As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
The robotic sigmoidectomy dissection was carried out in standard fashion, following which the descending colon and rectosigmoid junction were transected with electrocautery, allowing for a trans-anal specimen extraction. Preoperative bowel preparation limited intra-peritoneal contamination from these maneuvers. An end-to-end anastomotic stapler was introduced through the anus. The anvil was detached intra-corporeally, and both the anvil and stapler body were secured in their respective locations with endoloops prior to firing. Thus, the patient received a totally robotic sigmoidectomy with an intra-corporeal, end-to-end anastomosis, using a single stapler technique.
Indications to proceed with a totally robotic sigmoidectomy with an intra-corporeal, end-to-end anastomosis, using a single stapler technique includes recurrent diverticulitis without evidence of malignancy.
Malignancy extraction via this technique places the patient at risk for seeding along the extraction site.
Port placement for use with the daVinci XI system includes with 4 ports in a linear fashion spanning from the left upper quadrant to the right lower quadrant with the right lower quadrant being 12mm for the stapler. An additional 12mm AirSeal port is placed in the right upper quadrant for the bed-side assist.
Pre-operatively, mechanical and antibiotic bowel preparation is necessary.
Important anatomy to be aware of is the sigmoid and descending colon, the left ureter, the inferior mesenteric artery pedicle, and the left iliac vessels. Care must be taken during dissection to mobilize and free the inferior mesenteric artery pedicle while protecting the ureter and iliac vessels.
Advantages:
Omitting an extraction incision can reduce pain, reduce the risk of hernia formation, and reduce hospital length of stay. A single stapler technique reduces procedural cost and eliminates potential intersecting staple lines.
Disadvantages:
This technique should not be used in cases of colon cancer, due to the risk of spreading malignancy upon extraction. In addition, this technique is technically more difficult than the standard 3 stapler technique.
Risks for this surgical procedure include, bleeding, infection, injury to surrounding structures, port-site hernias, adverse cardiac events, deep venous thrombosis, gas embolus, anastomotic leak, ureteral injury, adjacent bowel injury, sepsis, muti-system organ failure, and death.
None of the authors have any financial disclosures with any commercial interest.
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Cheng CL and Rezac C. The role of robotics in colorectal surgery. BMJ. 2018;360:j5304.
Clinical Outcomes of Surgical Therapy Study G, Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050-2059.
Color IISG, Buunen M, Bonjer HJ, Hop WC, Haglind E, Kurlberg G, et al. COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan Med Bull. 2009;56:89-91.
Diana M and Marescaux J. Robotic surgery. Br J Surg. 2015;102:e15-28.
Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg. 2013;100:75-82.
Leung KL, Kwok SP, Lam SC, Lee JF, Yiu RY, Ng SS, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet. 2004;363:1187-1192.
Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224:59-74.
Migaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum. 2019;62:3-8.
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Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Gastrointestinal stromal tumors (GIST) occur most frequently at the gastric level. Surgical resection is the mainstay of treatment and can usually be performed using laparoscopic approaches (1). The resection strategy must be adjusted to each case, the selection of location, size and growth pattern of the tumor (2).
We present the case of a 78-year-old female patient who, after going to the Emergency Department due to symptoms of upper gastrointestinal bleeding, showed a 5 cm heterogeneous tumor depending on the muscular layer itself in a posterior gastric wall, endoluminal growth, and without objectifying others injuries in the study of extension. A wide posterior resection of the gastric posterior wall and primary closure with a barbed suture was performed laparoscopically. The postoperative evolution was satisfactory. The histopathological study shows low-risk GIST (5 mitosis / 50 CGA) with free margins; during follow-up, no recurrence was observed. Simple laparoscopic resection of gastric GIST tumors seems to be a useful strategy in terms of oncological safety, reducing excessive resection of tumor-free tissue and increasing gastric remnant.
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