ROBOTIC LOW ANTERIOR RESECTION FOR SIGMOID COLON CANCER WITH INTESTINAL MALROTATION IN ADULT: A CASE REPORT
Jessica Chin*, Hani Ghandour, Jared Emolo, Jan P. Kaminski, Joaquin J. Estrada
Advocate Illinois Masonic Medical Center, Chicago, IL
Introduction
Colon cancer is the third most common cancer diagnosed in the United States. Intestinal malrotation is primarily considered a disease of infancy, though with increased use of cross sectional imaging studies, radiographic diagnosis of asymptomatic variations of malrotation is becoming increasingly more common, especially in the adult population. Here we present a minimally invasive low anterior resection for sigmoid colon cancer in a patient incidentally found to have intestinal malrotation on staging imaging studies.
Case report
A 71 year old male with previous distal pancreatectomy and splenectomy for pancreatic cancer was found to have a 20mm sigmoid colon mass on screening colonoscopy. Endoscopic mucosal resection was attempted and complete resection was unsuccessful. He was referred to us for surgical colonic resection for invasive adenocarcinoma. Preoperative imaging studies were suggestive of intestinal malrotation, with the majority of his small bowel in the left hemiabdomen and the large bowel on the right. Normal mesenteric vasculature was intact. He subsequently underwent a robotic-assisted low anterior resection with lysis of Ladd's bands, and had an unremarkable post-operative course. To our knowledge, this is the first reported case of a minimally invasive colectomy for colon cancer with malrotation in the United States.
Discussion
Pre-operative diagnosis of concomitant malrotation on cross sectional imaging facilitated planning our operative approach. Standard trocar placement for a right hemicolectomy was used, instead of a low anterior resection, given our knowledge of the patient's unique anatomy. We were able to perform a successful R0 colonic resection and full lysis of Ladd's bands in a minimally invasive fashion. Malrotation in the setting of colon cancer is a rare presentation, and variations of the mesenteric vasculature can complicate traditional surgical approaches. There are numerous reported cases of malrotation and colorectal cancer in Japan and India, however only one case in the United States that required laparotomy for accurate identification of vascular anatomy.
Conclusion
Diagnosis of intestinal malrotation in adults is increasingly more common with the routine use of cross-sectional imaging studies. Cross-sectional imaging studies are integral for the detection of metastatic disease spread in colon cancer and for delineation of relevant anatomy for operative planning. Careful analysis of the vascular anatomy in patients with intestinal malrotation can enhance the feasibility of a minimally invasive approach for colon cancer resection.
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