Emilio Morpurgo

Robotic and Laparoscopic Surgery for Treatment of Colorectal Diseases

PURPOSEIn the last ten years, several robotic systems have been developed to overcome the loss of the three-dimensional view and dexterity characteristic of laparoscopic surgery. The aim of this study was to compare the traditional laparoscopic approach and robotic techniques in the treatment of colorectal diseases.METHODSThe study compares a consecutive series of patients treated surgically for colorectal disease from June 2001 to May 2003 with the da Vinci™ robotic system (Intuitive Surgical®) and a matched number of patients who underwent conventional laparoscopy during the same time interval. The factors analyzed were the time required to prepare the patient and the room, total time of surgery, length of specimens, number of lymph nodes retrieved, blood loss, complications, and postoperative results.RESULTSThe study included 106 patients (53 in each group). No differences were observed in total time of surgery (laparoscopic group, 222 ± 77 minutes vs. robotic group, 240 ± 61 minutes), specimen length (laparoscopic group, 29 ± 11 cm vs. robotic group, 27 ± 13 cm), or number of lymph nodes retrieved (laparoscopic group, 16 ± 9 vs. robotic group, 17 ± 10). It took significantly longer to prepare the operating room and patient in the robotic group (24 ± 12 minutes) than in the laparoscopic group (18 ± 7 minutes). There were three conversions to laparotomy in the laparoscopic group; in the robotic group, two cases were converted to laparoscopy and three to hand-assisted laparoscopy. No significant differences were observed between the two groups in terms of recovery of bowel function and postoperative hospital stay.CONCLUSIONSRobot-assisted surgery proved to be as safe and effective as laparoscopic techniques in the treatment of colorectal diseases. Because of its dexterity and three-dimensional view, the da Vinci™ system was particularly useful in specific stages of the procedure, e.g., takedown of the splenic flexure, dissection of a narrow pelvis, identification of nervous plexus, and handsewn anastomosis. The cost-effectiveness of the procedure still needs to be evaluated.

Fournier's gangrene

Fourniers gangrene can still be a life-threatening condition with a high mortality rate. Diagnosis and treatment should be prompt and adequate. Radiological studies may help to define the extent of the disease preoperatively in cases in which this is unclear. Surgery with extensive debridement of all necrotic tissue is the mainstay of treatment.

Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results.

BACKGROUND Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System. MATERIALS AND METHODS Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed. RESULTS Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8). CONCLUSIONS Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

Robotic right colon resection: evaluation of first 50 consecutive cases for malignant disease.

Background. Colorectal cancer is the fourth leading cause of death in the world. Minimally invasive surgery has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic-assisted right colon resection in malignant disease. Methods. Fifty consecutive patients affected by rightsided colon cancer were operated from May 2001 to May 2009 using the da Vinci surgical system. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis. Results. Twenty-four male and 26 female patients underwent robotic right colectomy. Median age was 73.34 ± 11 years. Median operative time was 223.50 (180–270) min. No conversion occurred. Specimen length was 26.7 ± 8 cm (range 21–50 cm), number of harvested lymph nodes was 18.76 ± 7.2 (range 12–44), and mean number of positive lymph nodes was 1.65 ± 3 (range 0–17). Surgeryrelated morbidity was 1/50 (2%): one twisting of the mesentery in one case with extracorporeal anastomosis. All patients were included in a follow-up regimen. Diseasefree survival was 90% (45/50), and overall survival was 92% (46/50). Cancer-related mortality was 8% (4/50). Conclusions. Robotic assistance allows performance of oncologically adequate dissection of the right colon with radical lymphadenectomy and to fashion a handsewn intracorporeal anastomosis as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes. Since 2002, laparoscopic technique has revolutionized the treatment of malignant colorectal disease, showing the same oncological results as open technique. However there are some technical drawbacks to the laparoscopic approach, including lack of three-dimensional (3-D) visualization, limited range of motion due to fixed trocar sites and rigid instrumentation, poor ergonomics, amplification of physiologic tremor, and decreased sense of touch. In the last 10 years, robotic systems have been developed to overcome the limitations of laparoscopic surgery. The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was the first telerobotic system approved for intra-abdominal surgery in the USA by the Food and Drug Administration (FDA). The first robotic colorectal surgical procedure was reported in 2001. After that, various experiences of robotic colorectal surgery were reported for treatment of benign and malignant diseases. However, there are few studies analyzing accuracy in larger series of robotic right colectomy for malignancy. This study aims to evaluate the feasibility and the short-term surgical and oncological outcomes of robotic-assisted right colon resection in malignant disease.

Robotic-Assisted Intracorporeal Anastomosis Versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy for Cancer: A Case Control Study

INTRODUCTION Extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for cancer has a significant risk of complications. The aim of this study is to evaluate the operative and postoperative results of hybrid right hemicolectomy with intracorporeal robotic-assisted anastomosis for adenocarcinoma of the ascending colon compared with the standard extracorporeal anastomosis in a case control study. PATIENTS AND METHODS Forty-eight right hemicolectomies for cancer (2009-2012) with laparoscopic medial to lateral dissection, vascular ligation, bowel transection, and robotic-assisted intracorporeal anastomosis with specimen extraction through a Pfannestiel incision (robotic group [RG]) were compared with 48 laparoscopic hemicolectomies (2009-2011) with extracorporeal anastomosis (laparoscopic group [LG]). RESULTS The two groups were comparable with respect to age, gender, stage of cancer, and body mass index. Surgery time was significantly longer in RG patients (RG, 266±41 minutes; LG, 223±51 minutes; P<.05). Operative results were similar in the two groups. Recovery of bowel function (day of first bowel movement: RG, 3.0±1.0 days; LG, 4.0±1.2 days; P<.05) and hospital stay (RG, 7.5±2.0 days; LG, 9.0±3.2 days; P<.05) were quicker and shorter, respectively, in RG. There were four anastomotic complications and four incisional hernias in LG and none in RG (P<.05). CONCLUSIONS There are fewer anastomotic and wound complications in RG patients. Intracorporeal robotic-assisted ileocolic anastomosis allows a faster recovery compared with extracorporeal anastomosis.

Clinical Characteristics of Familial Adenomatous Polyposis and Management of Duodenal Adenomas

The aim of this study was to evaluate the clinical characteristics of patients with familial adenomatous polyposis (FAP) undergoing surgical treatment over a 10-year period and specifically to evaluate the incidence and clinical outcome of patients treated for duodenal adenomas. Patients with FAP who underwent surgical treatment for colonic polyposis at the University of Louisville from January 1992 to July 2002 were investigated. Surgical treatment included colectomy and ileal J-pouch-anal anastomosis (IPAA) or completion proctectomy with or without IPAA in those who had previously undergone subtotal colectomy elsewhere. All patients underwent screening gastroduodenoscopy at 3-year intervals beginning at the time of diagnosis or referral. Postoperative morbidity, mortality, and functional outcome were evaluated, as well as the occurrence of extracolonic manifestations and results of treatment for duodenal adenomas when required. Fifty-four patients were included in the study (mean age 28 ± 2 years). Twentyseven of them (50%) underwent colectomy and IPAA as the initial operation. Twenty-seven patients had previously undergone subtotal colectomy. Eight of these 27 patients had cancer in the rectum, of which three were T4 and one was T2N1 cancer. Twenty-two patients underwent a completion proctectomy and three required abdominoperineal resection. Twenty of the 54 patients developed duodenal adenomas. The mean age of diagnosis of duodenal disease was not significantly different from that of patients who were still free of duodenal polyps (40 ± 11 vs. 34 ± 12 years). Seven of these 20 patients underwent local excision of duodenal polyps (either endocopically or transduodenally); four of these patients developed recurrent disease. Six patients underwent pancreaticoduodenectomy for duodenal adenomas with severe dyplasia. These patients experienced an increased number of bowel movements, from five per day (range 4 to 8) to 10 per day (range 6 to 15). One patient required pouch excision and end ileostomy to control diarrhea. Our data demonstrate the following: (1) patients with FAP who have undergone prior subtotal colectomy and ileorectal anastomosis have a high risk of developing advanced cancer in the rectal stump; (2) duodenal adenomas are common in patients with FAP and may occur at an early age; (3) screening duodenoscopy should be initiated at the time of diagnosis of FAP; (4) local excision of duodenal adenomas is associated with a high risk of local recurrence; and (5) even though pancreaticoduodenectomy is the treatment of choice for advanced duodenal adenomas, this procedure may adversely affect pouch function in some patients.

Characterization and clinical behavior of Crohn's disease initially presenting predominantly as colitis.

AbstractPURPOSE: We studied patients with Crohn’s disease affecting the colon to characterize disease behavior and to determine whether such patients might be candidates for sphincter-sparing surgery. METHODS: Ninety-two consecutive patients with Crohn’s colitis were studied prospectively. Mean follow-up after diagnosis was 82 (range, 6–291) months. Parameters that were evaluated included previous surgery for Crohn’s disease, granulomatous vs. nongranulomatous disease, extent of colonic involvement, and presence or absence of extracolonic disease. The clinical course of the disease and postoperative outcome were evaluated. The outcome of Crohn’s colitis patients who underwent ileal pouch-anal anastomosis for presumed ulcerative colitis was also evaluated. RESULTS: There were 39 patients with granulomatous colitis and 53 patients without granulomas. There was no statistical difference in the age of diagnosis or presence of small-bowel (23 vs. 27 percent), ileocolic (34 vs. 30 percent), or perineal (36 vs. 22 percent) disease in these patients. At initial presentation, 88 percent of patients with pancolitis had colitis alone without other sites of intestinal disease compared with only 37 percent of patients with segmental colitis (P < 0.001). Kaplan-Meier analysis showed that patients with granulomas and patients with segmental colitis at presentation have a significantly higher recurrence when compared with patients without granulomas and patients with pancolitis (P < 0.03). Thirteen patients without granulomatous disease and eight with granuloma underwent ileal pouch-anal anastomosis. Seven patients (3 with granuloma, 4 without granuloma) had a recurrence of Crohn’s disease in the ileal pouch; 2 required pouch removal and permanent diversion for fistulizing disease in the ileal pouch and 5 were successfully treated conservatively without surgery. CONCLUSION: The presence of granulomas and segmental involvement of the colon in patients with Crohn’s colitis may reflect a more virulent clinical course. Ileal pouch-anal anastomosis may be considered as an option in select patients with Crohn’s colitis without small-bowel or perianal disease. Based on our data, patients with nongranulomatous pancolitis may be better candidates for sphincter-sparing surgery.

The Role of Laparoscopy in the Treatment of Anastomotic Leaks After Minimally Invasive Colorectal Resections for Cancer.

Aim of the Study: The aim of this study was to describe the role of laparoscopy in the treatment of leaks occurring after minimally invasive colorectal resections. Materials and Methods: Thirty-four of 566 consecutive patients who underwent minimally invasive colorectal resection for cancer between January 2004 and December 2012 and who showed signs of anastomotic leakage (6%) requiring reoperation were studied using a prospectively maintained database. Patient characteristics, clinical signs, the surgical approach, the role of laparoscopy, operative and postoperative results, and the rate of permanent stoma were analyzed. Results: The median time to diagnosis of an anastomotic leak after surgery was 5.5 days. The median time to reoperation from the diagnosis of leakage was 2 days. Leaks were treated laparoscopically in 21 of 34 (61.8%) patients. Anastomoses were dismantled in 14 patients (41.2%) and the procedure was performed laparoscopically in 28.6% of the cases. The postoperative morbidity was 55.9%, the perioperative mortality 5.7%, and the rate of permanent stoma was 8.8%. Conclusions: Laparoscopic reoperation can be performed in most cases of anastomotic leaks occurring after minimally invasive colorectal resection for cancer. Anastomosis can be dismantled laparoscopically in 28.6% of the cases. A permanent stoma was necessary only in patients with terminal stomas.

An unusual complication of renal transplantation: a fistula between the sigmoid colon and the graft.

The wide-spreading of organ transplantation [1–3] with consequent immuno-suppressive and steroid therapy [4] has led to an increase of complications of the gastrointestinal tract, with percentages ranging from 8 to 20 % [5–7]. Complications include perforated gastro-duodenal ulcers, cholecystitis, acute pancreatitis, appendicitis, perforated or fistulized diverticulitis, pseudo-membranous colitis, and perianal fistulas [5, 6]. Diverticulitis is the most common cause of colonic perforation in the renal-transplanted population. These complications have high morbidity and mortality rates in immuno-suppressed patients [5]. Immunosuppression and steroid therapy reduce the inflammatory response [7], often masking the symptoms and giving ambiguous clinical presentations that can result in diagnostic delay. We describe the case of a fistula between the sigmoid colon and the transplanted kidney due to diverticular disease and chronic inflammation after repeated surgeries for a stricture of the anastomosis between the bladder and the ureter. The fistula appeared approximately 2 years after the immuno-suppressive therapy was stopped. The patient was treated with an en-bloc resection of the graft, the sigmoid colon and part of the bladder. To our knowledge this is the first case described in the literature with such a complication.

Laparoscopy for the Treatment of Crohn’s Disease

From the data currently available, firm and absolute recommendations cannot be drawn for the use of laparoscopy in the surgical treatment of Crohn’s disease, due to the heterogeneous features of the disease.