Perineal-First Approach in Robotic Abdominoperineal Resection.

INTRODUCTION: Although abdominoperineal resection (APR) is required for rectal cancer invading the levator ani muscle, its curative outcomes remain poorer than those of other rectal surgeries.1-3 In particular, the anatomic complexity around the anterior wall of the rectum increases the technical difficulty during APR, resulting in a high frequency of margin involvement that causes local recurrence. In this video, we present the technical details of a robotic perineal-first APR approach. METHODS: For a 46 year-old man, locally advanced rectal cancer invading the levator ani muscles was diagnosed. Although total neoadjuvant therapy (8 cycles of induction FOLFOXIRI followed by chemoradiotherapy 50.4 Gy) decreased the tumor size, invasion was suspected still to remain. Therefore, robotic APR was performed. Written informed consent was obtained from the patient. For the perineal-first approach, we created a circular incision around the anus, then divided the fat tissues of the ischiorectal fossa until the levator ani muscle was exposed on both sides. Posterior and anterior dissections were performed along the coccyx and external anal sphincter, respectively. After placement of a lap protector to maintain air-tightness, the robotic approach was initiated. Posterior dissection was performed along the coccyx, then was connected to the already-dissected space created earlier by the perineal approach. Next, the levator ani muscle was divided from the dorsal to the lateral side. Finally, anterior dissection was performed along the prostate, followed by division of the rectourethral muscle, the smooth muscle fibers running vertically. The creation of the already-dissected space on the perineal side offers advantages of robotic manipulation from the abdominal side, especially anterior dissection. RESULTS: We performed robotic APR using the perineal-first approach for 17 consecutive patients (12 men and 5 women) between 2019 and 2023. All 17 patients achieved complete total mesorectal excision with negative margins. The mean time required for the perineal approach was about 25 min. In anterior dissection using the robotic approach, division of the smooth muscle fibers at the perineal body (i.e., rectourethral muscle in males4 or muscular intermingling in females5) was reproducibly performed in both males and females. CONCLUSION: Robotic APR with a perineal-first approach can be advantageous in ensuring surgical margin safety (especially for the anterior aspect of the rectum).

A gallstone in the Roux-en Y limb during pregnancy in a female patient with biliary atresia.

A 28-year-old female developed liver dysfunction at the 13th gestation week of her second pregnancy. A postpartum radiological examination revealed a stone in the Roux-en Y (RY) limb. She underwent surgical removal of the gallstone in the RY limb. Bile congestion during pregnancy led to the development of a gallstone.

Pancreatic head resection preserving the main pancreatic duct for congenital hyperinsulinism of infancy.

Surgical intervention for congenital hyperinsulinism with an unclear focal lesion in the pancreatic head sometimes require the resection of most of the pancreas head and pancreaticojejunotomy. This report presents the case of a patient that underwent pancreatic head resection preserving the main pancreatic duct to avoid pancreaticojejunostomy.

Yolk sac tumor of the vulva: a case report with recurrence after long-term follow-up.

A yolk sac tumor (YST) of the vulva is extremely rare and highly malignant with recurrence frequently occurring within a year. This report presents the 13th known case of vulvar YST, with recurrence occurring after the longest known follow-up period so far reported in the literature.

A modified Foker's technique for long gap esophageal atresia.

External traction using the Foker's technique enables elongation in the esophageal segments within days, and allows the primary repair of the long gap. This article presents our modified Foker's technique which was easily applicable for long-gap esophageal atresia.

Acute perforating appendicitis caused by metastatic squamous cell carcinoma from the lung: A case report.

INTRODUCTION: Lung cancer is one of the most common cancers. On the other hand, lung cancer metastasis to the appendix is extremely rare, and in many cases it has been diagnosed with the onset of acute perforating appendicitis. PRESENTATION OF CASE: An 85-year-old man with fever and abdominal pain visited our hospital. He had a history of squamous cell carcinoma of the left upper and lower lobes, metastasis to the ipsilateral lung and femur. CT showed that a finding of acute perforating appendicitis, emergency cecal resection was performed. Examination of the resected specimen showed that the appendix was thickened overall, with a white nodular structure at the root and a perforation in the middle. The final diagnosis was acute perforating appendicitis caused by metastatic squamous cell carcinoma from the lung. The patient had no particular problems during the postoperative course. DISCUSSION: A PubMed search was performed, this appears to be the first reported case of appendiceal metastasis of squamous cell carcinoma of the lung. Since squamous cell carcinoma of the lung has a stronger tendency for local extension than other histological types, perforating appendicitis due to distant metastasis to the abdominal organs and metastasis to the appendix was reported as a very valuable case. CONCLUSION: Because the progression of concomitant or secondary appendicitis is rapid, we recommend frequent imaging modalities, prophylactic appendectomy be considered for patients who also have lung cancer and imaging findings show suspected metastasis to the appendix.

Arthralgia and osteolytic lesions associated with traumatic pancreatitis in a 10-year-old girl.

A case of traumatic pancreatitis with subsequent joint pain and osteolytic lesions is presented. A 10-year-old girl was admitted to our hospital with abdominal pain caused by blunt epigastric injury. She was diagnosed with traumatic pancreatitis, and multiple pancreatic pseudocysts subsequently developed. Two weeks after admission, she complained of joint pain, and MR revealed osteolytic lesions of both knee joints. On the 58th day, endoscopic transgastric pseudocyst drainage was performed. Joint pain and osteolytic lesions resolved rapidly, in parallel with the decrease in serum amylase level and pseudocyst size.

Congenital intrathoracic kidney with right Bochdalek defect.

Intrathoracic kidney is a rare congenital anomaly. Since most reported cases are asymptomatic, it is extremely rare for this ectopia to be diagnosed in the neonatal period. We report a male infant with right intrathoracic kidney associated with Bochdalek defect. Chest X-ray demonstrated a right posterior mediastinal mass and intestinal gas in the right lung field. Contrast-enhanced CT and intravenous urography led to a diagnosis of intrathoracic kidney. Due to the presence of Bochdalek defect, the intrathoracic kidney was reduced into the abdominal cavity at the time of diaphragmatic repair. The intrathoracic kidney with attached adrenal gland was located at the level of the carina and was covered with protruded retroperitoneum. The kidney was thought to have been pushed this high by the small intestine and left lobe of the liver, which had also herniated through the defect. Postoperative hemodynamics and renal function were normal.