resection remaining the mainstay of management. There is evidence that complete mesocolic excision (CME) of lymph nodes is associated with superior oncological outcomes including longer disease-free survival in patients with colorectal cancer than standard lymph node dissection and there is increasing evidence to suggest that the robotic approach may be superior to laparoscopic or open CME. This report discusses a robotic-assisted approach to CME with central vessel ligation (CVL) and para-aortic lymph node dissection in a case of multifocal neuroendocrine tumour of the small bowel. PRESENTATION OF CASE AND TECHNICAL APPROACH: This report details the case of a 73-year-old male with multifocal small bowel neuroendocrine tumour. He underwent a robotic-assisted right hemicolectomy, small bowel resection, CME, CVL and para-aortic lymph node dissection. The approach described involved undertaking CME, CVL and bowel resection with a standard right hemicolectomy robotic set-up before re-docking the robot to perform the retroperitoneal para-aortic lymph node dissection. DISCUSSION: This case highlights the management of multifocal small bowel neuroendocrine tumour using a robotic approach for surgical resection and lymph node clearance. CONCLUSION: The robotic approach provides a safe and effective technique for undertaking surgical resection of small bowel neuroendocrine tumour as well as complete mesocolic excision of lymph nodes. With a change in port positions, a robotic approach can be utilised for CME/CVL as well as retroperitoneal node dissection.