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Robotic Loop Ileostomy Closure

71 yrs old male s/p robotic low anterior resection with primary coloproctostomy and diverting loop ileostomy for bulky, locally advanced rectal cancer. Robotic approach for loop ileostomy closure was planned due to obese body habitus. We utilized DaVinci Xi robotic platform. The set up consisted in 4-port placement, with ports # 2, 3 and 4 positioned starting in the left upper abdominal quadrant along MCL and port # 1 in suprapubic area. After docking and insertion of robotic instruments, the RLQ ileostomy was visualized. Appropriate orientation of efferent and afferent limbs was confirmed. Two enterotomies were created with electrocautery at the antimesenteric border of each limb, approximately 10 cm from the fascia. Head and anvil components of a robotic 60 mm stapler were then inserted in each enterotomy and the stapler fired in order to create a common channel between the lumens. After stay suture with 3-0 Vicryl was placed at the crotch of the anastomosis, common enterotomy defect was approximated with running 3-0 V-Lock suture in two layers. The matured portions of the loop ileostomy were then divided right below the fascia level with robotic 60 mm stapler after gentle dissection of the mesenteric border of each limb, while the mesentery was divided with robotic vessel sealer. The robotic system was then undocked and the ports removed. The remaining portion of the loop ileostomy was finally dissected from the abdominal wall at the mucocutaneous junction and the fascia defect approximated in the usual fashion (not included in the video).

Diverting loop ileostomy is an established surgical procedure usually performed to protect colorectal anastomoses that are considered at increased risk of anastomotic leak. The technique is commonly adopted in Colorectal Surgery at the time of complex pelvic dissections, especially during rectal cancer surgery with creation of low anastomosis or after neoadjuvant chemotherapy and radiation regimen. Loop ileostomy reversal is generally considered a straight-forward operation and mostly performed open by dissecting the two limbs of the loop from the abdominal fascia bluntly and blindly through the same fascial opening that initially accomodated the stoma. Even though formal midline laparotomy is rarely necessary, the literature indicates that loop ileostomy closure carries significant morbidity. Despite the proved benefits of laparoscopy and intracorporeal creation of anastomosis in terms of faster bowel recovery and better visualization, only few reports of laparoscopic loop ileostomy closure have been published, none of robotic loop ileostomy closure. We would like to present our initial experience with robotic loop ileostomy closure as a viable option to provide better visualization during intraabdominal dissection of the loop ileostomy limbs and segment of small bowel and to facilitate the creation of intracorporeal anastomosis, especially in morbidly obese patients.
Loop ileostomy creation is commonly performed for fecal diversion to mitigate potential consequences of anastomotic leaks when new colon and rectal anastomoses are created. Loop ileostomy reversal is then performed after several weeks, when radiologic contrast study and colonoscopy have confirmed that the anastomosis is patent, intact and with no evidence of contrast extravasation. The closure is commonly performed via open or, less commonly, laparoscopic approach. One of the most important steps in an ileostomy reversal is adhesiolysis, which is the takedown of the inflammatory bands between loops of bowel and anterior abdominal wall that are often seen at re-operations. These adhesions make stoma and small bowel mobilization difficult, especially when performed blindly and bluntly through the same fascial defect that accomodates the ostomy. Despite the perceived ease of the operation, these difficulties have been associated to increased rates of post-operative ileus and small bowel obstruction. Several reports of laparoscopic loop ileostomy closure have been described in the literature as a mean to provide better visualization during the adhesiolysis, in order to allow an easier and safer dissection than open procedure and improve bowel mobilization. Laparoscopic reversal procedures are also associated with less post-operative pain, faster recovery, and shorter hospital stay than open procedures1, especially when intracorporeal anastomosis can be performed. While there are several articles that describe laparoscopic loop ileostomy reversal, to our knowledge, a robotic approach has not yet been described in the literature. The use of robotics has been gaining popularity in colorectal surgery, as it can often overcome the technical challenges that come with laparoscopic procedures by creating more fluid and accurate movements, 3-D optics in narrow spaces, and improved surgeon ergonomics. The indications for the use of robotics are the same in colorectal surgery as laparoscopy. Similar to laparoscopy, contraindications for robotic use include inability to tolerate insufflation, emergency surgery, shock, uncontrollable bleeding and poor visualization. Operative time for colorectal surgery tends to be longer with robotics, but this issue has been shown to be easily managed by the creation of institutional robotic programs that can rationalize the use of the robotic platform, provide resources and training to the surgeons and the staff as well as follow-up outcomes and complications of the different robotic procedures, in order to constantly evolve and improve the settings of the different procedures. As with laparoscopic or open ileostomy reversal, complications include ileus, SBO, bleeding, anastomotic leak, wound infection, intra-abdominal abscess, and incisional hernia. Specifically to robotic surgery, complications include robotic system malfunctions that are either recoverable or non-recoverable and may require conversion to open. The purpose of this video is to demonstrate how to perform a robotic loop ileostomy reversal after LAR for rectal cancer.
Da Vinci robotic Xi platform was used. Setup of the robotic ports was identical to the one that we use for right colectomy, with the 4 ports placed vertically at the midclavicular line.
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While loop ileostomy creation is a common practice for anastomotic protection via fecal diversion, its reversal requires a second surgery that can be complicated by poor visualization from extensive adhesions, difficult mobilization of the stoma or small bowel. The use of the robotic platform provides an advantage because it has a higher degree of motion and tactile feedback than laparoscopy, allows for more ergonomic movement, and eliminates surgeon tremors, unlike open or laparoscopic surgery. Additionally, an obese patient body habitus does not affect the complexity of this case, which is an important factor that often complicates open and laparoscopic approach. Current literature also shows that robotic surgery is a safe and feasible alternative to laparoscopy, and has lower overall conversion to open rates than laparoscopy . As seen in our video, complete visibility of the stoma and small bowel was obtained and adhesiolysis was safely performed under direct visualization. Critical steps of the procedure include proper robotic trochar placement, correct orientation of the afferent and efferent ileostomy limbs, suture repair of the common enterotomy defect, and takedown of adhesions that may prevent adequate mobilization of the ileostomy and adjacent bowel. One important consideration and potential limitation is that surgeons performing the robotic ileostomy reversal must have extensive robotic training and practice prior to performing this procedure. Not only must the surgeon know how to use to robotic operating system, they must be able to troubleshoot robot specific issues such as inability to reach target anatomy, failure or inflexibility of the robotic arms, make camera adjustments, etc. Another criticism of robotic surgery is cost, as the upfront cost of buying a robotic surgical system can be anywhere from 1-2.5 million dollars per unit . Additionally, not all hospitals have the resources, training, and staffing to support a robotic surgical program so this approach may not be feasible in all operative environments. This video shows a novel way of performing a loop ileostomy reversal, which has not yet been described in the literature. As seen in this video, the robot offers advantages such as ease of articulating instruments, three dimensional optics, and surgeon ergonomics over current open or laparoscopic techniques.
The three authors have no conflict of interest.
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Russek K, George JM, Zafar N, Cuevas-Estandia P, Franklin M. Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes. JSLS 2011 15:475–479. Cheng Christina L, Rezac Craig.The role of robotics in colorectal surgery. BMJ 2018; 360 :j5304. Bhama AR, Obias V, Welch KB, Vandewarker JF, Cleary RK. A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Surg Endosc 2016;30:1576-84. Speicher PJ, Englum BR, Ganapathi AM, Nussbaum DP, Mantyh CR, Migaly J. Robotic low anterior resection for rectal cancer: a national perspective on short-term oncologic outcomes. AnnSurg2015;262:10405.

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