Rodrigo Pedraza

Robotic-assisted single-incision laparoscopic partial cecectomy.

Single‐incision laparoscopic surgery is an emerging approach in the field of minimally invasive colon and rectal surgery. This modality utilizes a ‘scarless’ incision concealed within the umbilicus, and results in improved cosmesis with the potential for reduced trauma, pain and length of hospital stay. However, unique technical challenges have curbed its adaptation. Robotic‐assisted technique may help overcome these limitations when applied to the single‐incision approach.

Robotic-assisted laparoscopic surgery for restorative proctocolectomy with ileal J pouch-anal anastomosis

Abstract Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.

Single-Incision Laparoscopic Colectomy for Cancer: Short-Term Outcomes and Comparative Analysis

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n = 33) and anterior resections (n = 12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques.

Minimally Invasive Approaches for the Management of “Difficult” Colonic Polyps

Traditionally, patients with colonic polyps not amenable to endoscopic removal require open colectomy for management. We evaluated our experience with minimally invasive approaches including endoscopic mucosal resection (EMR), laparoscopic-assisted endoscopic polypectomy (LAEP), and laparoscopic-assisted colectomy (LAC). Patients referred for surgery for colonic polyps were selected for one of three minimally invasive modalities. A total of 123 patients were referred for resection of “difficult” polyps. Thirty underwent EMR, 25 underwent LAEP, and 68 underwent LAC. Of those selected to undergo EMR or LAEP, 76.4% were successfully managed without colon resection. The remaining 23.6% underwent LAC. Nine complications were encountered, including two requiring reoperative intervention. Of the 123 patients, three were found to have malignant disease on final pathology. Surgical resection can be avoided in a significant number of patients with “difficult” polyps referred for surgery by performing EMR and LAEP. In those who require surgery, minimally invasive resection can be achieved.

Pelvic Muscle Rehabilitation: A Standardized Protocol for Pelvic Floor Dysfunction

Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes. Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1) initial baseline phase; (2) rapid contraction phase; (3) tonic contraction and endurance phase; and (4) late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1) down-training; (2) accessory muscle isolation; (3) discrimination training; (4) muscle strengthening; (5) endurance training; and (6) electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications. Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course.

Laparoscopic Primary Colorrhaphy for Acute Iatrogenic Perforations during Colonoscopy

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations. Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge. Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58–83), mean BMI of 26.4 ± 3.4 kg/m2 (range: 21.3–30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma (n = 3) or thermal injury (n = 2) and were localized to the sigmoid (n = 4) or cecum (n = 1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3–5). There were no readmissions or reoperations. Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes.

Minimally Invasive Colorectal Surgery in the Morbidly Obese: Does High Body Mass Index Lead to Poorer Outcomes?

Background: Obesity is associated with increased surgical risk and major abdominal procedures performed in morbidly obese patients may prove challenging when compared with normal weight patients. There are limited data regarding outcomes after minimally invasive colorectal surgery in morbidly obese patients. The aim of this study was to compare the outcomes between morbidly obese and normal weight patients. Materials and Methods: Forty morbidly obese were matched to three normal weight patients (n=120), based on type of surgical approach and procedure. The patients underwent minimally invasive colorectal surgery by one of two colorectal surgeons. Patients were considered morbidly obese or normal-weight based on body mass index. Demographic data and operative outcomes were compared. Results: Mean body mass index differed significantly between the morbidly obese (median 43.9 kg/m2) and normal weight (median 22.7 kg/m2) groups, p<0.00001. Both groups were comparable in regards to age, gender, history of prior abdominal operations, and clinical diagnosis. Surgical approaches included multiport laparoscopic colectomy (47.5%), hand-assisted laparoscopic colectomy (35%), robotic-assisted laparoscopic colectomy (12.5%), and single-incision laparoscopic colectomy (5%). The most common procedures were anterior resection (42.5%) and right hemicolectomy (40%). Morbidly obese patients required a significantly longer operative time (median 199 min vs. 139 min, p=0.0004) and resulted in significantly greater blood loss (median 100 cc vs. 75 cc, p=0.004), with no higher conversion rate to open surgery (7.5% vs. 2.5%, p=0.15) compared to normal weight patients. The mean length of hospital stay, 30-day postoperative complication, readmission, and reoperation rates were comparable between groups. Conclusions: Minimally invasive surgery for the treatment of colorectal disorders in morbidly obese patients results in short-term outcomes comparable to those observed in normal weight patients. Although technically challenging, morbidly obese population may benefit from minimally invasive surgery in regard to enhanced recovery.

Robotic-assisted laparoscopic primary repair of acute iatrogenic colonic perforation: case report

Colonic perforation during colonoscopy is a rare complication and is usually considered a surgical emergency. Traditionally, such perforations have required laparotomy with repair or resection. Minimally invasive approaches have recently been successfully implemented. We describe our initial experience with a robotic‐assisted laparoscopic technique for primary colorrhaphy following colonoscopic perforation.

Emergent Laparoscopic Colorectal Surgery

Laparoscopic intervention for colorectal emergencies depends on both patient and surgeon factors. While mainly used for surgery complications of diverticulitis and cancer, a wide spectrum of applications is possible. Emergent laparoscopic colorectal surgery is safe and feasible in many cases, and permits exploration while limiting incision size, reducing overall morbidity. The ultimate success of emergent laparoscopic colorectal surgery lies in proper patient selection. In this chapter, we address the trends in utilization, indications, technical considerations, and pitfalls of emergent laparoscopic colorectal resection.

Sigmoid Colectomy and Left Hemicolectomy: Robotic Approach

Following the overview of laparoscopic techniques to sigmoid resection and Hartmann’s reversal in the previous chapters, we will expand on the utilization of the da Vinci robotic system for this procedure. Certain operative steps described in this chapter are part of a total robotic low anterior resection and proctectomy described in a later chapter for this book.