Incidence of Symptomatic Internal Hernia following Minimal Invasive colorectal surgery: A Single Center Experience

Laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant diseases. Recent reviews suggest that the incidence of symptomatic internal hernias after laparoscopic colorectal resection is from 0.39 to 0.65%. Unlike in open surgery, laparoscopic closure of a mesenteric defect is inherently challenging as inadvertent injury to the marginal vessels may compromise blood supply to the anastomosis. For these reasons, many surgeons leave the defect open during laparoscopic surgery. But this may lead to development of post-operative internal hernia through the defect. This is a retrospective study where we included 149 patients who underwent laparoscopic/ robotic colorectal surgeries from March 2019 to March 2020. Data pertaining for following variables were collected which included age, sex, indication for surgery, location of the pathology, splenic flexure mobilization. The incidence of internal hernia among these patients were calculated and assessed using SPSS 20. Incidence of internal hernia was found to be 0.67% which was diagnosed and treated on the 18th post-operative day of initial surgery. Internal hernia is a rare but important complication of laparoscopic/robotic colorectal surgery with a high mortality rate if not diagnosed early. Defect closure is still controversial during the initial surgery and probably not indicated for all patients and depends on surgeon’s preference.

1367 Five Years of Robotic Surgery in Colorectal Service: James Cook University Hospital Experience

Aim This paper gives an account of our institutional experience with safe adoption of robotic surgery in colorectal service. Method Analysis of our prospectively maintained database of all patients who underwent robotic colorectal surgery in our institute between February 2015 and February 2020. Overall surgical and oncological outcomes were interrogated. Results A total of 255 patients underwent robotic surgery between 2015 and 2020. 148 were males, and 107 were females. Median age was 68 years (range: 35–89). 198 patients had bowel cancer and 57 had benign conditions. Operative procedures performed were anterior resection (n = 125), right colectomy (n = 77), abdominoperineal resection (n = 40), subtotal colectomy (n = 5), completion proctocolectomy (n = 2) and reversal of Hartmann’s procedure (n = 6). Mean operative time was 164 (SD ± 47.5) for right colectomy and 267 (SD ± 77.8) for anterior resection. Median length of hospital stay was 6 days (IQR: 4 – 9). There was no 30 days mortality or intraoperative complications. Conversion to open or laparoscopy surgery rate was 5.1% (n = 13). Anastomotic leakage occurred in 3 patients (1.2%). Median lymph nodes harvested were 21 (range 4 – 79) and the R0 resection rate was 96.5%. Conclusions Our results demonstrate that colorectal robotic surgery is feasible and can be adopted safely for both benign and neoplastic conditions without undermining clinical or oncological outcomes.

Robotic Surgery for Complicated Diverticular Disease

Diverticular disease is common, and increasing in prevalence worldwide. The treatment for acute and chronic diverticular disease has a huge clinical and economic burden. Surgery is standard for complicated diverticulitis, and there are several benefits to using robotic surgery in these cases. Complicated diverticular disease can result in fistula, fibrosis, and deranged anatomy, which present technical challenges to the surgeon. Understanding and anticipating these anatomical challenges is key to successful surgery. While fears of conversion in complicated cases may stop surgeons from using traditional laparoscopic surgery, robotic surgery is especially promising for enhancing dexterity, visualization, and facilitating completely minimally invasive surgery in these complicated cases. In this chapter, we review end-to-end technical strategies of robotic colorectal surgery for complicated diverticular disease, including cases with colovesicular, colovaginal, and colocutaneous fistulae.

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

Teaching and Training Surgeons in Robotic Colorectal Surgery

Robotic surgery is becoming more popular among practicing physicians as a new modality with improved visualization and mobility (1–2). As patients also desire minimally invasive procedures with quicker recoveries, there is a desire for new surgical residents and fellows to pursue robotic techniques in training (3–4). To develop a new colorectal robotics training program, an institution needs a well-formulated plan for the trainees and mentors with realistic expectations. The development of a robotics training program has potential obstacles, including increased initial cost, longer operative times, and overcoming learning curves. We have devised a four-phase training protocol for residents in colorectal surgical fellowship. Each of these phases attempts to create a curricular framework that outlines logical progression and sets expectations for trainees, Program Directors, and residency faculty. Phase zero begins prior to fellowship and is preparatory. Phase one focuses on an introduction to robotics with learning bedside console troubleshooting and simulation exercises. Phase Two prioritizes operative experience and safety while completing steps independently in a progressive fashion. Phase Three polishes the resident prior to graduation for future practice. We recommend frequent evaluation and open-mindedness while establishing a focused robotics program. The end goal is to graduate fellows with an equivalency certificate who can continue to practice colorectal robotic surgery.

Surgical Outcomes of Robotic Resection for Sigmoid and Rectal Cancer: Analysis of 109 Patients From a Single Center in China

Background: Robotic colorectal surgery has been increasingly performed in recent years. The safety and feasibility of its application has also been demonstrated worldwide.However, limited studies have presented clinical data for patients with colorectal cancer (CRC) receiving robotic surgery in China. The aim of this study is to present short-term clinical outcomes of robotic surgery and further confirm its safety and feasibility in Chinese CRC patients.Methods: The clinical data of 109 consecutive CRC patients who received robotic surgery at Sun Yat-sen University Cancer Center between June 2016 and May 2019 were retrospectively reviewed. Patient characteristics,tumor traits, treatment details, complications, pathological details, and survival status were evaluated.Results: Among the 109 patients, 35 (32.1%) had sigmoid cancer, and 74 (67.9%) had rectal cancer. Thirty-seven (33.9%) patients underwent neoadjuvant chemoradiotherapy. Ten (9.2%) patients underwent sigmoidectomy, 38 (34.9%) underwent high anterior resection (HAR), 45 (41.3%) underwent low anterior resection (LAR), and 16 (14.7%) underwent abdominoperineal resection (APR). The median surgical procedure time was 270 min (range 120–465 min). Pathologically complete resection was achieved in all patients. There was no postoperative mortality. Complications occurred in 11 (10.1%) patients, including 3 (2.8%) anastomotic leakage, 1 (0.9%) anastomotic bleeding, 1 (0.9%) pelvic hemorrhage, 4 (3.7%) intestinal obstruction, 2 (1.8%) chylous leakage, and 1 (0.9%) delayed wound union. At a median follow-up of 17 months (range 1–37 months), 1 (0.9%) patient developed local recurrence and 5 (4.6%) developed distant metastasis, with one death due to disease progression.Conclusions: Our results suggest that robotic surgery is technically feasible and safe for Chinese CRC patients, especially for rectal cancer patients who received neoadjuvant treatment. A robotic laparoscope with large magnification showed a clear surgical space for pelvic autonomic nerve preservation in cases of mesorectal edema.