Management of Complicated Ostomy Dehiscence: A Case Study.

BACKGROUND: Stoma creation is a common procedure in colorectal surgery. Despite improved surgical techniques, ostomy-related wound complications may prolong the recovery period and impair health-related quality of life. Negative pressure wound therapy (NPWT), autolytic debridement agents, and silver dressings are often used for managing complex wound infection and dehiscence. These applications have the potential to increase patient comfort and accelerate recovery. CASE: We report our experience in a 66 year old female who had a wound dehiscence involving the ostomy after robotic abdominoperineal resection. Her medical history was significant for a rectovaginal fistula which occurred after a low anterior resection for rectal cancer 5 years ago. Interventions for treatment of the dehiscence were use of NPWT, autolytic debriding agent, and silver dressing. CONCLUSION: Combined use of these interventions for dehiscence of an ostomy can minimize patient discomfort and accelerate wound healing.

Robotic complete mesocolic excision for right-sided colon cancer.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Comparison of Postoperative Outcomes and Long-Term Survival Rates between Patients Who Underwent Robotic and Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer.

Introduction: Right colon cancer often requires surgical intervention, and complete mesocolic excision (CME) has emerged as a standard procedure. The study aims to evaluate and compare the safety and efficacy of robotic and laparoscopic CME for patients with right colon cancer and 5-year survival rates examined to determine the outcomes. Materials and Methods: Patients who underwent CME for right-sided colon cancer between 2014 and 2021 were included in this study. Group differences of age, body mass index, operation time, bleeding amount, total harvested lymph nodes, and postoperative stay were analyzed by the Mann-Whitney U test. Group differences of sex, American Society of Anesthesiology, and tumor, node, and metastasis stage were analyzed by the Chi-squared test. Disease-free and overall survival were assessed using Kaplan-Meier curves with the log-rank Mantel-Cox test. Results: From 109 patients, 74 of them were 1:1 propensity score matched and used for analysis. Total harvested lymph node (P ≤ .001) and estimated blood loss (P = .031) were found to be statistically significant between the groups. We found no statistically significant difference between the groups in terms of disease-free and overall survival (P = .27, .86, respectively), and the mortality rate was 9.17%, with no deaths directly attributed to the surgery. Conclusions: Study shows that minimally invasive surgery is a feasible option for CME in right colon cancers, with acceptable overall survival rates. Although the robotic approach has a higher lymph node yield, there was no significant difference in survival rates. Further randomized trials are needed to determine the clinical significance of both approaches.

Robotic sphincter saving rectal cancer surgery: A learning curve analysis.

BACKGROUND: Longer operation time is one of the major obstacles in front of the proposed benefits of robotic rectal surgery. We intended to evaluate the learning process for robotic surgery in sphincter saving rectal cancer surgery. METHODS: The learning curve was evaluated using the cumulative sum (CUSUM) method. The variable evaluated for learning curve calculation was the operative time. RESULTS: The learning curve was divided into two phases: initial 52 operations comprised phase 1 and the following 44 operations represented phase 2. Interphase comparisons showed that phase 2 patients had shorter operation times (323.3 ± 102.8 vs. 379.9 ± 108.7 min, p = 0.011), less blood loss (37.2 ± 51.0 vs. 87.7 ± 124.8 mL, p = 0.009), longer distal resection margins (4.5 ± 4.3 vs. 2.5 ± 1.7 cm, p = 0.008), and higher rates of grade 3 mesorectal completeness (p = 0.001). CONCLUSION: In this study, we saw that the cut-off level in the learning curve of a laparoscopically experienced surgeon could be beyond the numbers reported in the literature.

Short-term Results After Totally Robotic Restorative Total Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

In this study, we aimed to present our initial experience on totally robotic total restorative proctocolectomy in ulcerative colitis (UC) patients. Patients undergoing a totally robotic restorative total proctocolectomy with ileal J-pouch anal anastomosis for UC between January 2015 and November 2017 were included. The da Vinci Xi was used for the operations. Patient demographics, perioperative and short-term operative outcomes were evaluated. Ten patients were included. The median operative time was 380 minutes(range, 300 to 480 min). The median blood loss was 65 mL (range, 5 to 400 mL). No conversion to open surgery was needed. The median time to flatus was 1 day (range, 1 to 2) and length of stay was 6 (4 to 12) days. Short-term complications (≤30 d) were superficial wound infection (n=3), anal bleeding (n=1), pouchitis (n=1). No mortality was observed during the study period. Our study, which is the largest series so far, reveals that totally robotic restorative proctocolectomy is a safe and feasible option for the surgical treatment of UC.

Learning curve analysis of robotic transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: The purpose of this study was to assess the learning curve (LC) for inguinal hernia repair with robotic transabdominal preperitoneal (R-TAPP) approach. METHODS: Between April 2016 and October 2019, patients who underwent R-TAPP were retrieved. Patient demographics, operative variables and postoperative outcomes were assessed. The moving average method and cumulative sum of operation times (OT) were used to evaluate the LC. The surgeon (BB) in this study had completed his laparoscopic (Lap) TAPP experience. RESULTS: There were 50 (two females) consecutive patients (mean age was 51.7 ± 16.9 years). The first phase (learning phase) included initial 35 operations. The second phase included the next 15 operations. It was observed that, with increasing experience, a statistically significant shortening in the average OT by about 25 min was achieved (p = 0.041). CONCLUSION: The LC phase for R-TAPP, for surgeon with previous experience in Lap TAPP, seems to be very quick without compromising the operative morbidity.

Laparoscopic totally extraperitoneal vs robotic transabdominal preperitoneal inguinal hernia repair: Assessment of short- and long-term outcomes.

BACKGROUND: In this study, we aimed to compare short- and long-term outcomes between laparoscopic totally extraperitoneal (L-TEP) and robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair. METHODS: Patients were classified into two groups: L-TEP and R-TAPP. The groups were case-matched in a 1:1 ratio based on age, gender, and body mass index (BMI). RESULTS: Out of 86 patients, 43 patients were matched in each group based on the study criteria. Demographics were comparable between the groups. Operative time was significantly longer for the R-TAPP compared to L-TEP (129.1 ± 47.2 min vs 92.5 ± 28.3 min; P < .001). VAS scores at 24 hours after surgery were significantly higher in the L-TEP compared to R-TAPP (36.8 ± 20.1 vs 20.3 ± 18.7; P < .001). Total hospital costs were 4778$ for R-TAPP and 3852$ for L-TEP. CONCLUSION: The current study demonstrates similar long-term postoperative outcomes and recurrence rates between robotic and laparoscopic inguinal hernia repair in a case-matched fashion.

Totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma.

BACKGROUND: Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma. METHODS: Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes. RESULTS: Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047). CONCLUSION: Totally robotic technique with the da Vinci Xi® robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.

Operative and long-term oncological outcomes in patients undergoing robotic versus laparoscopic surgery for rectal cancer.

BACKGROUND: This study aimed to compare short- and long-term outcomes after robotic versus laparoscopic approach in patients undergoing curative surgery for rectal cancer. METHODS: Patients undergoing elective robotic and laparoscopic resection for rectal cancer were included. Perioperative clinical characteristics, postoperative short- and long-term outcomes were compared between groups. RESULTS: There were 72 and 44 patients in robotic (RG) and laparoscopic (LG) groups respectively. No differences were detected regarding patients' demographics, histopathologic outcomes, conversion rates and 30-day overall postoperative complication rates. Operative time was longer in the RG (341 ± 111.7 vs. 263 ± 97.5 min, p = 0.001) and length of stay was longer in the LG (4.4 ± 1.9 vs. 6.4 ± 2.9 days, p = 0.001). The 5-year overall and disease-free survival rates were similar (97.1% and 94.9%, p = 0.78; 86.2% and 82.7%, p = 0.72) between the groups. CONCLUSION: This study showed both short and long-term outcomes of a limited number of included patients between the robotic and laparoscopic surgery were similar. However, future studies and randomized trials are necessary to establish these findings.

Adoption of robotic technology in Turkey: A nationwide analysis on caseload and platform used.

BACKGROUND: Limited data exist regarding adoption of evolving robotic technology in surgery. This study evaluated trends and the current condition of robotic platforms in surgical specialties and general surgical subspecialties. METHODS: Between January 2013 and December 2017, all robotic operations performed in Turkey were included. RESULTS: In the study period, 13 760 robotic operations were performed at 32 hospitals. The median numbers of general surgical procedures were 43and eight cases per hospital and per general surgeon, respectively. The high-volume general surgeons performed 1734 (81%) of the cases. Forty-five percent and 55% of the general surgical operations were performed with the Xi and S/Si robots, respectively. CONCLUSION: Use of the Xi platform seems to increase caseload in general surgery operations possibly by facilitating robotic colorectal surgery. Targeting the high-volume centres and surgeons for further training and implantation of upcoming robotic technology can be more effective in terms of increasing case volume and improving outcomes.

En-Bloc Excision of the High-ligated Inferior Mesenteric Vein Pedicle With the Specimen in Patients Undergoing Minimally Invasive and Open Sphincter Saving Rectal Resections for Cancer.

Although high-ligated pedicle of the inferior mesenteric artery is usually kept in the resected specimens, the value of preserving high-ligated pedicle of the inferior mesenteric vein within the resected specimens of the sphincter saving rectal resections for cancer is not well defined. In the current study, patients undergoing open, laparoscopic, and robotic sphincter saving rectal resection for cancer were prospectively included. Lymph node invasion and presence of lymph nodes along the IMV pedicles were analyzed. In total 100 patients were included. There were lymph nodes in 63 patients at the IMV and 71 patients at the IMA pedicles. En-bloc removal of the high-ligated IMV pedicle with the resected specimen significantly increased the number of harvested lymph nodes(P<0.001) regardless of surgical modality (P=0.36). Although it increases the number of harvested lymph nodes with acceptable operative morbidity, no oncological benefits were found related to preservation of high-ligated pedicle of the inferior mesenteric vein within the resected specimen of the rectum.

Effects of prior abdominal surgery on laparoscopic cholecystectomy.

OBJECTIVES: With increased experience and technological advancement, laparoscopic cholecystectomy is reported to be safe and feasible even in the presence of most of the previously recognized contraindications. The purpose of this study was to explore the effects of prior upper and lower abdominal surgery on laparoscopic cholecystectomy. MATERIAL AND METHODS: A retrospective evaluation of all sequential patients who underwent laparoscopic cholecystectomy from January 2014 to June 2016 was conducted. Patients were divided into three groups (Group A: patients without any prior abdominal surgical procedures; Group B: patients with prior upper abdominal surgical procedures; and Group C: patients with prior lower abdominal surgical procedures). RESULTS: A total of 329 patients were assessed. Group A consisted of 223, Group B of 18, and Group C of 88 patients. A statistically significantly higher operative time, postoperative pain, and complication rate after laparoscopic cholecystectomy were noted in patients with prior upper abdominal surgery. The groups were comparable regarding patients' demographics and surgery indications. The length of hospital stay was not statistically different between the groups (p=0.065). CONCLUSION: According to the results of the current study, prior upper abdominal surgery leads to a significantly longer procedure time, higher postoperative pain, and complication rates after laparoscopic cholecystectomy. However, the length of hospital stay was not affected by the parameters investigated.

Portal vein ligation and in situ liver splitting in metastatic liver cancer.

The most serious complication after major liver resection is liver failure. Depending on preoperative liver function, a future liver remnant of 25%-40% is considered sufficient to avoid postoperative liver failure. A new technique known as portal vein ligation combined with in situ splitting has been developed to obtain rapid liver hypertrophy. Herein, we present a case where we performed portal vein ligation combined with in situ splitting. A 37-year-old male patient with a diagnosis of sigmoid adenocarcinoma and liver metastasis underwent anterior resection because of an obstructing sigmoid tumor and received palliative chemotherapy. After chemotherapy, abdominal computed tomography revealed a lesion, 50 mm in diameter, localized between segments 5-8 of the liver on the bifurcation of the anteroposterior segmental branch of the right portal vein. Computed tomography volumetric assessments of the liver were performed in the preoperative period, and it was found that the remnant left liver volume was less than 25%. In the first stage, portal vein ligation and in situ splitting of the liver parenchyma were performed. On the second and sixth postoperative days, computed tomography revealed hypertrophy of the left liver lobe. On the sixth day, a right hepatectomy was performed. Portal vein ligation combined with in situ splitting has been used by surgeons worldwide to obtain rapid and adequate liver hypertrophy. This new approach yields hope for patients with locally advanced liver tumors and may increase the number of curative resections for primary or metastatic liver tumors.

Surgery for Intestinal Crohn's Disease: Results of a multidisciplinary approach.

OBJECTIVES: Crohn's disease is a chronic inflammatory bowel disease that requires lifelong multidisciplinary management. Seventy percent of patients affected by Crohn's disease will require at least one surgical procedure over their lifetime. The aim of this retrospective study was to present our series of patients suffering from Crohn's disease who were scheduled for surgery by a multidisciplinary team. MATERIAL AND METHODS: The data were retrieved from a review of 950 patients with Crohn's disease treated at our institution between March 2000 and March 2016. Only patients with intestinal Crohn's disease were included into the study. A multidisciplinary team assessed the decision to perform surgery. RESULTS: There were 203 patients who underwent surgery included in this study. One hundred and sixty-six were intestinal and 37 were perianal Crohn's disease. The mean age was 36±11.5 (range, 12-75) years. Ninety-two were stricturing, 45 were fistulizing, and 12 were inflammatory. The most commonly affected site was the ileocecal region (n=109, 65.7%), and the most common surgical procedure was the ileocecal resection (n=109, 65.6%). Laparoscopic approach was the procedure of choice in 56 (33.7%) patients. Of the patients enrolled, the most common early (<30 days) complications observed were the wound infection as the first (n=11) and anastomotic leak as the second (n=10). The mortality rate was 2.4% (n=4). CONCLUSION: Multidisciplinary approach to Crohn's disease may decrease the surgical complications and recurrence rates leading to a better treatment.

Predictive parameters of early postoperative complications in Crohn's disease: Single team experience.

BACKGROUND/AIMS: Most of the patients with Crohn's disease (CD) may require at least one surgical procedure over their lifetime. However, these patients tend to have a high incidence of postoperative complications. The aim of this retrospective study was to investigate the predictive parameters of postoperative complications in CD. MATERIALS AND METHODS: All consecutive patients with CD between March 2001 and March 2016 who underwent bowel resection were included to this study. Postoperative complications were divided as; major complications including anastomotic leakage, ostomy complications, acute mechanical intestinal obstruction and hemorrhage, and minor complications including wound infection. RESULTS: A total of 147 patients (74 females, 73 males) with a mean age of 36±11.9 years met the inclusion criteria. Behaviors of CD were stricturing in 90 (62%), fistulizing in 45 (30%) and inflammatory in 12 (8%) patients. Minimally invasive approach was applied in 35% (n=51) of the patients. Twentysix (17%) patients had early (≤30 days) postoperative surgical complications including anastomotic leak (n=10), intra-abdominal bleeding (n=2), complications related to ostomy (n=2), acute mechanical intestinal obstruction (n=1) and wound infection (n=11). Only fistulizing disease behavior was associated with early postoperative complications (p=0.014). CONCLUSION: This study suggests that postoperative complications are still more common in fistulizing CD. Surgical approach did not affect the complication rate. The decision should be individualized according to the prominent risk factors and surgeons' preference.