We present the case of a 70-year-old male with a presacral tumor known to be recurrent prostate cancer with an operative plan of a low anterior resection versus abdominoperineal resection. Intraoperatively, the presacral tumor was adherent to both the sacrum and rectum. Careful dissection of the tumor off of the sacrum allowed for full mobilization of the colon and rectum, which in turn allowed for a stapled coloanal anastomosis with preservation of the sphincter complex and restoration of function.
Keyword: Robotic surgery
Robotic-Assisted Low Anterior Resection of a Rectal Tumor with Concern for Invasion of the Seminal Vesicles
We present a case of a 60-year-old male with low-lying rectal cancer initially staged as a T4b tumor with concern for seminal vesicle invasion. A multidisciplinary decision was made to proceed with a jejunal-sparing operation, resecting only the seminal vesicles to preserve urinary continence. The anatomy of the Denonvilliers’ fascia remains controversial, with important implications for the surgical management of rectal cancers affecting adjacent urogenital structures. The anterior and posterior layers of the Denonvilliers’ fascia were successfully dissected, preserving the seminal vesicles and prostate. Pathology confirmed a mucinous adenocarcinoma with negative margins, and the patient is scheduled for ileostomy reversal. This case highlights how meticulous robotic-assisted dissection of the Denonvilliers’ fascia can avoid the need for urostomy and colostomy, preserving urinary function and demonstrating the potential benefits of improved anatomical understanding in pelvic surgery.
ROBOTIC LEFT HEMICOLECTOMY FOR AN ERODING BLADDER DIVERTICULUM OF THE SIGMA
We present the case of a 60-year-old male patient with a history of recurrent acute sigmoid diverticulitis episodes. Comorbidities were limited to suspected obstructive sleep apnea (OSAS). The patient did not exhibit pneumaturia, fecaluria, or recurrent urinary tract infections. Colonoscopy revealed sigmoid diverticulosis, while contrast-enhanced abdominal CT demonstrated a large sigmoid diverticulum adhered to the posterior bladder wall, suggestive of a pre-fistulous state.
Given the clinical presentation, we opted for surgical intervention, performing a robot-assisted hemicolectomy using the Da Vinci system. The surgery involved ligation of the inferior mesenteric artery and vein, followed by the mobilization of the left colon up to the splenic flexure. Subsequent meticulous dissection was carried out to separate the sigmoid colon from the bladder, to which it was tenaciously adhered. This revealed a diverticulum that had eroded the bladder wall down to the muscular layer. We resected the diverticulum from the sigmoid colon, leaving a portion adhered to the bladder wall.
The rectum was resected up to the peritoneal reflection using a linear stapler. To remove the remaining diverticulum fragment adhered to the bladder wall, the bladder was filled with a solution of physiological saline and methylene blue, facilitating safer dissection and visualization of potential suture lines. The fragment was cautiously dissected from the bladder wall, with no evidence of fistulas. The bladder wall was subsequently reinforced with a continuous suture using Stratafix PDS 2/0.
Following the removal of the surgical specimen, a termino-terminal colorectal anastomosis was created using a circular stapler. Postoperatively, the patient experienced an uneventful recovery, maintaining a urinary catheter until the 5th postoperative day with no signs of hematuria or fecaluria. Following catheter removal, diuresis was normal and spontaneous.
This case highlights the successful management of a complicated sigmoid diverticulum with robotic-assisted surgery, emphasizing the importance of meticulous dissection and bladder wall reinforcement in such cases.
Robot-Assisted One Anastomosis Gastric Bypass: 10 Steps Standardized Technique
Step into the world of advanced surgical procedures with our comprehensive video on Robot-Assisted One Anastomosis Gastric Bypass. This meticulously edited video guides you through each of the 10 standardized steps employed in our high-volume surgical unit, showcasing a state-of-the-art approach to gastric bypass surgery. The steps are:
Treitz Ligament Identification;
Biliary Loop Measurement;
His angle dissection;
Lesser Sac Opening;
Gastric Pouch Creation;
Gastrojejunostomy;
Gastrojejunostomy Fixation;
Methylene Blue Test;
Alimentary Loop Fixation;
Petersen Defect Closure.
This video provides an invaluable resource for surgeons, medical professionals, and enthusiasts interested in the intricacies of Robot-Assisted One Anastomosis Gastric Bypass. Our standardized technique aims to contribute to the advancement of knowledge and skills in the field of bariatric surgery. Embrace innovation and precision in every step of this transformative surgical journey.
Total Laparoscopic Hysterectomy and Bilateral Salpingectomy with Broad Ligament and Cervical Fibroids: Techniques
A 50 year old gravida 2 para 1011 with a history of abnormal uterine bleeding and dysmenorrhea secondary to uterine fibroids (including cervical and broad ligament fibroids) underwent a robotic-assisted total laparoscopic Hysterectomy, bilateral salpingectomy, cystoscopy, with insertion and removal of bilateral ureteral stents.
20 cc of Vasopressin was diluted in 60 cc of normal saline and injected into the uterus. The left round ligament was cauterized and the retroperitoneum was accessed. The left ureter was found to be anteriorly displaced to the level of the external iliac artery due to a broad ligament fibroid. The right round ligament was similarly cauterized and cut. The uterovesical peritoneum was dissected and the bladder flap was created. The ascending branches of the uterine arteries were coagulated and cut. Due to a 5 cm cervical fibroid, a supracervical hysterectomy was initially performed. Next, a cervical myoma enucleation was performed followed by a trachelectomy. Additional excess fibroid tissue was removed. A small Alexis retractor and Endocatch bag was inserted vaginally and the specimens were collected and removed. Pelvis was copious irrigated and suctioned with normal saline. The vaginal cuff was closed in two layers with multiple figure of eight sutures using 2-0 PDS.