Validation of a novel virtual reality simulation system with the focus on training for surgical dissection during laparoscopic sigmoid colectomy

Background Mastery of technical skills is one of the fundamental goals of surgical training for novices. Meanwhile, performing laparoscopic procedures requires exceptional surgical skills compared to open surgery. However, it is often difficult for trainees to learn through observation and practice only. Virtual reality (VR)-based surgical simulation is expanding and rapidly advancing. A major obstacle for laparoscopic trainees is the difficulty of well-performed dissection. Therefore, we developed a new VR simulation system, Lap-PASS LP-100, which focuses on training to create proper tension on the tissue in laparoscopic sigmoid colectomy dissection. This study aimed to validate this new VR simulation system. Methods A total of 50 participants were asked to perform medial dissection of the meso-sigmoid colon on the VR simulator. Forty-four surgeons and six non-medical professionals working in the National Cancer Center Hospital East, Japan, were enrolled in this study. The surgeons were: laparoscopic surgery experts with > 100 laparoscopic surgeries (LS), 21 were novices with experience < 100 LS, and five without previous experience in LS. The participants’ surgical performance was evaluated by three blinded raters using Global Operative Assessment of Laparoscopic Skills (GOALS). Results There were significant differences (P-values < 0.044) in all GOALS items between the non-medical professionals and surgeons. The experts were significantly superior to the novices in one item of GOALS: efficiency ([4(4–5) vs. 4(3–4)], with a 95% confidence interval, p = 0.042). However, both bimanual dexterity and total score in the experts were not statistically different but tended to be higher than in the novices. Conclusions Our study demonstrated a full validation of our new system. This could detect the surgeons' ability to perform surgical dissection and suggest that this VR simulator could be an effective training tool. This surgical VR simulator might have tremendous potential to enhance training for surgeons.

Study to Determine the Short-Term Outcomes of Laparoscopic Colonic Surgery

Introduction: The article presents early Outcomes in laparoscopic colorectal surgery according to tumour size, duration of surgery, duration of postoperative analgesic requirements, recovery of bowel function, postoperative complications, and mortality. Aim: The aim of the analysis is to describe the short-term outcomes of our patients who endured laparoscopic colonic surgery because of various colon pathologies. Study Design: A Retrospective Case Review cohort study. Methods: The surgical and clinical records of all laparoscopic assisted colon procedures were reviewed and selected for the study held in the Surgical department of Social Security Landhi Hospital Karachi for two years duration from June 2019 to June 2021. All patients underwent surgery under general anaesthesia. Results: During this period, 62 total laparoscopic assisted colon (LAC) procedures were achieved. 41were male and 21 females. 54 patients underwent cancer surgery out of which 51 patient had adenocarcinoma of colon, 2 patient had carcinoids of bowel , and 1 patient had Hodgkin’s lymphoma. Ileocecal tuberculosis was noted in 5 patients and submucosal polyps in one patient. Of these 54 procedures for colonic cancer , 12 were left hemicolectomy, 34 right hemicolectomy, 2 segmental splenic flexure resections, 3 segmental resection with transverse colostomy and 3 sigmoid colectomy The average time of LAC surgery was 140 minutes (range 60 to 250). The average duration of analgesic drugs was 3 days (range 3–6). The median time to the first movement in the bowel was 2.5 days (range 2–4) and the hospital stay was 6 days (range 5–10). Conclusions: Laparoscopically assisted colon procedures are associated with early return of bowel function, less analgesic consumption, short hospital stays, and a lower rate of post operative complication. Laparoscopic colorectal surgery is achievable with optimum operative time and is a logical advantage for good operative outcomes with advanced laparoscopic skills. Keywords: Laparoscopically assisted colon surgery, laparoscopy and Colon cancer.

EP.FRI.476 Routine group and save sampling prior to elective laparoscopic colorectal cancer resection – Is it necessary?

Introduction Laparoscopic colorectal cancer resection (LCCS) has been shown to reduce blood loss when compared to open surgery. There are no national guidelines regarding need for pre-operative group and save(G&S) sampling in LCCS patients. Our study aims to assess the necessity of G&S samples through identifying rates of post-operative transfusion following LCCS. Methods Retrospective study of all patients who underwent LCCS between 1st January 2019 and 31st December 2019. Results Of 102 surgical procedures, 42 right hemicolectomy, 21 anterior resection, 19 sigmoid colectomy, 12 left hemicolectomy, and 8 APER. The median age was 67(range 56-86) years. All received two valid G&S samples. 13 cases were converted. The median pre-operative haemoglobin was 127g/L, and median post-operative haemoglobin was 114g/L. The median blood loss was &lt;100mls. Only 4(3.9%) patients required post-operative transfusion, 3 of whom were converted due to intra-operative bleeding. The fourth case had decreased haemoglobin post-operatively without need for return to theatre. A significant difference was evident in pre-operative haemoglobin level in patients who needed transfusion compared to those who did not (P = 0.031). A total of 9 units were transfused. Twenty-one pre-operative cross-matched units were not used. Conclusion Evidently, blood transfusion is most likely required in open conversion cases due to intra-operative blood loss, as well as in patients with low pre-operative haemoglobin. A patient specific approach to assessing requirement for pre-operative G&S in elective LCCS patients is required to improve cost-effectiveness, particularly taking into account those with normal pre-operative haemoglobin.

187 A Rare Case of Colovesical Fistula in A Patient with Situs Inversus

A 47 year old man with no past medical history presented to the urology clinic with recurrent urinary tract infections caused by E.Coli. He subsequently had a number of investigations including imaging and cystoscopy which showed a high possibility for a colovesical fistula and incidentally demonstrated subdiaphragmatic Situs inversus. The sigmoid colon was inflamed and adherent to the posterior wall of the bladder. Surgical management following a multi-disciplinary decision resulted in an elective Ureteric stent insertion followed by laparotomy with sigmoid colectomy and primary anastomosis. The bladder wall defect caused by fistula formation was repaired. We report an extremely rare case of colovesical fistula in the setting of subdiaphragmatic situs inversus in a relatively young patient. This would likely be seen in older patients with more severe diverticulitis and usually in an acute setting. Anatomical variation resulted in more severe diverticular disease and predisposed to fistula formation.

559 One Mesenteric Defect, Two Segments of Colon, A Number of Surgical Strategies! A Rare Case of An Internal Hernia Causing Bowel Ischemia

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with signs and symptoms of an acute abdomen. Following surgical review, taking into consideration the patient’s clinical, biochemical, and radiological findings, the patient was taken for immediate emergency surgical exploration. A laparoscopic approach was initially taken, which revealed dilated and ischemic colon, and therefore an open approach was then adopted. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischemic. A number of surgical strategies were considered, and given the patients age it was decided to preserve as much normal bowel as possible. Thus, a right hemi- and sigmoid colectomy were performed with an ileo-transverse anastomosis and formation of an end colostomy. In this case, radiological diagnosis pointed to a suspicion of an internal hernia, and operative diagnosis highlighted a rare mesenteric defect causing herniation and subsequent ischemia. Relying on the patient’s clinical condition and an early decision for surgical intervention resulted in a positive outcome for outpatient. The patient made a good recovery following the bowel preserving surgery.

Acute Colonic Pseudo-obstruction and Volvulus: Pathophysiology, Evaluation, and Treatment

Acute colonic pseudo-obstruction (ACPO) and volvulus are two disease processes that affect the colon causing abdominal distension and may necessitate operation intervention. ACPO may be associated with multiple comorbidities, infectious diseases, and cardiac dysfunction. It may be treated with conservative management including endoscopic decompression or neostigmine. If the distension is not addressed, high mortality may result if peritonitis develops. Volvulus most commonly occurs in the sigmoid colon or cecum. If left-sided, endoscopic decompression may resolve the obstruction if detorsion is successful, although sigmoid colectomy should be performed during the admission. If cecal volvulus is identified, right hemicolectomy should be performed.

A rare cause of lower gastrointestinal bleeding treated with robotic colorectal surgery

Background Metastatic melanoma to the colon is rarely diagnosed with an incidence of only 0.3% and more than 95% of cases identified post-mortem. Survival for patients with metastatic melanoma to the colon is poor, with 5-year survival rates of 26.5%. Nonetheless, surgical resection of the colonic metastatic melanoma lesions is recommended as it is associated with improved survival. Additionally, surgical resection is also indicated for palliative reasons, as symptom resolution is achieved in 90% of such patients. Use of the surgical robot has increased dramatically in the past decades, especially in the field of colorectal surgery. Furthermore, recent studies have demonstrated comparable outcomes between patients undergoing either laparoscopic or robotic-assisted colorectal surgery for cancer. Here, we describe the first case, to the authors knowledge, of a robot-assisted sigmoid colectomy for metastatic melanoma. Case presentation A 72-year-old male with a history of metastatic melanoma diagnosed in 2015 with a favorable response to immunotherapy presented to the emergency department with symptomatic lower gastrointestinal bleeding (LGIB). Endoscopy demonstrated a friable melanotic lesion of the sigmoid colon with biopsy demonstrating histopathologic evidence of metastatic melanoma. After further evaluation, the patient consented for an elective robot-assisted segmental colectomy for palliative intent. Diagnostic laparoscopy identified no evidence of further intra-abdominal metastatic disease. After identifying the metastatic lesion in the sigmoid colon, the mesentery of involved segment of sigmoid colon adjacent to the lesion was divided using the bipolar electrosurgical vessel sealer device. The colon was divided both proximal and distal to the lesion using a robotic stapler and a tension-free colo-colonic anastomosis was created intracorporeally. Postoperatively, the patient had an unremarkable course and was discharged home on post-operative day 3. On follow-up, the patient was doing well with resolution of preoperative LGIB. Conclusion This case highlights a rare presentation of metastatic melanoma to the colon in a patient presenting with LGIB. Furthermore, this case demonstrates the feasibility of the minimally invasive robotic-assisted approach for an uncommon pathology.

Minimally Invasive Management of Diverticular Disease

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy.While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective.Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion.In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.