Clinical Scorecard: Simultaneous Robotic Right Hemicolectomy and Partial Gastrectomy

At a Glance

Key Highlights

• Approximately 4% of stomach cancer patients have synchronous colorectal cancer requiring combined surgery.
• Robotic right hemicolectomy and partial gastrectomy are feasible and safe minimally invasive techniques.
• Single trocar positioning with two dockings optimizes operative efficiency for dual abdominal compartment surgery.

Guideline-Based Recommendations

Diagnosis

• Perform colonoscopy and esophagogastroduodenoscopy (EGD) to identify synchronous tumors.
• Complete staging with CT scan and multidisciplinary team discussion.
• Use AJCC 8th edition for tumor staging.
• Assess patient anesthetic risk using ASA score.
• Test for COVID-19 prior to surgery during pandemic conditions.

Management

• Plan synchronous robotic right hemicolectomy and partial gastrectomy with D2 lymphadenectomy.
• Use the Intuitive Da Vinci Xi® system with optimized trocar placement for both sub-mesocolic and supra-mesocolic phases.
• Induce pneumoperitoneum at 14 mmHg using Veress needle.
• Position patient in Trendelenburg and reverse-Trendelenburg with lateral inclinations for respective resections.
• Perform medial-to-lateral dissection for right colon mobilization and lymphadenectomy.
• Mobilize stomach and perform lymphadenectomy of stations 4sb, 4d, 6, 7, 8a, 9, and 12a during partial gastrectomy.
• Use robotic staplers (SureForm® 60 mm) for bowel and duodenal division.
• Extract specimen and perform ileocolic anastomosis during open phase.

Monitoring & Follow-up

• Monitor pneumoperitoneum pressure and trocar positioning intraoperatively.
• Ensure adequate lymph node dissection and hemostasis during robotic phases.
• Assess patient recovery postoperatively for complications related to multi-organ resection.

Risks

• Challenges related to operating in two different abdominal compartments requiring precise trocar placement.
• Potential intraoperative complications from vascular ligations and lymphadenectomy.
• Risks associated with prolonged operative time and patient positioning.
• COVID-19 infection risk mitigated by preoperative testing and robotic approach.

Patient & Prescribing Data

Patients with synchronous right colon and gastric cancers eligible for minimally invasive surgery

Robotic synchronous resection offers a standardized, reproducible technique with potential benefits in postoperative recovery and surgical precision, especially relevant during pandemic conditions.

Clinical Best Practices

• Plan trocar placement on a single line with precise measurements after pneumoperitoneum induction to minimize dockings.
• Use the right colic flexure and gastric antrum as targeting points for respective resections.
• Maintain appropriate patient positioning (Trendelenburg and reverse-Trendelenburg) with lateral inclinations to optimize surgical access.
• Perform thorough lymphadenectomy according to oncologic standards (D2) during both hemicolectomy and gastrectomy.
• Utilize robotic staplers for safe and precise bowel and duodenal transections.
• Coordinate multidisciplinary team discussions for case planning and staging.

References

• Incidence of synchronous colorectal cancer in stomach cancer patients
• Feasibility of robotic right hemicolectomy
• Feasibility of robotic partial gastrectomy
• Laparoscopic synchronous resections case series
• Robotic synchronous resections case series
• Use of Intuitive Da Vinci Xi® system
• Trocar positioning optimization for robotic surgery