Robotic Complete Mesocolic Excision and Paraaortic Lymph Node Dissection for Cecal Cancer and Paraganglioma

Abstract

In relation to the treatment of colorectal cancer, extraregional lymph node dissection refers to the dissection of lymph nodes in the extramesenteric area including the lateral pelvic or the para-aortic area. Although the role of para-aortic lymph node dissection (PALND) in the management of colorectal cancer has not been established, this extended lymphadenectomy might be beneficial in carefully selected patients. 1

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Robotic surgery offers technical advantages, including a reliable lymph node dissection along the central vascular trunk. 3

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We present a video presentation of robotic complete mesocolic excision and PALND for ascending colon cancer and paraganglioma. A 79-year–old man was referred to our hospital for treatment of cecal cancer. Colonoscopic examination revealed a fungating ulcerated cecal mass measuring 6 cm in size with complete obstruction. Abdominal CT and radionuclide positron emission tomography of the torso revealed a hypermetabolic cecal lesion with enlarged pericolic, ileocolic, and aortocaval lymph nodes and a small metastatic lesion in the right hepatic lobe. We attempted to administer neoadjuvant chemotherapy with self-expanding metallic stent insertion. However, we could not insert the stent because of the technical challenge attributed to the location of the lesion in the ileocecal area and thus decided to perform the surgery first after small-bowel decompression. The patient underwent robotic right hemicolectomy with right PALND and laparoscopic excision of a diaphragmatic seeding nodule. The total procedure time was 490 minutes. Histopathological examination of the specimen showed a moderately differentiated T4bN1bM1b adenocarcinoma measuring 6.0 × 5.5 cm in size. The total and positive lymph nodes harvested were 26 and 3. No positive lymph node was observed in the central area among the 3 apical lymph nodes excised. The 4 para-aortic lymph nodes excised were diagnosed as paraganglioma without margin involvement. A diaphragmatic nodule identified in close proximity to the right lobe of the liver revealed metastatic adenocarcinoma. The patient was discharged on postoperative day 10 without postoperative complications. Robotic complete mesocolic excision and PALND can be performed safely with accurate staging and diagnosis of ascending colon cancer.