Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity.

BACKGROUND: Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery. OBJECTIVE: The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation. DESIGN: Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed. SETTINGS: The study was conducted at a single teaching institution. SUBJECTS: Residents and trained surgeons were included. INTERVENTION: The study intervention included total mesorectal excision on an inanimate model. MAIN OUTCOME MEASURES: Metrics confirming or refuting that the model can distinguish between novices and experts were measured. RESULTS: A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation. LIMITATIONS: The use of a da Vinci microblade instead of hook electrocautery was a study limitation. CONCLUSIONS: The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.

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.

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

BACKGROUND: Today, 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. METHODS: Over 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. RESULTS: All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, 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 14 months, all patients remain disease-free. CONCLUSIONS: Modified 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.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

BACKGROUND: The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. OBJECTIVE: We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 5-year period. SETTING: Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. PATIENTS: Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. INTERVENTIONS: All patients received a robot-assisted extralevator abdominoperineal resection. MAIN OUTCOME MEASURES: Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. RESULTS: Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. LIMITATIONS: This was a single-institution study with no comparative open or laparoscopic group. CONCLUSION: Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Endoscopic control of enterocutaneous fistula by dual intussuscepting stent technique.

INTRODUCTION: Large high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. METHODS: This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2 cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents-10 cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25 mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). RESULTS: The patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig. 1), the patient was nutritionally optimized with oral feeds from albumin of 0.9-3.4 g/dl within 2 months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20 cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. CONCLUSIONS: Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. OBJECTIVE: We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 7-year period. SETTINGS: Procedures took place in the colorectal division at a tertiary hospital. PATIENTS: From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. INTERVENTIONS: Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. MAIN OUTCOME MEASURES: Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. RESULTS: There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). LIMITATIONS: This was a single-institution study with no head-to-head comparative group. CONCLUSIONS: Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Single-Site Robotic Cholecystectomy: The Timeline of Progress.

AIM: To investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant. RESULTS: The female to male ratio was 2:1. The mean age was 51 years (18-87) and the mean BMI was 28.26 (18-41). Overall, 69 % of the patients underwent elective cholecystectomy and 31 % required urgent surgery. In all, 17 % of patients had previous abdominal surgeries. In total, 45 % of procedures were regarded as same day surgery. The total mean length of stay was 1.97 days (0-8). The mean operative time was 110 min (36-265), mean robotic console time 70 min (26-179), and mean docking time 9 min (1-26). The overall conversion rate was 3.9 % and the complication rate was 4 %. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (P = 0.001). CONCLUSION: Single-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

Current status of robotic surgery for rectal cancer: A bird's eye view.

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors' own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included.

Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program.

BACKGROUND: Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. METHODS: This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. RESULTS: Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. CONCLUSIONS: Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.

Endoclip closure of a large colonic perforation following colonoscopic leiomyoma excision.

BACKGROUND AND OBJECTIVE: Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect. METHODS: A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips. RESULTS: Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints. CONCLUSIONS: Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.

Cost-effectiveness of laparoscopic vs open resection for colon and rectal cancer.

BACKGROUND: Whether laparoscopic surgery for colon and rectal cancer is cost-effective in comparison with open surgery remains unclear, because laparoscopic surgery results in shorter hospital stays but is associated with increased equipment costs. OBJECTIVE: This study aimed to investigate the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, incorporating factors not included in previous cost-effectiveness studies. DESIGN: A decision analysis model was constructed, and extensive sensitivity analyses were performed to test the assumptions of the model. SETTING: Data were taken from previously published studies; data from large randomized trials were used whenever possible as inputs into the model. PATIENTS: Patients enrolled in the trials from which data were gathered for the model. INTERVENTIONS: There were no interventions. MAIN OUTCOME MEASURES: The primary outcome measured was the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, expressed as cost per quality-adjusted life-year. RESULTS: Laparoscopic resection results in savings of $4283 and essentially no difference in quality-adjusted life-years (0.001 more quality-adjusted life-years than open resection). Sensitivity analyses indicate that laparoscopic surgery is cost-effective at <$50,000 per quality-adjusted life-year under almost all conditions. The only circumstance that affects the cost-effectiveness of laparoscopic surgery is postoperative hernia rates. Because of the additional time off work for hernia repair, laparoscopic resection is cost-effective only if it results in a hernia rate less than or equal to open surgery. For all other variables, the laparoscopic approach remains less costly than the open approach with no difference in quality of life. LIMITATIONS: The model relies on data from other studies, rather than being an independent trial designed to specifically collect these data. CONCLUSIONS: Laparoscopic resection for colon and rectal cancer results in decreased costs and equivalent quality of life, making it the preferred approach in suitable patients.

Ligation of intersphincteric fistula tract: early results of a pilot study.

BACKGROUND: Transsphincteric fistulotomy is associated with a variable degree of fecal incontinence that is directly related to the thickness of the sphincter mechanism overlying the fistula. Staged fistulotomy with seton or the use of cutting seton designed to reduce the proportionate incontinence rates have failed to do so. This has resulted in attempts to find novel sphincter-sparing techniques in the past 2 decades including draining seton, fibrin sealant, anal fistula plug, dermal advancement, and endorectal advancement flaps. These operations have a variable success rates of 30% to 80% reported in the literature. OBJECTIVE: In 2007, Rojanasakul from Thailand demonstrated a novel technique, ligation of intersphincteric fistula tract, and reported a 94% success rate in a small series. Since then, a few other small cohorts of patients have been reported in the literature with success rates varying from 57% to 82%. An institutional review board-approved study was proposed to measure our results and compare them with the published data. DESIGN: This study was undertaken to evaluate the success of ligation of intersphincteric fistula tract procedures in a group of unselected transsphincteric fistulas deemed unsuitable for lay-open fistulotomy. SETTING: The procedure was performed in 3 different settings: a public institution, a major university hospital, and a large private hospital. PATIENTS: A total of 40 patients underwent 41 ligation of intersphincteric fistula tract procedures performed by 6 Board-certified colon and rectal surgeons. RESULTS: In a mean follow-up of 18 weeks, 74% of the patients achieved healing. In patients who underwent ligation of intersphincteric fistula tract as their primary procedure, the healing rate was 90%. The limitation of this study is its "case series" nature and the short mean follow-up period of 18 weeks. CONCLUSION: Ligation of intersphincteric fistula tract has had excellent success in transsphincteric fistulas in multiple small series. A larger number of patients and longer follow-up period are needed to validate the early favorable results.

A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma.

PURPOSE: This retrospective study was designed to compare open with robot-assisted total mesorectal excision for rectal adenocarcinoma. METHODS: With use of predefined exclusion criteria, all consecutive laparoscopic-assisted (51 patients) and robot-assisted (36 patients) rectal resections for adenocarcinoma from August 2005 to November 2009 at a single institution were considered. Hand-assisted laparoscopy was used for splenic flexure mobilization in all cases. Patients were assigned into robotic and open groups on the basis of the technique used for total mesorectal excision. All 36 robot-assisted resections had the total mesorectal excision performed with robotic assistance and were included in the robotic group. Forty-six of the 51 patients who received a laparoscopic-assisted procedure had the total mesorectal excision performed through the hand port using open surgical technique and were included in the open group. Both groups were compared with respect to patient demographics, perioperative outcomes, and pathology. RESULTS: The robotic and open groups were comparable in age, sex, body mass index, history of prior abdominal surgery, ASA class, number of patients receiving neoadjuvant chemoradiation, and tumor stage. There were more abdominoperineal resections (P = .019) and more low and mid rectal tumors (P = .007) in the robotic group. Total procedure time was longer in the robotic group (P = .003), but blood loss was less (P = .036). Lymph node yield, intraoperative and postoperative complications, and length of stay were all comparable. There were 3 positive circumferential margins in the open group vs none in the robotic group, but this did not reach statistical significance. CONCLUSIONS: Robotic total mesorectal excision is feasible and safe, and is comparable to open total mesorectal excision in terms of perioperative and pathological outcomes. The longer operative time associated with robotic total mesorectal excision could decrease as experience with this relatively new technique increases. Large randomized trials are necessary to validate the potential benefits of less blood loss and lower margin positivity rates observed in this study.

Robotic cylindrical abdominoperineal resection with transabdominal levator transection.

PURPOSE: The extralevator approach to abdominoperineal resection is an emerging surgical option for patients with low rectal cancer. This technique involves a wide excision of the levator muscles that could reduce the high incidence of circumferential margin positivity associated with conventional abdominoperineal resections. We present our technique of robotic cylindrical abdominoperineal resection where the daVinci robot is used to perform a controlled transection of the levator muscles transabdominally under direct visualization. METHODS: Five patients with rectal adenocarcinoma within 5 cm of the anal verge underwent robot-assisted cylindrical abdominoperineal resection. Safety, feasibility, immediate postoperative outcomes, and pathological adequacy of the specimen were assessed. RESULTS: The procedure was successfully completed in all 5 patients without any intraoperative complications, robot-associated morbidity, or conversion to the open approach. The mean operative time and length of hospital stay were 343 minutes and 5.8 days. An intact mesorectal envelope and negative circumferential margin was achieved in all cases. All specimens had a cylindrical shape. CONCLUSIONS: Robotic assistance enables the transabdominal transection of the levator muscles in cylindrical abdominoperineal resection, with acceptable perioperative and pathological outcomes. Further studies are essential to objectively define the safety, efficacy, and long-term results of this new technique.

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

BACKGROUND: Minimally 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. METHODS: From 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. RESULTS: There 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 (p = 0.015) 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%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. CONCLUSION: A 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.

Robotic pursestring technique in low anterior resection.

PURPOSE: Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system. METHODS: Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed. RESULTS: The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day. CONCLUSIONS: The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.