Assessment of the Versius surgical robotic system for dual-field synchronous transanal total mesorectal excision (taTME) in a preclinical model: will tomorrow's surgical robots promise newfound options?

BACKGROUND: The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting. METHODS: Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver. RESULTS: Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system. CONCLUSIONS: This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.

Robotic-assisted stereotactic real-time navigation: initial clinical experience and feasibility for rectal cancer surgery.

BACKGROUND: Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting. METHODS: After pre-clinical assessment, and configuration of a robotic-assisted navigational system, two patients with locally advanced rectal cancer were selected for enrollment into a pilot study designed to assess the feasibility of navigation coupled with the robotic da Vinci Xi platform via TilePro interface. In one case, fluorescence-guided surgery was also used as an adjunct for structure localization, with local administration of indocyanine green into the ureters and at the tumor site. RESULTS: Each operation was successfully completed with a robotic-assisted approach; image-guided navigation provided computed accuracy of ± 4.5 to 4.6 mm. The principle limitation encountered was navigation signal dropout due to temporary loss of direct line-of-sight with the navigational system's infrared camera. Subjectively, the aid of navigation assisted the operating surgeon in identifying critical anatomical planes. The combination of fluorescence with image-guided surgery further augmented the surgeon's perception of the operative field. CONCLUSIONS: The combination of stereotactic navigation and robotic surgery is feasible, although some limitations and technical challenges were observed. For complex surgery, the addition of navigation to robotics can improve surgical precision. This will likely represent the next step in the evolution of robotics and in the development of digital surgery.

Robotic transanal surgery for local excision of rectal neoplasia, transanal total mesorectal excision, and repair of complex fistulae: clinical experience with the first 18 cases at a single institution.

BACKGROUND: Robotic transanal surgery represents a natural evolution of transanal minimally invasive surgery. This new approach to rectal surgery provides the ability to perform local excision of rectal neoplasia with precision. Robotic transanal surgery can also be used to perform more advanced procedures including repair of complex fistulae and transanal total mesorectal excision. METHODS: Data from patients who underwent transanal robotic surgery over a 33-month period were retrospectively reviewed. Patients underwent three types of procedures using this approach: (a) local excision of rectal neoplasia, (b) transanal total mesorectal excision, and (c) closure of complex fistulae, such as rectourethral fistulae. RESULTS: Eighteen patients underwent robotic transanal surgery during the 33-month study period. Of these, nine patients underwent local excision of rectal neoplasia; four patients underwent transanal total mesorectal excision; four patients underwent repair of rectourethral fistulae; and one patient underwent repair of an anastomotic fistula. Of the patients undergoing robotic transanal surgery for local excision, 6/9 were resections of benign neoplasia, while 3/9 were resections for invasive adenocarcinoma. There was no fragmentation (0/9) noted on any of the locally excised specimens, while one patient (1/9) had a positive lateral margin. During the mean follow-up of 11.4 months, no recurrence was detected. Four patients underwent robotic-assisted transanal total mesorectal excision for curative intent resection of rectal cancer confined to the distal rectum. Mesorectal quality was graded as complete or near complete, and an R0 resection was performed in all four cases. Other transanal robotic procedures performed were the repair of rectourethral fistulae (n = 3) and anastomotic fistula (n = 1). This approach was met with limited success, and only half of the rectourethral fistulae were closed. CONCLUSIONS: Robotic transanal surgery for local excision, transanal total mesorectal excision, and repair of fistulae is feasible, although these new approaches represent a work-in-progress. Improvement in platform design will likely facilitate the ability to perform more complex procedures. Further research with robotic transanal approaches is necessary to determine whether or not this approach can provide patients with significant benefit.

Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique.

The approach to local excision of benign and early-stage, well-selected neoplasms of the rectum continues to evolve. We demonstrate here that local excision of a rectal neoplasm using the da Vinci Robotic Surgical System can be successfully performed. To our knowledge, this is the first time robotic transanal surgery (RTS) has been used in this manner.

Hernia repair: the search for ideal meshes.

BACKGROUND: Effective repair of hernia is a difficult task. There have been many advances in hernia repair techniques over the past 50 years, but new strategies must be considered to enhance the success of herniorrhaphy. DISCUSSION: At the 30th International Congress of the European Hernia Society, nine experts in hernia repair and experimental mesh evaluation participated in a roundtable discussion about today's unmet needs in hernia repair, including what constitutes an "ideal" hernia repair and the portfolio of "ideal" mesh prostheses. Defining characteristics of lightweight mesh, mesh alternatives, the surgeon's role in hernia repair, adverse events, the unmet requirements for today's hernia repair, and optimized animal models were among the topics discussed. CONCLUSION: The ideal mesh's construction is still in progress, but greater understanding of its critical characteristics was explored. It is hoped that these suggestions will lead to the development of improved hernia treatments and a maximally effective portfolio of hernia mesh prostheses.

Choledochal cysts diagnosed in pregnancy: a case report and review of treatment options.

An 18-year-old woman at 18 weeks' gestation presented with abdominal pain and jaundice. After extensive evaluation, she was diagnosed as having a choledochal cyst. Ten days after percutaneous drainage, she underwent complete excision and Roux-en-Y hepaticojejunostomy anastomosis. At term, she delivered vaginally without complications. Although choledochal cysts are rare in pregnancy, it is important for the obstetrician to be familiar with the presentation and the best treatment modalities available. Delay in diagnosis and inappropriate treatment can result in maternal morbidity and fetal mortality.

Laparoscopic-assisted colonoscopic polypectomy: the Texas Endosurgery Institute experience.

PURPOSE: The advent of laparoscopic surgery has altered the manner by which surgical specialties address pathologies of the abdominal cavity. This advance in technology has also changed colorectal surgery. One of the more common procedures of colorectal surgery is segmental resection for polyps that are large, broad based, or inaccessible for colonoscopic removal. We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections. METHODS: From May 1990 to September 1999 laparoscopic-monitored colonic polypectomies were performed in 47 patients, with a total of 60 polyps being removed. After laparoscopic mobilization of the involved segment of the colon, the proximal bowel is cross-clamped and the colonoscope passed to the involved portion of the colon. The polyp is then presented to the colonoscopist by the laparoscopist facilitating removal. The serosal surface is monitored for any indications of transluminal injury, and the area is repaired if needed. All polyps undergo immediate frozen section analysis. If the pathologic evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short time before discharge. RESULTS: The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubulovillous adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (1 low anterior resection and 2 right hemicolectomies), which were performed laparoscopically. Patients received a liquid diet within 6 hours, were discharged in an average of 21 hours, and returned to full activity, usually within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97 percent) behaved as if only a colonoscopy had been performed. Pain at the trocar sites was managed with acetaminophen 600 mg by mouth as needed. CONCLUSION: Laparoscopic-monitored colonoscopic polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonoscopy alone, and the potential complications of a segmental resection are avoided. All polyps are examined by frozen section, and if a malignancy is encountered, a laparoscopic resection can be performed.

Gasless laparoscopic-assisted intestinal stoma creation through a single incision.

Intestinal stoma creation has been performed using both open and laparoscopic surgery. However, each technique still has disadvantages. We created the intestinal stoma through one incision, with the use of the laparoscope in a gasless fashion. This method has not been reported previously. Fourteen adult patients underwent this technique between February 1996 and December 1998. Indications for stoma creation were for various anorectal disease processes, most commonly for purposes of hygiene in patients with spinal cord injury. The average operative time to perform the stoma was 58 (range, 15-78) minutes, with minimal blood loss (<35 ml). Follow-up ranged from 1 to 22 months. Two cases (14 percent) were converted secondary to severe adhesions. All nonconverted patients were able to tolerate a regular diet within two days of surgery. There was only one stoma-related complication. Two patients (14 percent) died of comorbidities during follow-up. In conclusion, the initial experience with gasless laparoscopic-assisted intestinal stoma creation through a single incision is encouraging. Patients requiring ostomy creation as a single intervention may benefit from this approach.

Mesenteric panniculitis: case report and literature review.

Mesenteric panniculitis is an extremely rare inflammatory condition of the adipose tissue of unknown etiology in which the mesentery is replaced with fibrosis. Knowledge of this rare syndrome should prevent any unwarranted aggressive therapy and help to use the clinical, radiological, and surgical sources to obtain the diagnosis. This paper is a review of symptomatology, pathology, treatment, and outcome of this disorder. A case report is described that presented with obstruction of the sigmoid colon.

Retroperitoneal abscess as a complication of retained gallstones following laparoscopic cholecystectomy.

Retroperitoneal abscess formation secondary to retained spilled gallstones after laparoscopic cholecystectomy is a rare complication. We describe the case of a patient with this complication as well as a novel method utilizing interventional radiologic localization with subsequent operative drainage and removal of the stones. A review of the literature is provided.

Ciliated foregut cyst of the pancreas.

Cystic lesions of the pancreas are relatively uncommon. We describe the case of a young man with a complex cystic mass located within the head of the pancreas. The patient underwent exploration with resection of the mass. Pathology revealed a ciliated epithelial cyst, a rare cystic lesion of the pancreas.