Article / Case Report
General, Gastric and Minimally Invasive Surgeons at Vila Nova Star Hospital, São Paulo, Brazil.
Marina Gabrielle Epstein,
General, Gastric and Minimally Invasive Surgeon at Vila Nova Star Hospital, São Paulo,
Brazil.
5 June 2025 ; 21 June 2025
The global population is aging, and with it, the prevalence of colorectal cancer (CRC) is increasing. Individuals aged ≥80 years represent a unique and growing subset of CRC patients. These patients often present with multiple comorbidities, functional decline, and increased surgical risk. Despite this, surgical resection remains the cornerstone of curative treatment.
Minimally invasive surgery (MIS), particularly robotic-assisted colorectal surgery (RACS), has gained attention for its potential benefits in this demographic. While laparoscopy is well-established, its technical limitations—including restricted dexterity and ergonomics—pose challenges in complex cases. RACS, developed to overcome these limitations, provides three-dimensional (3D) vision, wristed instrumentation motion scaling, tremor elimination, and improved ergonomics.
Despite growing data supporting the safety and efficacy of RACS, its application in patients over 90 years remains scarcely reported. This report presents a successful case of robotic right colectomy in a 92-year-old woman with a malignant cecal tumor, highlighting surgical strategy, perioperative considerations, and outcomes. Our objective is to present a case of a robotic right colectomy for malignant cecal neoplasm in an elderly patient.
Keywords: Colorectal cancer; Elderly, Minimally invasive surgery, Right colectomy, Robotic surgery.
Globally, life expectancy has risen significantly, increasing from 66.8 years in 2000 to 73.4 years in 2019 (Teo & Ngu, 2023). As a result, the geriatric population (individuals aged 65 and older) is projected to grow substantially. The incidence of colorectal cancer (CRC) increases with age, with peak occurrence typically seen in the seventh and eighth decades of life (Teo & Ngu, 2023). According to estimates from the Surveillance, Epidemiology, and End Results database, approximately 70% of CRC cases occur in individuals over 65, and nearly 40% affect those older than 75 (Teo & Ngu, 2023). The adoption of robotic surgery for segmental colon resections has expanded globally, driven by the advantages of enhanced three-dimensional visualization and superior instrument dexterity offered by the robotic platform (Chen et al., 2024).
A 92-year-old female with a medical history of arterial hypertension, dyslipidemia, obesity (BMI 40kg/m2), and pulmonary thromboembolism under chronic anticoagulation presented with melena. She required red blood cell transfusion to maintain hemoglobin levels around 8 g/dL. Colonoscopy revealed a bleeding cecal mass with invasion of the ileocecal valve (Figure 1). Biopsy confirmed adenocarcinoma. Computed tomography showed a cecal tumor approximately 7.8 cm in diameter (Figure 2), without evidence of distant metastasis.
Figure 1: Colonoscopy showing a cecal tumor invading the ileocecal valve
Figure 2: CT scan confirming the tumor mass
The multidisciplinary team elected for an upfront resection via right hemicolectomy. A robotic approach was proposed and informed consent obtained.
Due to the patient’s comorbidities, a pneumoperitoneum of 12 mmHg was utilized. Intraoperative exploration revealed tumor invasion of the abdominal wall (Figure 3).
Figure 3: Intraoperative image showing tumor invasion of the abdominal wall.
Right colectomy was performed with 12 mmHg pneumoperitoneum. Operative time was 60 minutes with 30 mL blood loss. One unit of blood was transfused. No intraoperative complications occurred. Recovery was uneventful and the patient was discharged on postoperative day 11. Pathology revealed a moderate adenocarcinoma of the Cecum 7.8cm in size with free margins. Stage T4aN1c and a total of 25 lymph nodes were removed.
The role of robotic surgery in older patients remains unclear and there are still few studies about it. Buchs et al. evaluated feasibility, safety, and short-term outcomes of robotic surgery in elderly patients (Palomba et al., 2022). These authors showed that robotic surgery can be performed with low mortality, acceptable morbidity, and short hospital stay. We only found one study that compared robotic colorectal resection surgery versus laparoscopic colorectal resection surgery in elderly patients (Palomba et al., 2022). In this retrospective study, there are similar results between the two approaches in terms of operative and oncologic outcomes, despite longer operative times for the robotic surgery (de’Angelis et al., 2018). There are other studies that report a reduction in hospitalization after robotic colorectal surgery, but no one targets elderly patients (Al-Mazrou et al., 2017).
Early results from comparative studies show that RACS is safe and feasible in the elderly and despite an increased operative time, it potentially confers the benefit of lower conversion, earlier return of gut function and shorter length of stay with comparable oncological outcomes. As such, age alone should not be a strict exclusion criterion for RACS.
- Teo, N. Z., & Ngu, J. C. Y. (2023). Robotic surgery in elderly patients with colorectal cancer: Review of the current literature. World J Gastrointest Surg, 15(6), 1040-1047. DOI: https://doi.org/10.4240/wjgs.v15.i6.1040
- Chen, E., Zhang, W., & Chen L. (2024). Robotic right colectomy versus laparoscopic right colectomy in patients with right colon cancer: a comparative study. BMC Surg, 24(1), 332. DOI: https://doi.org/10.1186/s12893-024-02593-y
- Palomba, G., Dinuzzi, V. P., Capuano, M., Anoldo, P., Milone, M., De Palma, G. D., & Aprea, G. (2022). Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience. J Robot Surg, 16(4), 981-987. DOI: https://doi.org/10.1007/s11701-021-01332-2
- de’Angelis, N., Abdalla, S., Bianchi, G., Memeo, R., Charpy, C., Petrucciani, N., Sobhani, I., & Brunetti, F. (2018). Robotic versus laparoscopic colorectal cancer surgery in elderly patients: a propensity score match analysis. J Laparoendosc Adv Surg Tech A, 28(11), 1334–1345.
DOI: https://doi.org/10.1089/lap.2018.0115 - Al-Mazrou, A. M., Chiuzan, C., & Kiran, R. P. (2017). The robotic approach significantly reduces length of stay after colectomy: a propensity score-matched analysis. Int J Colorectal Dis, 32(10), 1415–1421. DOI: https://doi.org/10.1007/s00384-017-2845-1