Slawomir J. Marecik

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

BackgroundMinimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision.MethodsFrom March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups.ResultsThere were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (pxa0=xa00.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, pxa0=xa00.36). At a mean follow-up of 17.5xa0months, not a single patient with a Pfannenstiel incision developed an incisional hernia (pxa0<xa00.001). BMI (pxa0=xa00.019), follow-up (pxa0<xa00.001), and Pfannenstiel incision (pxa0<xa00.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis.ConclusionA Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Robot-assisted right colectomy: surgical technique and review of the literature

Following the successful introduction of robotic surgery to the field of urology and gynecology, its use gained even more interest among those in the field of colorectal surgery. Rectal resection is believed to be among the best suited for robotic assistance. In particular, the right hemicolectomy procedure has been proposed as a training tool in order to gain clinical experience with the robot. This article and attached video demonstrates, in detail, the robot-assisted right hemicolectomy, including key landmarks of the procedure. The case presented involved a 58-year-old man with an advanced cecal adenocarcinoma. In our opinionrobot-assisted right colon resection is a procedure that offers particular value for the novice robotic team who is in the beginning stages of their colorectal surgery experience. Although no concrete advantages for use of the robot in this particular procedure have been demonstrated in the literature, because it is a relatively straightforward and simple procedure, it can serve as a valuable training tool for the novice robotic surgeon.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand‐assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra‐operative and short‐term outcomes.

Transverse incision transvaginal rectocele repair combined with levatorplasty and biological graft insertion: technical details and case series outcomes

BackgroundThe purpose of this report is twofold: first, to detail our operative approach to rectocele repair, and second, to report on the outcomes.MethodsTransverse incision transvaginal rectocele repair combined with levatorplasty and biological graft placement is detailed using hand-drawn sketches and intraoperative photographs. All patients with symptoms of functional constipation and non-emptying rectocele operated on from May 2007 to March 2013 at our institution were enrolled in this study. Data from a prospectively maintained database were retrospectively analyzed. Preoperative and postoperative functional outcomes were studied using a validated 31-point obstructed defecation (OD) scoring system. Follow-up was 1xa0year.ResultsTwenty-three patients underwent the procedure. The mean age of patients was 55xa0years (range 28–79xa0years). The OD severity score improved from the preoperative mean of 21.6 to postoperative mean of 5.5 (pxa0=xa00.001). Three out of four patients with initial symptoms of dyspareunia (75xa0%) reported significant improvement in dyspareunia, while 2 out of 19 patients without initial symptoms of dyspareunia (11xa0%) reported mild dyspareunia following the repair. One patient (4xa0%) required operative drainage of a hematoma. Another patient (4xa0%) developed symptomatic recurrence which was confirmed radiologically.ConclusionsIn properly selected patients, the technique described leads to significant improvement in symptoms of OD and low recurrence without an increased rate of dyspareunia.

Endoscopic-assisted closure of a chronic colocutaneous fistula.

In the absence of such factors as distal obstruction, a complete rosette of mucosa at the external opening, foreign body, malignancy, inflammatory bowel disease, or epithelialization of the tract, conservative management should allow healing of a postoperative, anastomotic, enterocutaneous fistula. Chronic or high-output fistulae usually require surgical correction. We describe the combined use of endoscopic clips and fibrin glue in the closure of a chronic colocutaneous fistula.

Robotic Colorectal Surgery for Neoplasia

Robotic colorectal surgery has become increasingly prevalent, with several reported benefits for surgeons and patients alike. Although its use is well-supported for pelvic surgery, there is less evidence that it is beneficial for abdominal surgery. There are several technical limitations of robotic surgery, and newer generations of robot platforms have addressed these, which may lead to increased use in the near future. In general, robotic surgery is more beneficial for surgeons than it is for patients.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse.

BACKGROUND: The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. OBJECTIVE: The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. DESIGN: A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. SETTINGS: Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. PATIENTS: Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. INTERVENTIONS: All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. MAIN OUTCOME MEASURES: The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. RESULTS: Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). LIMITATIONS: This study was limited by nature of being a retrospective review. CONCLUSIONS: Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Sacral nerve stimulation in the treatment of bowel dysfunction from imperforate anus: A case report

Highlights • SNS is an effective treatment for fecal incontinence.• SNS can be applied in adults with history of congenital imperforate anus.• SNS can improve quality of life in adults with history of imperforate anus.

Rectal Anatomy: Clinical Perspective

This chapter will discuss the anatomy of the rectum and pelvis as it relates to the diagnosis and surgical management of rectal cancer.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors

AbstractBackgroundnToday, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity.MethodsOver a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed.ResultsAll procedures were successfully completed without conversion. Average body mass index was 32xa0kg/m2. The mean operative time and blood loss were 370xa0min and 130xa0ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14xa0months, all patients remain disease-free.ConclusionsModified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.n