C D’Isidoro

Use of the new Da Vinci Xi® during robotic rectal resection for cancer: technical considerations and early experience

Dear Editor: Robotic rectal resection with the Da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) is a well-defined approach to rectal cancer. The tremor filter, three-dimensional vision, and wrist-like movements facilitate the preparation of autonomic nerves in a narrow space such as the pelvis. These technical advantages translate into clinical and surgical benefits as suggested by a reduced conversion rate, a shorter learning curve, and good functional outcomes compared with the same parameters applied to standard laparoscopy. Nevertheless, there are still several limitations in robotic rectal surgery, such as the reduced skill to perform a multi-quadrant operation, which could result in difficulty performing a complete splenic flexure mobilization. Additionally, a fixed position of the patient after docking limits the possibility to change it during the procedure. These characteristics may require multiple undocking and re-docking, repositioning the entire platform, or use of conventional laparoscopy. Recently, Intuitive Surgical marketed a new product called Da Vinci Xi®, which is expected to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use for minimally invasive techniques in all surgical fields. Whereas increasingly more studies are being published about the use of the Da Vinci Si® System for robot-assisted proctectomy to treat rectal cancer, the Da Vinci Xi® is still in its infancy. Hence, correct standardization is required for all surgical procedures but explicitly for rectal resection. Rectal cancer surgery could be a valid benchmark for testing the new robotic platform because of its multi-quadrant approach for splenic and left colon mobilization and the need to deal with the risks of external collision and problems related to rectal transection down the pelvis. Additionally, the technique for full robotic rectal resection with total mesorectal excision (TME) using the new Da Vinci Xi® is not yet well defined. Particularly, patient and port positions have not yet been standardized. We describe our successful experience with robot, patient, and trocar positioning that allowed us to perform ten consecutive full robotic rectal resections for a low-lying cancer using Da Vinci Xi® between January and May 2015. For the first phase of the procedure (left colon mobilization, ligation of the inferior mesenteric vessels, and complete mobilization of the splenic flexure), the patients were placed in a modified lithotomy position, with 30° Trendelenberg, and tilted to the right side. After establishing the pneumoperitoneum at 12 mmHg, the first 8-mm robotic trocar was placed in the umbilical region along the right pararectal line. More trocars were then placed following the Universal Port Placement Guidelines provided by Intuitive Surgical for Bleft lower^ abdominal procedures. Four trocars were then inserted under visualization: an 8-mm port in the right iliac fossa, a 12-mm assistant trocar in the right flank, and two 8-mm robotic ports in the periumbilical region and the left hypochondriac space, respectively. A modified version of the Universal Port Placement Guidelines for Bleft lower^ abdominal procedures^ was the same as just described but translating all the trocars of 2–5 cm to the right side. BPatient-left^ was the selected approach, and the surgical cart was driven to position the * Gregorio Di Franco gregoriodifranco@yahoo.it

Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer

Dear Editor: Laparoscopic total mesorectal excision (LapTME) is a validated surgical technique for the treatment of rectal cancer, but the surgery is still challenging and therefore functional outcomes are uncertain. Thanks to a 3-D view, better view of the pelvic structures, and articulated instruments, robotic rectal surgery allows for finer dissection and nerve-sparing during total mesorectal excision; thus it is supposed to better preserve urinary and sexual functions versus open and laparoscopic surgery as described in some literature. The aim of this study is to compare pre-operative and post-operative autonomic function after LapTME versus robotic TME (RobTME) for mid to low rectal cancer, in a single surgeon experience. For this purpose we compared the outcomes of the first 30 RobTME, with those of the first 30 Lap TME performed by a single surgeon between January 2009 and July 2013 at our institution. The impact of surgery on autonomic function was assessed with validated questionnaires. For sexual dysfunction, the International Index of Erectile Function (IIEF) questionnaire for males and the Female Sexual Function Index (FSFI) for females were used. For evaluation of urinary dysfunction, the International Consultation on IncontinenceMale/Female Lower Urinary Tract Symptoms (ICIQ-MLUTS, ICIQ-FLUTS) questionnaires were used. The questionnaires submitted to patients pre-operatively and at months 1, 6, and 12 postoperatively. Data were analyzed with Statistical Production and Service Solution (SPSS for Windows, SPSS Inc., Chicago, IL, USA). Of the 30 LapTME, 26 were anterior rectal resections (ARR), 2 intersphincteric resection (ISR), and 2 abdominoperineal resection (APR), while of the 30 RobTME, 20 were ARR, 6 ISR, and 4 APR. A temporary diverting ileostomy was fashioned in 26 cases of LapTME group and in 25 of the RobTME group. With regard to the urinary function, males presented with a significant worsening of voiding symptoms 1 month after surgery in both groups (p<0.05). Urinary retention after catheter removal was observed in two patients in each group. Incontinence worsened 1 month after surgery in both groups (p<0.05). Nevertheless, a gradual improvement in incontinence was observed at 6 months, and at 1 year after surgery, the grade of incontinence was not statistically different when compared with the pre-operative status (p=ns). The analyses of urinary function in female patients showed no difference between the pre-operative and post-operative scores concerning voiding and filling symptoms, in both groups (p=ns). Conversely, there was a significant increase of incontinence in females in the LapTME group 1 and 6 months after surgery (p<0.05 for each pair-wise comparison). Incontinence worsened also in the RobTME group after surgery, but there was a difference not statistically significant with the pre-operative score at 6 months (p=ns). A gradual improvement in incontinence was observed in both groups with no difference at 1 year when compared with the pre-operative status (p=ns). With regard to the impact of urinary symptoms on quality of life (QoL), patients experienced a worsening of QoL in the first month after surgery in both groups (p<0.05). However, with improvement of urinary symptoms 1 year after * Gregorio Di Franco gregoriodifranco@yahoo.it

Hand-assisted hybrid laparoscopic–robotic total proctocolectomy with ileal pouch–anal anastomosis

PurposeFew studies have reported minimally invasive total proctocolectomy with ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic–robotic technique for patients with FAP and UC.MethodsBetween February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic–robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy.ResultsThe mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day.ConclusionsThe hand-assisted hybrid laparoscopic–robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.

Full Robotic Colorectal Resections for Cancer Combined With Other Major Surgical Procedures: Early Experience With the da Vinci Xi

Background. The da Vinci Xi has been developed to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use in robotic multiorgan surgery. Methods. Between January 2015 and October 2015, 10 patients with synchronous tumors of the colorectum and others abdominal organs underwent robotic combined resections with the da Vinci Xi. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for “left lower quadrant,” with trocars centered on the umbilical area, or shifted 2 to 3 cm to the right or to the left, depending on the type of combined surgical procedure. Results. All procedures were completed with the full robotic technique. Simultaneous procedures in same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-targeting operation. No external collisions or problems related to trocar positions were noted. No patient experienced postoperative surgical complications and the mean hospital stay was 6 days. Conclusions. The high success rate of full robotic colorectal resection combined with other surgical interventions for synchronous tumors, suggest the efficacy of the da Vinci Xi in this setting.

Short-term clinical outcomes of robot-assisted intersphincteric resection and low rectal resection with double-stapling technique for cancer: a case-matched study

Dear Editor: Survival for patients with rectal cancer has been improving with the development of surgical techniques and combined neo-adjuvant therapies. Traditionally, low rectal cancer located less than 5 cm from the anal verge required abdominoperineal resection (APR) with permanent colostomy. The advent of mechanical low-stapling, double-stapling techniques have made low anterior resection (AR) the procedure of choice for the majority of patients with low rectal cancer increasing the frequency of sphincter salvage. However, in some patients, a narrow pelvis and very low tumor site pose limitations to the use of stapled colorectal anastomosis. For such patients, intersphincteric resection (ISR) with coloanal anastomosis as employed by Schiessel in 1994may be an acceptable alternative. ISRmay also be done laparoscopically; however, it was historically associated with a higher functional complication rate than the Knight Griffen technique. The Da Vinci Si HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) can render an operation more like an open surgery with all the benefits of laparoscopy, expanding the range of feasibility of minimally invasive surgery. However, the use of robotic-assisted surgery for ISR has been reported in few centers and some surgeons question the value of robotic assistance to treat patients with low rectal cancer and allows to manage this type of procedures with good functional results. Herein, we present our experience with robotic-assisted ISR with total mesorectal excision (R-ISR-TME) and provide a case control comparison with robotic TME, using the double-stapling technique (R-DS-TME) for low rectal cancer with specific attention to functional and short-term oncologic outcomes. Between April 2010 and December 2014, 52 patients with histologically proven rectal cancer underwent robot-assisted rectal resection with TME at our General Surgery Unit, including 15 R-ISR-TME (eight males and seven females, mean age 70.1 years, mean body mass index 24.9 kg/m). A control group of 15 patients (eight males and seven females, mean age 69.6 years, mean bodymass index 23.1 kg/m) with low rectal tumors (<5 cm from the dentate line) undergoing R-DS-TME was selected by one-to-one case-matched methodology, where each patient undergoing R-ISR-TME was matched with a patient undergoing R-DS-TME according to the following criteria: age, gender, body mass index, American society of Anesthesiologists score, and neo-adiuvant chemo-radiotherapy. Patients with cT3 or node-positive disease (five in each groups) received preoperative chemoradiotherapy (capecitabine 825 mg bid plus 50.4 Gy in 28 fractions). The operation was performed 6–8 weeks after the end of the radiation. Exclusion criteria for robotic surgery were preoperative diagnosis of locally advanced malignancy, history of major lower abdominal surgery, and contraindications to anesthesia. Analyzed variables included overall operative time (from creation of pneumoperitoneum to application of dressing), blood loss, length of hospital stay, postoperative complications, number of harvested lymph nodes, margin status, and functional results. Patients received a physical exam and blood tests 1 and 2 weeks and 1 month after discharge. Just before ileostomy The study was supported by ARPA foundation, www.fondazionearpa.it/.

Diaphragmatic endometriosis: review of the literature and first case of robot-assisted laparoscopic treatment

Background Thoracic endometriosis is a rare disorder affecting women in reproductive age. The etiopathogenesis of this disease is not well understood. The symptoms appear, but not necessarily, during periods in person affected by the condition. Methods A 35-year-old woman came to our clinic, the Infertility and Assisted Reproduction Center of the University of Pisa, for infertility treatment. She described a clinical history of abdominal pain with irradiation up to the right shoulder, depending on her breathing or position, during menstruation. She also reported that she did not experience these symptoms while taking an oral contraceptive. Pelvic ultrasound examination and thorax X-ray were normal. The patient also underwent thoracic and abdominal pelvis magnetic resonance imaging (MRI). Thoracic MRI revealed a nodule on the right hemidiaphragm. It was decided to perform surgical removal of the nodule. Robotic-assisted surgery was used because of its multiple advantages in comparison with laparoscopic surgery, such as a 3-dimensional view, a decrease in surgeon fatigue and tremors, and an increase of wrist motion with improved dexterity and greater surgical precision. The surgery was performed in May 2012. The patient was put on the left lateral bedside. Pneumoperitoneum with CO2 was established with an intra-abdominal pressure of 12 mm Hg using a Veress needle. Robotic trocars of 8-mm diameter were introduced at the diaphragmatic level and connected to the robot arms. Her pelvic and abdominal organs appeared healthy. The right hemidiaphragm presented adherence with the liver due to endometriosis disease. We removed the adhesion, and we performed the excision of the diaphragmatic endometriotic nodule. The nodule was extracted through an endobag. Operative time lasted 2 hours. Conclusions The postoperative evolution was satisfactory, and the patient left the hospital on the third postoperative day. No complications occurred. We showed that this approach is feasible and safe, without conversion to laparotomy.