Received: 2 February 2022 | Revised: 28 March 2022 | Accepted: 12 April 2022 DOI: 10.1111/codi.16159 TECHNICAL NOTE A standardized stepwise approach to minimally invasive ileocolic anastomosis: Tips and tricks for laparoscopic and robotic surgery Alejandro Solís-­Peña1 | Arturo Cirera1 | Miquel Kraft Carré1 | Gianluca Pellino1,2 | Eloy Espín-­Basany1 Abstract 1 Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain Aim: Intracorporeal anastomosis has been associated with earlier recovery of postopera- 2 Department of Advanced Medical and tive bowel function, shorter length of stay and lower surgical site infection rates. The Surgical Sciences, Università degli Studi aim of this work is to describe a step-­by-­step standardized technique for intracorporeal della Campania “Luigi Vanvitelli”, Naples, Italy ileocolic and ileosigmoid anastomosis suitable for laparoscopic and robotic colectomy. Method: Each step of the technique is illustrated using a composite collection of three Correspondence Gianluca Pellino, Department of Advanced operative patient videos. Two procedures were performed robotically and one was lapa- Medical and Surgical Sciences, Università roscopic. Tips are provided to construct a two-­layer anastomosis (both posteriorly and degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy. anteriorly). The procedures are presented in stepwise fashion, discussing the advantages Email: gipe1984@gmail.com; gianluca. and feasibility of the technique. pellino@unicampania.it Results: The standardized technique described herein was used in three patients for this Eloy Espn-­íBasany, Colorectal Surgery, Vall d'Hebron University Hospital, report, of whom two underwent right colectomy and one subtotal colectomy for cancer. Universitat Autonoma de Barcelona UAB, The median operating time was 255 (206–­333) min. There were no intraoperative com- Barcelona, Spain. Email: eespin@vhebron.net plications. No major postoperative complications or 30-­day readmissions occurred. The median length of stay was 4 (3–­5) days. Conclusion: The described technique of a two-­layer anastomosis can be used with any available minimally invasive approach. It is safe and feasible. Using a standardized ap- proach, the technique can be easily taught and mastered, optimizing operating times and reducing adverse events. KEYWORDS ileocolic anastomosis, intracorporeal anastomosis, laparoscopic approach, robotic approach I NTRO D U C TI O N right colectomy and extended right colectomy are well-­established procedures for the treatment of right-­sided colon neoplasms [2]. As Several studies have demonstrated the advantages of minimally in- with right colectomy, the laparoscopic approach shows the same vasive surgery compared with open surgery after an oncological col- advantages in subtotal colectomy [3]. Robotic-­assisted procedures orectal resection [e.g. fewer surgical site infections (SSI), less use of seem to have reduced conversion rates in ‘difficult cases’ and fa- analgesics, etc.] with equivalent results. By means of these findings, cilitate the procedure by means of increased dexterity and range the minimally invasive approach is now considered by many groups of motions [4]. Ileocolic anastomoses can be performed using sev- to be the standard of care for colorectal cancer [1]. Both laparoscopic eral techniques, for example extracorporeal versus intracorporeal, This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland. 1238 |  wileyonlinelibrary.com/journal/codi Colorectal Disease. 2022;24:1238–1242. SOLÍS-­PEÑA et al. | 1239 mechanical versus hand-­sewn and single-­versus double-­layered. with the patient in a supine position, the lateral tilt is removed (both Intracorporeal anastomosis has potential advantages over extracor- during right colectomy and subtotal colectomy). During laparoscopic poreal, such as reduced traction on the mesentery, full visualization surgery, the operating surgeon stands on the left of the patient, with of every step with the reduction of ileum twist or specimen ex- the assistant surgeon on his/her left side; during robotic surgery, the traction via smaller incisions, with better cosmesis [2,5,6]. Although assistant is on the left of the patient while the operating surgeon sits there are many ways to fashion an intracorporeal anastomosis, some at the console. studies have demonstrated that a double-­layered anastomosis re- duces the clinical impact of anastomotic leaks [7]. Both laparoscopic and robotic intracorporeal anastomosis have been associated with Port placement earlier return of bowel function, shorter length of stay, lower mor- bidity and lower SSI rates [5,8]. Thus, the main indications for this In robotic-­assisted right colectomy five trocars are positioned as fol- technique are ileocolic and ileosigmoid anastomosis after right, ex- lows: one 8 mm port is placed in the midline, 4–­5 cm above the pubis; tended right and subtotal colectomies, respectively. then, three robotic trocars are placed cranially between the midline and midclavicular line (two 8 mm ports and a 12 mm port in position 3 or 4). In addition, one 8 mm laparoscopic assistant trocar is placed M E TH O D at the level of the midclavicular left line, between trocars 2 and 3 (Figure 1). We present our standardized technique of intracorporeal, stapled, A total of seven trocars are required to perform fully robotic ileocolic and ileosigmoid anastomosis reinforced on both sides with subtotal colectomy. These comprise four 8 mm robotic ports lo- a hand-­sewn suture, thereby creating a ‘double-­layered’ (both ante- cated respectively in both upper quadrants, the lower left quad- riorly and posteriorly) anastomosis. Video S1 (parts 1 and 2) shows rant and periumbilical. The 12 mm fifth robotic trocar is located, a step-­by-­step technique for performing the anastomosis both with as shown in the figure, in the right lower quadrant. In addition, laparoscopy and robotic-­assisted surgery. At our hospital we use the two 5 mm laparoscopic assistance trocars are used, located in both DaVinci Xi™ platform (Intuitive Surgical™). Each step is illustrated flanks (Figure 1B). using a composite collection of three operative patient videos. Two In the laparoscopic technique, two different alternatives for tro- procedures were performed robotically and one was laparoscopic. car placement are suggested. In the first one, a periumbilical Hasson port is placed, through which the camera is inserted. Next, a 12 mm trocar is positioned in the left flank and two 5 mm ports go in the Patient positioning epigastrium and the left lower quadrant, respectively (Figure 2A). Alternatively, the 12 mm trocar can be positioned just above the After the entire dissection has been completed and both the ileum pubis, so that the 5 mm port would move towards the left flank and colon have been sectioned either robotically or laparoscopically, (Figure 2B). (A) (B) 4-5 cm F I G U R E 1 Trocar placement for robot-­ 12 mm 8 mm 12 mm 8 mm assisted right colectomy (A) and for robot-­ assisted subtotal colectomy (B) 8 mm assistant port 5 mm assistant port 1240 | SOLÍS-­PEÑA et al. (A) (B) F I G U R E 2 Trocar placement for laparoscopic right colectomy (A, standard technique; B, alternative disposition) Camera (Hasson) 12 mm 5 mm TA B L E 1 Patient characteristics, surgical details, and postoperative outcomes Clinical case 1 Clinical case 2 Clinical case 3 Age (years) 74 38 68 Gender Female Male Male 2 Body mass index (kg/m ) 28.3 26.9 27.7 Location of the tumour Right colon Right colon Mid-­transverse colon Signs and symptoms at diagnosis Asymptomatic Microcytic anaemia Asymptomatic Surgical details Type of surgery Robot-­assisted right colectomy D3 laparoscopic right colectomy Robot-­assisted subtotal colectomy Duration of surgery (min) 206 255 333 Blood loss (ml) <100 <100 <100 Intraoperative complications None None None Outcomes Postoperative complications None None Nausea and vomiting Hospital stay (days) 3 4 5 Pathology Adenocarcinoma (pT3 pN1a pM0) Adenocarcinoma (pT3 pN0 pM0) Adenocarcinoma (pT3 pN0 pM0) Docking closest corner to the posterior suture and ending a few centime- tres beyond the end of the buttonhole. The standardized technique The robot is at the right side of the patient at a 90° angle during also includes an anterior reinforcement using a continuous barbed the right colectomy, and between the legs during subtotal colec- suture. tomy. The robot arms are aligned with the trocars and docking is performed. Robotic instruments are introduced under direct vision. CO M PA R I S O N W ITH OTH E R M E TH O D S , A DVA NTAG E S A N D D I S A DVA NTAG E S Surgical steps Compared with other ileocolic anastomotic techniques, our proce- The anastomosis is started with a running suture of the posterior dure has been standardized to be utilized by all surgeons in our team, plane using a barbed thread. Once the posterior component of the including surgeons in training and fellows. Intra-­and interoperator anastomosis has been completed, an ileal and a colonic enterotomy variabilities are eliminated, likely reducing postoperative complica- are performed with monopolar energy. A side-­to-­side mechanical tions related to the anastomosis. The adoption of a homogeneous anastomosis is fashioned using an Endostapler. Another continu- approach facilitates the learning process for surgical trainees and ous barbed suture is used to close the defect, starting from the audit of the skills training process. SOLÍS-­PEÑA et al. | 1241 The use of the ‘double layer’ or hand-­sewn reinforcement of the degli Studi della Campania Luigi Vanvitelli within the CRUI-CARE anterior and posterior sides of the anastomosis has not been asso- Agreement. [Correction added on 18 May 2022, after first online ciated with reduced rates of anastomotic leak, but it has reduced publication : Funding statement has been added.] the need for reoperation in the case of anastomotic leak, that is, it reduces the clinical impact of an anastomotic leak [7]. C O N FL I C T O F I N T E R E S T With the current technique, the closure of the enterotomy is The authors declare that they have no conflict of interests. achieved with a double-­layer, full-­thickness, running barbed suture. Some studies have demonstrated the feasibility and safety of this AU T H O R C O N T R I B U T I O N S type of suture, with similar complication rates of conventional su- ASP, AC, MKC collected data, prepared the video, and drafted the ture closure [9,10]. In addition, in a multicentre case–­control study manuscript. GP and EEB critically revised the article. All authors ap- published in 2020 with 1092 patients who underwent right colec- proved the last version that was accepted for publication. tomy with ileocolic anastomosis, a significant reduction was found on both anastomotic leak and bleeding with the running suture E T H I C A L A P P R OVA L performed with a barbed suture thread. No differences were seen This work adhered to the Declaration of Helsinki. All patients pro- between laparoscopic and the robotic-­assisted approaches [11]. vided consent before undergoing the surgical procedure. Lastly, intracorporeal anastomosis, compared with the ex- tracorporeal approach, not only has similar rates of anastomotic DATA AVA I L A B I L I T Y S TAT E M E N T leak but has also been shown to lower the risk for global, medical The data that support the findings of this study are available from and surgical complications, SSI and wound complications, includ- the corresponding author upon reasonable request. ing the rate of incisional hernias, and to shorten the hospital stay [2,12–­14]. ORCID Alejandro Solís-­Peña https://orcid.org/0000-0001-5536-9559 Arturo Cirera https://orcid.org/0000-0002-4972-5315 R E S U LT S Miquel Kraft Carré https://orcid.org/0000-0002-5642-1694 Gianluca Pellino https://orcid.org/0000-0002-8322-6421 We describe data from three different patients diagnosed with Eloy Espín-­Basany https://orcid.org/0000-0002-9139-4548 nonmetastatic colorectal cancer and who were operated on ei- ther by laparoscopy or robotic-­ assisted surgery: two cases of T WITTER right colectomy and one case of subtotal colectomy. After the Alejandro Solís-­Peña @AlejandroSolP colonic resection, an ileocolic anastomosis following the stand- Arturo Cirera @ArturoCirera ardized technique was performed in all cases. Pathology was con- Miquel Kraft Carré @MiquelKraft sistent with colon adenocarcinomas in all patients. In all cases, Gianluca Pellino @GianlucaPellino a Pfannenstiel incision was performed for the specimen extrac- Eloy Espín-­Basany @eloiespin tion because it has a lower incidence of incisional hernia as well as better cosmetic results. Demographic and operative details of REFERENCES the patients are listed in Table 1. No major intra-­and postopera- 1. Lee SW. Laparoscopic procedures for colon and rectal cancer tive complications were observed, including ones related to the surgery. Clin Colon Rectal Surg. 2009;22(4):218–­24. https://doi. org/10.1055/s-­0 029-­1242461 anastomotic status (leak, bleeding or stricture). The median length 2. van Oostendorp S, Elfrink A, Borstlap W, Schoonmade L, Sietses of hospital stay was 4 days. Detailed surgical and postoperative C, Meijerink J, et al. Intracorporeal versus extracorporeal anas- outcomes are shown in Table 1. tomosis in right hemicolectomy: a systematic review and meta-­ analysis. 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