Afag Aghayeva

Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? Comparison of the 2 Generations of da Vinci Systems.

Background: We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery. Patients and Methods: Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed. Results: The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes. Conclusions: Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times.

Robotic complete mesocolic excision for right-sided colon cancer.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Robotic Complete Mesocolic Excision for Splenic Flexure of Colon Cancer

Robotic surgery, with its enhanced dexterity and increased range of motion, is being increasingly used in colorectal surgery. In addition to the rectal approaches, where laparoscopic limitations are overcome by the dexterity and superior vision of robotics, colon cancer procedures could also be perf

The effects of hyperthermic intraperitoneal chemoperfusion on colonic anastomosis: an experimental study in a rat model

Introduction Cytoreductive surgery (CRS) with subsequent hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising modality to treat and prevent peritoneal metastases. However, this treatment is associated with signficant morbidity and mortality. Whether or not CRS with HIPEC interferes with anastomotic healing has also been debated. This study was designed to investigate the effects of mitomycin C, cisplatin, oxaliplatin, and doxorubicin used in HIPEC treatment on colonic anastomosis healing in a rat model. Methods Sixty Wistar albino rats were employed in the study. Sigmoid resection and end-to-end colorectal anastomosis was performed in all rats. Group 1 rats underwent the surgical procedure alone, while group 2 rats were given hyperthermic intraperitoneal lavage with heated saline following surgery. Groups 3, 4, 5, and 6 had surgery with concomitant HIPEC treatment with mitomycin C, cisplatin, oxaliplatin, and doxorubicin, respectively. Anastomotic bursting pressures and hydroxyproline levels were evaluated. Results Regarding the hydroxyproline levels, groups 1 and 2 showed significantly higher values than other groups (p<0.001). However, there was no significant difference between the HIPEC treatment groups (groups 3, 4, 5, and 6) (p>0.05). When groups were compared regarding bursting pressure values, no significant differences were observed (p = 0.81). Conclusions This study demonstrated that the HIPEC procedure with mitomycin C, cisplatin, oxaliplatin and doxorubicin had negative effects on hydroxyproline levels, but had no detrimental effect on anastomotic bursting pressure in a rat model.

Identification of mesenteric lymph nodes in robotic complete mesocolic excision by near-infrared fluorescence imaging

One of the most important prognostic factors in colorectal cancer is nodal status at the time of surgical treatment. Complete mesocolic excision (CME) with central vascular ligation, which follows similar oncologic principles to total mesorectal excision, has revolutionized the surgical treatment of colon cancer, showing a higher degree of lymphadenectomy and better oncologic outcomes compared to standard colectomy [1]. The rationale behind this technique is to remove the entire mesocolon and all potential routes of lymphatic spread by dissecting along embryologic tissue planes and transecting the supplying vessels at their origin [1, 2]. Since 2001, surgical treatment for colorectal cancer has seen another substantial development due to the introduction of robotic technology [3]. Thanks to its potential for overcoming the limitations of standard laparoscopy, the robotic approach is increasingly being employed in colorectal surgery. Recently, the technical feasibility and safety of robotic surgery in the CME technique for right colon cancer also has been reported [4]. Although CME is now the technique for optimal clearance of lymph nodes, a more sophisticated capability to visualize the actual lymphatic drainage from the tumor site into the colonic mesentery may further maximize nodal harvest in CME. This may also be of use in the determination of a suitable mesentery division line, especially in obese patients with excessive mesenteric adipose tissue. The near-infrared fluorescence imaging (NIFI) system has been developed for this type of navigation surgery, and now, this system is also available in robotic technology. The utility of NIFI has been previously reported in various colorectal procedures [5–7], but its role in the identification of both the lymphatic flow distribution and lymphatic basin in robotic CME has not been described. Here, we present a video to demonstrate intraoperative lymph node identification in an obese patient undergoing robotic CME for cecal adenocarcinoma. The patient was a 76-year-old female with a body mass index of 39.6 kg/m. One day before surgery, indocyanine green (ICG) solution was injected via colonoscopy into the submucosa in four quadrants around the lesion; 0.5 ml of ICG (2.5 mg/ml) was delivered with each injection. Intraoperatively, the da Vinci Xi Firefly NIFI system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was used to assess lymphatic flow distribution from the colonic wall into its mesentery. The lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in choosing the extent of mesenteric dissection. No complications occurred during surgery. Total operative time was 395 min, and blood loss was 100 ml. The patient did not show any adverse reaction to the ICG injection and was discharged home on postoperative day 5 following an uneventful recovery; histopathologic examination revealed a T3 tumor. The total number of harvested lymph nodes was 25, none of which were metastatic (pT3N0M0). Electronic supplementary material The online version of this article (doi:10.1007/s10151-015-1413-3) contains supplementary material, which is available to authorized users.

Vascular high ligation and embryological plane dissection in laparoscopic restorative proctocolectomy for ulcerative colitis - a video vignette.

abscesses and autonomic nerve damage. This can be done by an intersphincteric transperineal approach, avoiding an abdominal procedure [3]. If a uniquely perineal approach is not possible (e.g. in the case of a preexisting ileorectal anastomosis), an abdominal single port can be added. In 2012 a 40-year-old woman with an American Society of Anesthesiologists score of 2 and body mass index of 20 kg/m underwent a laparoscopic subtotal colectomy with ileorectal anastomosis and loop ileostomy for complicated Crohn’s colitis with perianal disease. Later, despite maximal therapy and diversion, rectal fistulating disease worsened and a completion proctectomy and definitive ileostomy was agreed upon. A combined abdominal and transanal procedure was planned. The perineal phase consisted of dissection in the intersphincteric plane to the pelvic floor with detachment of an anovaginal fistula, induction of a pneumorectum through a single-port device (GelPOINT Path, Applied Medical, Rancho Santa Margarita, California, USA) and close-rectal dissection carried distally to the peritoneal reflection. Synchronously, the loop ileostomy was closed and a single-port (GelPOINT) pneumoperitoneum was established. After dividing the adhesions, resection of the ileorectal anastomosis was performed and a terminal ileostomy was created. The patient was discharged 5 days after the procedure following an uneventful recovery.

Portal vein ligation and in situ liver splitting in metastatic liver cancer

The most serious complication after major liver resection is liver failure. Depending on preoperative liver function, a future liver remnant of 25%-40% is considered sufficient to avoid postoperative liver failure. A new technique known as portal vein ligation combined with in situ splitting has been developed to obtain rapid liver hypertrophy. Herein, we present a case where we performed portal vein ligation combined with in situ splitting. A 37-year-old male patient with a diagnosis of sigmoid adenocarcinoma and liver metastasis underwent anterior resection because of an obstructing sigmoid tumor and received palliative chemotherapy. After chemotherapy, abdominal computed tomography revealed a lesion, 50 mm in diameter, localized between segments 5-8 of the liver on the bifurcation of the anteroposterior segmental branch of the right portal vein. Computed tomography volumetric assessments of the liver were performed in the preoperative period, and it was found that the remnant left liver volume was less than 25%. In the first stage, portal vein ligation and in situ splitting of the liver parenchyma were performed. On the second and sixth postoperative days, computed tomography revealed hypertrophy of the left liver lobe. On the sixth day, a right hepatectomy was performed. Portal vein ligation combined with in situ splitting has been used by surgeons worldwide to obtain rapid and adequate liver hypertrophy. This new approach yields hope for patients with locally advanced liver tumors and may increase the number of curative resections for primary or metastatic liver tumors.

Adoption of robotic technology in Turkey: A nationwide analysis on caseload and platform used

Limited data exist regarding adoption of evolving robotic technology in surgery. This study evaluated trends and the current condition of robotic platforms in surgical specialties and general surgical subspecialties.

V-Y advancement flap reconstruction for anal stricture - a video vignette

meant to be analogous to the TME but the concepts are not directly transferable. Whilst some evidence suggests that CME is associated with improved survival outcomes, it is debatable whether this is related to an increased number of nodes [5]. As such, considering the increased morbidity with increased nodal yield, there is insufficient evidence to recommend its widespread adoption. Perhaps the right answer is to perform a more accurate dissection, not just procure more nodes. Techniques to improve nodal assessment and supplement pathological staging, such as radioimmunoguided surgery and sentinel lymph node mapping, have been described although their role remains poorly defined. The most meaningful tool for guiding the optimal resection margins may be intra-operative fluorescence imaging (FI) with a fluorophore such as indocyanine green. FI allows direct visualization of the tumour with its draining nodal basin, the sentinel node(s) and any aberrant nodes outside the planned resection field, thus permitting a more precise mesenteric lymphadenectomy, obviating a reliance on lymph node numbers alone. FI can also show the watershed areas in the mesentery and define the lateral extents of lymphatic spread, allowing a CME-style dissection to be completed. This type of lymphatic mapping may permit improved intra-operative cancer-targeting techniques. The clinical implications for this precision-guided surgery could impact staging and patient prognosis and guide adjuvant therapy recommendations the way simply harvesting more nodes could not. Studies are under way to validate these clinical assumptions with FI, and technical details are being standardized. In the meantime, ensuring pathological scrutiny of our surgery, we must continue to strive for optimal resections based on oncological principles to obtain a minimum of 12 nodes for our patients and the best outcomesn.

Surgery for intestinal Crohn’s disease: Results of multidisciplinary approach

OBJECTIVES Crohns disease is a chronic inflammatory bowel disease that requires lifelong multidisciplinary management. Seventy percent of patients affected by Crohns disease will require at least one surgical procedure over their lifetime. The aim of this retrospective study was to present our series of patients suffering from Crohns disease who were scheduled for surgery by a multidisciplinary team. MATERIAL AND METHODS The data were retrieved from a review of 950 patients with Crohns disease treated at our institution between March 2000 and March 2016. Only patients with intestinal Crohns disease were included into the study. A multidisciplinary team assessed the decision to perform surgery. RESULTS There were 203 patients who underwent surgery included in this study. One hundred and sixty-six were intestinal and 37 were perianal Crohns disease. The mean age was 36±11.5 (range, 12-75) years. Ninety-two were stricturing, 45 were fistulizing, and 12 were inflammatory. The most commonly affected site was the ileocecal region (n=109, 65.7%), and the most common surgical procedure was the ileocecal resection (n=109, 65.6%). Laparoscopic approach was the procedure of choice in 56 (33.7%) patients. Of the patients enrolled, the most common early (<30 days) complications observed were the wound infection as the first (n=11) and anastomotic leak as the second (n=10). The mortality rate was 2.4% (n=4). CONCLUSION Multidisciplinary approach to Crohns disease may decrease the surgical complications and recurrence rates leading to a better treatment.