Intracorporeal anastomosis for minimally invasive right colectomy - is it time for wider uptake?

Abstract

In 2023, minimally invasive surgery has become the default operative platform for colorectal procedures in the majority of specialist colorectal units, across Eastern and Western countries.1-3 However, there exist differing opinions and varying levels of evidence to support the indications for, and extent to which, minimally invasive surgery is utilized.4, 5 Wide surgical uptake of minimally invasive colonic surgery did not always follow compelling evidence; one could argue, it was encouraged by commercial and industry pressures. This reality is neither unique to colonic surgery nor the uptake of minimally invasive surgery. Fortunately, the advantages of minimally invasive colonic surgery in terms of short-term recovery outcomes, and its oncological equivalence, are now well supported in the literature.6-8 One aspect of minimally invasive colonic surgery, which has not been taken up with the enthusiasm applied to mobilization of the colon, is the intracorporeal anastomosis (ICA) after right hemicolectomy. ICA is more technically demanding, and given the need for an extraction site, ICA may seem like an unnecessary step that exposes patients to potential intra-abdominal contamination. Nonetheless, some units took up this challenge – perhaps driven by the cosmetic advantage of smaller incisions, the flexibility of extraction site (Pfannenstiel or natural orifice), or the response to a technical challenge. In auditing their results, and then backed up by formal trials, these groups observed improvements in gastrointestinal recovery, with lower rates of ileus, earlier return to bowel function, and reduced length of stay.9-12 Consider the typical body habitus of patients we care for in Australia and New Zealand. In patients with central adiposity and a fatty shortened mesentery, the extracorporeal anastomosis necessitates a wider extent of dissection to ensure there is sufficient mobilization to deliver the colon through a fatty abdominal wall to the wound surface. The extraction site must be larger to minimize trauma to the stretched mesentery when it is delivered, and accommodate the resultant bulky anastomosis when it is returned to the abdomen. Despite these steps, an extracorporeal anastomosis may sometimes result in a degree of tension and trauma to the join and the mesentery. Of course, all patients stand to benefit from an anastomotic technique that reduces anastomotic and mesenteric stress. During an ICA, the mesentery is not stretched for the purposes of extraction, and the potential to manually traumatize the anastomosis when it is returned to the abdomen through a fascial incision is eliminated. These could only add to the benefits ascribed to placing a smaller extraction wound in an anatomical location with improved cosmesis and lower risk of incisional hernia.12, 13 In fact, the argument to embrace the ICA is more compelling in the western world, given the higher BMI in our patient demographic. Interestingly, this is in direct contrast to the arguments which dominate most East versus West operative oncology discussions, for example in complete mesocolic excision and central vascular ligation during right hemicolectomy, where the marginal benefits from extended lymphadenectomy techniques may be outweighed by the higher potential morbidity in patients with a higher BMI.14-18 Although ICA may be more technically demanding, laparoscopy has dominated colorectal surgical training for the last 10 years, spawning computer-based simulation to expedite the acquisition and mastery of minimally invasive skills. Furthermore, developments by industry have complemented and encouraged this drive, with fit-for-purpose instruments to facilitate various steps and surgical manoeuvres; there is no need to attempt complex steps with existing basic equipment.19 Some argue the robot may provide the ultimate answer to new, more complex technical challenges. Regardless, in 2023, the surgical community should be well equipped to learn, teach and disseminate this skill set with low risk to the patient.20 Currently, there may not be clear evidence to support universal uptake of ICA after right hemicolectomy. However, it seems to the authors that there are potential benefits for the standard western patient cohort, which deserve to be explored. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. Edward A. Cooper: Conceptualization; writing – review and editing. David Z. Lubowski: Conceptualization; writing – review and editing. Kim-Chi Phan-Thien: Conceptualization; writing – original draft; writing – review and editing.