Robotic Abdominoperineal Resection with en Bloc Prostatectomy

Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5 Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5. Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.

Robotic-Assisted Right Middle Lobectomy of Central Lung Tumor

Contributors: Inderpal S Sarkaria This is a video of a 61 year old female with a history of smoking, TIA, and DVT undergoing robotic-assisted right middle lobectomy for a central and FNA-proven lung adenocarcinoma. DOI: http://dx.doi.org/10.17797/235p3c90cc

Robotic Inferior Mesenteric Artery, Common Iliac Artery, and Retroperitoneal Lymph Node Dissection

David Schwartzberg MD, Tushar Samdani MD, FASCRS, Mario M. Leitao MD, FACOG, FACS, Garrett M. Nash MD, MPH, FACS, FASCRS Recent data has shown an improved survival with metastasectomy for metastatic rectal cancer. Metastasectomy on a minimally invasive plateform (robotic) can be used for an R0 resection in patients who have retroperitoneal metastasis from rectal cancer after control of the primary tumor. DOI # http://dx.doi.org/10.17797/wd7d09sjgc

Robotic Assisted Right Hemicolectomy with Intracorporeal Anastomosis

Contributors: Nell Maloney Patel We present a case of a seventy-two year old female found on colonoscopy to have multiple polyps and an ascending colon mass that was biopsy proven adenocarcinoma who underwent a robotic assisted right hemicolectomy with intracorporeal anastomosis. DOI# http://dx.doi.org/10.17797/54hba94993 Editor Recruited by: Vincent Obias

Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3 Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior. Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children's Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management. Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy. First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue. She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children's Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy (LA) was first described by Gagner et al. in the early 1990s, and has since become the gold standard for removal of small and medium sized adrenal tumors. Most commonly, LA is performed for unilateral benign adrenal lesions, however the minimally invasive technique is also routinely used for bilateral disease, as well as myelolipomas, adrenal cysts, adrenal hemorrhage and androgen-secreting tumors.  Compared with the open approach, LA offers shorter hospital stay, improved patient satisfaction, decrease post-operative pain and markedly improved cosmesis.  Even more, the difficulty in obtaining adequate open surgical exposure, combined with the diminutive size of the adrenal gland make laparoscopy an especially attractive option. Given this, we decided to proceed with LA approach for our patient who presented with NSCLC metastasis to his right adrenal. DOI# http://dx.doi.org/10.17797/4ek02iupxd Mellon MJ, Sethi A, Sundaram CP. Laparoscopic adrenalectomy: Surgical techniques. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2008;24(4):583-589. doi:10.4103/0970-1591.44277. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.

da Vinci Total Abdominal Colectomy for Ulcerative Colitis

Contributors: Craig Rezac, MD This video demonstrates the basic steps of a Robotic-Assisted Total Abdominal Colectomy for Ulcerative Colitis using the da Vinci Xi Robotic System. DOI: http://dx.doi.org/10.17797/zr41dcfdmt

da Vinci Robot Assisted Right Hemicolectomy with Intracorporeal Anastamosis

Contributors: Jimmy Lin and Craig Rezac This procedure is a da Vinci Robot assisted Right hemicolectomy with intracorporeal anastomosis performed on a 52 year-old male who was found to have a cecal adenocarcinoma on screening colonoscopy. Metastatic work-up was negative. DOI:http://dx.doi.org/10.17797/gb6xh7cx7u Editor Recruited by: Vincent Obias

da Vinci Robot Assisted Low Anterior Resection with Diverting Loop Ileostomy

Contributors: Jimmy Lin and Craig Rezac This procedure is a da Vinci Xi Robot assisted low anterior resection with diverting loop ileostomy performed on a 64 year old male patient who on work-up of hematochezia and change in bowel habits was found to have a locally advanced rectal adenocarcinoma approximately 5-6cm from the anal verge. The patient was found to have a single subcentimeter metastatic liver lesion, which was treated with radiofrequency ablation. He was treated with neoadjuvant chemoradiation prior to undergoing surgery. DOI: http://dx.doi.org/10.17797/vk8yonl7gj Editor Recruited By: Vincent Obias, MD, MS

da Vinci Assisted Take Down of a Rectovaginal Fistula Through a Posterior Vaginectomy

A rectovaginal fistula (RVF) is an epithelial lined tract between the rectum and vagina. This can result in recurrent urinary tract or vaginal infections, but also creates a significant psychosocial burden for the patient. Unfortunately, due to the individual complexities of these patients, they are difficult to manage despite the numerous surgical options presently described.1 Generally RVFs are classified as low, middle or high, due to the location of the rectal and vaginal opening. Due to this, both low and middle RVFs may be approached via anal, perineal or vaginal routes. Where as high RVFs, which have their vaginal opening near the cervix, generally require an abdominal approach for repair.2 Traditionally for high RVFs patients underwent open surgery; however, minimally invasive surgery has recently been widely accepted as the preferred approach. Although surgeons are becoming more facile with these approaches, both pelvic surgery and a reoperative abdomen still impose significant technical difficulties.3,4 Here, we present the video of a female with a complex surgical history including a hysterectomy, bilateral salpingo-oopherectomy, creation and reversal of a Hartmann’s colostomy as well as a loop ileostomy due to a locally advanced recto-sigmoid cancer, who subsequently developed a rectovaginal fistula and was managed minimally invasively with a multidisciplinary novel approach through a posterior vaginectomy; an approach that utilized the enhanced magnification of the Robot, which improved visualization and allowed access into an uninflamed, virgin plane, resulting in minimal loss of vaginal length. Contributors: Milind D. Kachare, M.D. Osvaldo Zumba, M.D. Lorna Rodriguez-Rodriguez, M.D., Ph.D. Nell Maloney-Patel, M.D. Rutgers Robert Wood Johnson Medical School, Hackensack University Medical Center, City of Hope National Medical Center

da Vinci Assisted Low Anterior Resection and Colovesical Fistula Repair

Contributors: Jimmy Lin and Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions and faster recovery time, to better accuracy, flexibility and control.  Many procedures which had previously been conducted with laparoscopy, or open surgery, are becoming further improved upon in robotic surgery. This video demonstrates two such procedures, from different specialities, being performed; the low anterior resection and colovesical fistula repair. DOI#: http://dx.doi.org/10.17797/f1frvag53q

da Vinci Assisted Extended Right Hemicolectomy and End Ileostomy

Contributors: Jimmy Lin and  Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions and faster recovery time, to better accuracy, flexibility and control.  Many procedures which have previously been conducted with laparoscopy, or open surgery, are becoming further improved in robotic surgery. This video demonstrates once such procedure, the extended right hemicolectomy. DOI# http://dx.doi.org/10.17797/rv3nkbech0 Authors Recruited By: Vincent Obias. MD. MS

Transoral Robotic Assisted Radical Tonsillectomy

Contributors: Jeffery Scott Magnuson (University of Central Florida) 1) Purpose: The patient had a history of biopsy proven squamous cell carcinoma of the right palatine tonsil and elected for surgical resection as a primary treatment. 2) Instruments: The DaVinci surgical robot was used with the Maryland dissector and a monopolar cautery on the arms. The FK retractor was used to suspend the patient and gain exposure. 3) Landmarks: The right palatine tonsil is resected along with a cuff of pharyngeal musculature. 4) Procedure: In sequence, the initial incision on the anterior tonsillar pillar, the exposure of the parapharyngeal space, the removal of the specimen, and the final defect are shown. 5) Conflicts of interest: for JSM: Intuitive Surgical: Instructor/Proctor, Honoraria; Lumenis: Consultant, Honoraria; Medrobotics: Member Strategic Advisory Panel, Honoraria. 6) References: Chung, T. K., Rosenthal, E. L., Magnuson, J. S. and Carroll, W. R. (2014), Transoral robotic surgery for oropharyngeal and tongue cancer in the United States. The Laryngoscope. http://dx.doi.org/10.1002/lary.24870 DOI: http://dx.doi.org/10.17797/kjwgjsgxwk

Robotic Rectal Dissection; Total Mesorectal Excision (TME)

Robotic rectal dissection begins posteriorly in total mesorectal excision plane (TME) using 30° down-viewing scope. Posterior dissection in a TME plane provides a relatively bloodless plane of dissection and creates an anatomical reference point from which lateral and anterior dissection can proceed. With an assistant retracting the rectum anteriorly and cephalad, the robotic single fenestrated grasper retracts the posterior aspect of the mesorectum anteriorly and slightly caudally. When performed correctly the surgeon can visualize a “cotton candy”-like areolar tissue between the fascia propria of the rectum and presacral fascia. The hook cautery is used to divide the tissue in a U-shaped fashion. The dissection is taken to the level of Waldeyer’s fascia. Lateral Dissection and Division of Lateral Stalks The lateral dissection proceeds initially on the right side where the surgeon has a safer plane of dissection (away from left ureter). A monopolar hook moves from posterior to anterior at a deliberate pace while applying current. If the right and posterior dissection was performed correctly, the only structures that need to be divided on the left side are a layer of peritoneum and a small amount of remaining lateral stalks. The left lateral side is dissected by dividing the peritoneum over the left pararectal sulcus. The left ureter must be visualized during this step. It is important to control all vessels, even the ones that appear to be only mildly oozing. Failure to do so may result in the field becoming bloody and dark. In this video, a vessel, encounterd within the left stalk is coagulated using a bipolar grasper while retracting the mesorectum with the hook. After the vessel is sealed it is divided with hook cautery. Anterior Dissection As the dissection advances inferiorly, the right and left lateral peritoneal incisions that are created during lateral dissection at this point are connected in front of the rectum. At this stage in operation, with the switch to a 0° scope and change of the retraction of the rectum from anterior and cephalad to posterior and cephalad, the rectum is pulled straight out of the pelvis. Because the posterior dissection has now released the mesorectum, the rectum can be easily stretched placing under tension the anterior plane of dissection. Circumferential Dissection of the Rectum If the rectal cancer is distal within the rectum, the mobilization proceeds to the level of pelvic floor and occasionally performing some dissection within the levator muscle complex. As the surgeon advances towards the pelvic floor, the dissection alternates between the posterior, lateral and interior planes as the tissue tension changes based on dissection performed. One of the signs that the dissection is at the level of pelvic floor is observation of levator ani skeletal muscle fibers that contract upon contact with electrocautery and the tapering of the mesorectum. As it narrows at the level of pelvic floor, the rectum can be carefully grasped with a robotic grasper and retracted to obtain the necessary tension to provide dissection. Editor Recruited By: Jeffrey B. Matthews, MD DOI: http://dx.doi.org/10.17797/4bvv6oyrym

Robotic Pelvic Lymph Node Dissection

Contributors: Kristina Butler, MD and Javier Magrina, MD Pelvic lymphadenectomy is part of most gynecologic malignancy staging procedures. Knowledge of the retroperitoneal anatomy is key to safely completing this procedure. DOI: http://dx.doi.org/10.17797/5xzrp8fuk3 Editor Recruited By: Dennis S. Chi, MD, FACOG, FACS

Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Contributors: Sricharan Chalikonda and R. Matthew Walsh Two separate general approaches are described to perform minimally invasive pancreaticoduodenectomy (PD): pure laparoscopic and robotic. The technique shown is a hybrid utilizing laparoscopy for the resection and surgical robot for the reconstruction. We feel that this technique combines the advantages of both laparoscopic and robotic surgery.

Robotic Sigmoid Resection and Intracorporeal Anastomosis

This is a 60 yo woman with diverticulitis not responsive to medical management. Open, laparoscopic, and robotic operative options were discussed. We agreed on robotic sigmoid resection in the Enhanced Recovery Pathway. This video demonstrates an intracorporeal colorectal anastomosis between the descending colon and upper rectum. Sigmoid colectomies are typically characterized by by specimen extraction through an open incision after minimally invasive mobilization of the colon and mesentery, placement of an anvil into the descending colon through this open incision, and then laparoscopic or robotic colorectal anastomosis with a circular stapler after re-establishing pneumoperitoneum. This intracorporeal anastomosis does not require stretching colon and mesentery to an open extraction site with the possible need for extending the open incision. There is less visceral manipulation and potentially less ileus and quicker return to gastrointestinal activity. The extraction site can be anywhere the surgeon chooses and the extraction incision size is limited only by the sixe of the pathology. DOI # http://dx.doi.org/10.17797/p11gskfc90 Recruited By: Vincent Obias

Robotic Retroperitoneoscopic Partial Nephrectomy: 4-Arm Technique

In this video, we demonstrate the set-up, port configuration, and key steps involved in performing a robotic-assisted retroperitoneoscopic partial nephrectomy. DOI#: https://doi.org/10.17797/di559dgayo

Robotic Assisted Small Bowel Resection for Meckel's Diverticulum

We present a case of a 21-year-old male with a one-day history of right lower quadrant pain and CT scan findings suspicious for a perforated Meckel’s Diverticulum who underwent a robotic assisted small bowel resection with an intracorporeal anastomosis. Contributors: Milind D. Kachare, M.D. Nisha Dhir, M.D., FACS University Medical Center of Princeton at Plainsboro, Rutgers - Robert Wood Johnson Medical School

Robotic-assisted Low Anterior Resection with Proximal Colotomy

Contributors: Dr. Jimmy Lin and Dr. Craig Rezac Robotic surgery offers benefits to both patient and surgeon by allowing smaller incisions with faster recovery time, as well as better accuracy, flexibility and control. Many procedures which had previously been conducted with laparoscopy, or open surgery, are further improved upon with robotic surgery. This is a video of a robotic-assisted LAR in a male with a T4N2M0 rectal cancer with concern for invasion into the prostate and seminal vesicles. The patient also has a synchronous proximal tubulovillous adenoma which had been biopsied but not completely resected during a previous colonoscopy. He therefore also underwent an intra-operative colotomy and colon polyp resection. This video demonstrates the advantages of robotic-assisted surgery in conjunction with more traditional procedures in order to provide the best care possible for the patient.

Difficult Dissection during a Low Anterior Resection

It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot. The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.

Robotic-assisted Base of Tongue Resection for Adult Sleep Apnea

A 52-year-old female presented for an evaluation for sleep apnea surgery. She complained of choking sensation at night. She had an AHI of 6.7 events per hour, a oxygen saturation nadir of 71%, and BMI of 30.6. She and a prior history of adenotonsillectomy as a child. Flexible examination in the office revealed grade 4 lingual tonsil hypertrophy. She was deemed a candidate for lingual tonsillectomy and was taken to the operating for robotic lingual tonsillectomy. The technique for adult lingual tonsillectomy is shown in step-by-step fashion with tips for good results both operatively and functionally learned from robotic surgery for cancer of the unknown primary origin. Contributors: Jessica Moskovitz, MD, Leila J. Mady, MD, PhD, MPH, Umamaheswar Duvvuri, MD, PhD

Robotic Loop Ileostomy Closure

71 yrs old male s/p robotic low anterior resection with primary coloproctostomy and diverting loop ileostomy for bulky, locally advanced rectal cancer. Robotic approach for loop ileostomy closure was planned due to obese body habitus. We utilized DaVinci Xi robotic platform. The set up consisted in 4-port placement, with ports # 2, 3 and 4 positioned starting in the left upper abdominal quadrant along MCL and port # 1 in suprapubic area. After docking and insertion of robotic instruments, the RLQ ileostomy was visualized. Appropriate orientation of efferent and afferent limbs was confirmed. Two enterotomies were created with electrocautery at the antimesenteric border of each limb, approximately 10 cm from the fascia. Head and anvil components of a robotic 60 mm stapler were then inserted in each enterotomy and the stapler fired in order to create a common channel between the lumens. After stay suture with 3-0 Vicryl was placed at the crotch of the anastomosis, common enterotomy defect was approximated with running 3-0 V-Lock suture in two layers. The matured portions of the loop ileostomy were then divided right below the fascia level with robotic 60 mm stapler after gentle dissection of the mesenteric border of each limb, while the mesentery was divided with robotic vessel sealer. The robotic system was then undocked and the ports removed. The remaining portion of the loop ileostomy was finally dissected from the abdominal wall at the mucocutaneous junction and the fascia defect approximated in the usual fashion (not included in the video).

Transoral Robotic Surgery (TORS) Excision of a Base of Tongue Venolymphatic Malformation in a Pediatric Patient

This video demonstrates successful Transoral Robotic Surgery (TORS) excision of a large, midline, base of tongue venolymphatic malformation after pre-operative embolization in a 6-year-old boy.

Robotic-Assisted Posterior Mediastinal Mass Resection

A 34-year-old non-hypertensive, obese female with a history of smoking, asthma, fibromyalgia presented at the ED with hemoptysis, dyspnea, and emesis for two weeks. At presentation the patient was afebrile, vital signs were stable and labs showed unremarkable CBC and BMP. Chest X-ray showed an abnormal soft tissue density within the subcarinal region. A follow-up chest CT with contrast revealed a posterior mediastinal mass measuring 5.4 cm x 3.6 cm in size with well-circumscribed borders. The patient was referred to cardiothoracic surgery for complete excision of the mass. She underwent robotic-assisted posterior mediastinal mass resection.

Totally Robotic Sigmoidectomy with Trans-anal Specimen Extraction and Intra- corporeal, Single Stapler, End-to-End Anastomosis

As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially. We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.

Robotic-Assisted Transanal Polyp Resection

Contributors: Benjamin Biteman and Vincent Obias Robotic Transanal minimally invasive surgical removal of 1.8cm villous adenoma with high grade dysplasia at 22cm. DOI#:https://doi.org/10.17797/kzimoid3xj Editor Recruited By: Vincent Obias

Robotic Sigmoid resection for Colovesicular Fistula and use of Firefly

Contributors: Ben Biteman, MD 61 year old male with diverticulitis and colovesicular fistula. Patient underwent robotic sigmoid colectomy with takedown of fistula. Firefly used to help identify if fistula still present. Editor Recruited By: Vincent Obias, MD, MS DOI# http://dx.doi.org/10.17797/9qxwhlr1q5

Robotic Assisted Redo Rectopexy and Low Anterior Resection

Contributors: Craig Rezac, MD Low anterior resection and rectopexy is the optimal treatment for well functioning patients with rectal prolapse. Reoperations for rectal prolapse may be challenging due to significant adhesions. Use of the robot for low anterior resection and rectopexy is safe, feasible and may be more useful than laparoscopy especially in challenging cases. DOI:http://dx.doi.org/10.17797/vkp7axh60l

Low Anterior Resection for Diverticulitis

Contributors: Craig Rezac, MD Treatment for recurrent or complicated diverticulitis is surgical resection. Minimally invasive techniques are associated with decreased length of stay and decreased post operative pain. However, laparoscopic low anterior resection is challenging especially in the narrow pelvis. Robotic surgery may overcome these obstacles and allow more surgery for divertiuclitis to be performed minimally invasively. These surgeons always do a LAR for diverticulitis because they transect on the proximal rectum. They take down the lateral stalks in order to mobilize the rectum and get the eea stapler through the rectum easier. Bilateral ureteral stents are routinely placed to better identify the ureters. This is especially important in cases of chronic/active diverticulitis or diverticulitis that has been complicated by abscess or fistula. This is the preference of the surgeon. DOI# http://dx.doi.org/10.17797/y1f1omu3mt

Completely Robotic Total Proctocolectomy and Ileal Pouch Anal Anastomosis

Contributors: Nell Maloney Patel, MD and Craig Rezac, MD There is little role for the use of minimally invasive techniques in the emergent setting for ulcerative colitis. However, for elective procedures, studies have shown that laparoscopic restorative proctocolectomy with IPAA is equivalent to open IPAA with regards to safety and feasibility, and that laparoscopic IPAA is associated with shorter recovery times, earlier return to bowel function, less post operative pain and a better cosmetic result. However laparoscopic approaches are difficult especially in the narrow pelvis. These challenges maybe overcome with the daVinci robotic system. DOI:http://dx.doi.org/10.17797/r1oi8fx5c2 Editor Recruited by: Neil Tanna

Robotic Assisted Repair of Morgagni Hernia

Contributors: Thomas Bauer, MD and Glenn Parker, MD Up to 25 % of diaphragmatic hernias may be incidentally diagnosed in adulthood. If symptomatic, patients often present with epigastric pain, chest pain or persistent cough. When found, they should be repaired to prevent incarceration and strangulation. DOI #: http://dx.doi.org/10.17797/wy2y9m77gv

Flex Robotic-Assisted Branchial Cleft Excision via Retroauricular Approach

Contributors: Umamaheswar Duvvuri An 18-year-old African American female with a large, type II branchial cleft cyst and a history of keloid scars presented for removal of branchial cleft cyst. We present the first robotic-assisted excision of branchial cleft cyst using the new Flex Robotic© Surgery System.

Jack Elder, MD, FACS

Massachusetts General Hospital

• Chief of Pediatric Urology

Jack S. Elder, M.D., FACS, is Chief of Pediatric Urology, Mass General. Dr. Elder received an M.D. with distinction from the University of Oklahoma College of Medicine, and was Vice President of Alpha Omega Alpha. He completed general surgery training at Yale-New Haven Hospital and a residency in urology, including chief resident, at The Johns Hopkins Hospital. Dr. Elder completed a pediatric urology fellowship at Johns Hopkins and at Children’s Hospital of Philadelphia. He was Director of Pediatric Urology at Rainbow Babies and Children’s Hospital for 21 years, and tenured Carter Kissell Professor of Urology at Case Western University School of Medicine. Subsequently, Dr. Elder was appointed Chief of Urology and Chief of Pediatric Urology, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI.

Dr. Elder was the Pediatric Urology Section Editor of The Journal of Urology from 1998-2007. Currently, he is on the editorial board of European Urology, Pediatric Surgery International, BJU International, Annals of Urology, and International Scholarly Research Notices. Dr. Elder served as President of the Society for Pediatric Urology and the American Academy of Pediatric Urologists. He was the Chairman of the first American Urological Association Pediatric Vesicoureteral Reflux Guidelines Committee, and was the facilitator of the second AUA Reflux Guidelines Committee, which published updated recommendations in 2010. He also is the Section Head, Pediatric Urology, AUA Online Robotic Surgery Handbook and is an annual reviewer for the European Association of Urology Paediatric Urology Guidelines. Dr. Elder has been Visiting Professor or Visiting Surgeon at 54 U.S. and international medical centers. Dr. Elder has > 160 peer-reviewed publications, edited or authored 6 books, 150 book chapters, and writes the pediatric urology section of the Nelson Textbook of Pediatrics. He is listed in Boston Magazine 2016 Top Docs.

Craig Rezac, MD

Rutgers Robert Wood Johnson Medical School

• Associate Professor of Surgery
• Section Chief, Colon and Rectal Surgery

Craig Rezac, M.D., is a Double Board Certified Surgeon with clinical interest in Colon and Rectal Surgery. American-born, Dr. Rezac received his doctorate degree from Pisa Medical School in Pisa, Italy in 1995, and his undergraduate degree from Adelphi University in Long Island, NY in 1981. Dr. Rezac is licensed to practice in New Jersey and the Republic of Italy.

Currently, Dr. Rezac serves as Associate Professor of Surgery, Section Chief Colon and Rectal Surgery at Rutgers Robert Wood Johnson Medical School (RWJMS) in New Brunswick, NJ. He also serves as Staff Physician, General Surgery at Somerset Medical Center in Somerville, NJ.

After receiving his medical degree, Dr. Rezac completed a Surgical Externship at La Spezia Hospital in La Spezia, Italy. He then completed a General Surgery Internship at the Monmouth Hospital in Long Branch, NJ. This was followed by a General Surgery Residency at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, NJ, and a Colorectal Surgery Fellowship at UMDNJ-Robert Wood Johnson Medical School in Edison, NJ. Lastly, Dr. Rezac completed a Laparoscopic Fellowship at Hackensack University Hospital in Hackensack, NJ.

Dr. Rezac holds numerous medical certifications as follows: Cyberknife, Davinci Laparoscopic Robotic Surgery, Davinci Advanced Laparoscopic Robotic Surgery for Colon and Rectal Surgery, American Heart Association (BLS/CPR), Trans Anal Endoscopic Microsurgery (TEM), and Stapled Trans Anal Rectal Resection (STARR). Dr. Rezac has the distinct honour of being the first doctor in New Jersey to be certified in both TEM and STARR.

Dr. Rezac is a member of several professional associations, including: American College of Surgeons (Fellowship), American Society of Colon and Rectal Surgeons, Society of Laparoendoscopic Surgeons, American College of Surgeons, New Jersey Chapter, and the New Jersey Chapter of American Society of Colon and Rectal Surgeons (past-President).

Dr. Rezac has received a number of honors and awards for outstanding performance both academically and professionally. He currently serves on several major committees, in addition to school and hospital committees, while continuing to meet various teaching and clinical responsibilities.

Dr. Rezac has received substantial grant support for medical studies and has been widely published in national and international medical journals, books, monographs, chapters, and articles. Dr. Rezac has generously shared his time and talents to deliver over 30 scientific and clinical presentations around the world.

Adam Zanation, MD

University of North Carolina at Chapel Hill

• Director, Head and Neck Robotic Surgery Program
• Director of the Advanced Head and Neck Oncology, Skull Base, and Rhinology Fellowships
• Associate Professor, Department of Otolaryngology – Head and Neck Surgery

Dr. Adam Mikial Zanation is a tenure tract Associate Professor within the Department of Otolaryngology – Head and Neck Surgery at the University of North Carolina at Chapel Hill. He is also the Director of the Head and Neck Robotic Surgery Program and the Director of the Advanced Head and Neck Oncology, Skull Base, and Rhinology Fellowships. He was born on July 11, 1976, in Concord, North Carolina and attended the University of North Carolina where he was a three-year graduate with honors and research commendation in 1997. He then matriculated to the University of North Carolina School of Medicine where he graduated 1of 4 students in his class with highest honors. Following residency, Dr. Zanation completed a Cranial Base Surgical Oncology Fellowship at the University of Pittsburgh Medical Center. Dr. Zanation’s clinical practices focus on cranial base surgery, specifically employing endoscopic and minimally invasive approaches to complex tumor locations. His clinical research focuses on quality of life, neurofunctional, and neurocognitive outcomes, as well as application of new surgical technology such as robotic surgery to reduce patient morbidity. Dr. Zanation’s translational basic research interests focuses on genomic analyses of head and neck tumors and thyroid cancers for diagnostic and prognostic purposes. Dr. Zanation currently has 70 PubMed Indexed publications and in the last five years has presented at over 60 national and international meetings. Dr. Zanation is married to Jennifer Stegall Zanation who is a Neonatal ICU Pharmacist at UNC Hospitals. They have two young children and enjoy a multitude of outdoor activities.

Inderpal S. Sarkaria, MD, FACS

University of Pittsburgh Medical Center

• Vice Chairman for Clinical Affairs
• Director of Thoracic Robotic Surgery
• Co-Director of the Esophageal and Lung Surgery Institute
• Department of Cardiothoracic Surgery  

Dr. Sarkaria is an expert in minimally invasive approaches to benign and neoplastic diseases of the esophagus, mediastinum, and lung. He is a recognized leader in robotic assisted approaches to these operations, and developed the minimally invasive esophageal program at Memorial Sloan Kettering Cancer Center prior to moving to UPMC. Dr. Sarkaria has one of the largest international experiences with robotic assisted minimally invasive esophagectomy (RAMIE) and other esophageal operations. Dr. Sarkaria has lectured, published, and presented his research and experience nationally and internationally and is a member of the major national and international thoracic surgical societies.

Board-certified in general surgery and thoracic surgery, Dr. Sarkaria earned his medical degree from the University of Medicine and Dentistry of New Jersey in Newark. He completed a residency in general surgery and cardiac surgery fellowship at New York Presbyterian Hospital – Weill Cornell Medical Center. He also completed fellowships in thoracic surgical oncology and cancer research at Memorial Sloan Kettering Cancer Center and in minimally invasive thoracic surgery at the University of Pittsburgh Medical Center.

Umamaheswar Duvvuri, MD, PhD

University of Pittsburgh Medical Center

• Director of Robotic Surgery, Division of Head and Neck Surgery
• Director of the Center for Advanced Robotics Training (CART)
• University of Pittsburgh School of Medicine

Umamaheswar Duvvuri, MD, PhD, is a graduate of the University of Pennsylvania obtaining his Medical Degree in 2000 and his PhD in Biophysics in 2002. He completed an internship in General Surgery in 2003 and residency training in Otolaryngology in 2007 at the University of Pittsburgh Medical Center. He completed fellowship training in Head and Neck Surgery in 2008 at the University of Texas MD Anderson Cancer Center.

He joined the University of Pittsburgh in August 2008 as an Assistant Professor in the Department of Otolaryngology, Head and Neck Surgery Division and is also a staff physician in the VA Pittsburgh Healthcare System.

He serves as the Director of Robotic Surgery, Division of Head and Neck Surgery, at the University Of Pittsburgh School Of Medicine and is the current Director of the Center for Advanced Robotics Training (CART) at the University of Pittsburgh Medical Center. He directs the Cart Training Courses which provide technical and circumstantial resources to initiate and optimize robotic surgery programs.

He has authored numerous research publications and book chapters and is an invited guest lecturer/speaker on the subject of robotic surgery both nationally and internationally.

A Fulbright scholar, his research interests include minimally invasive endoscopic and robotic surgery of the head and neck, tumors of the thyroid and parathyroid glands and molecular oncology of head and neck cancer.

He directs a federally funded laboratory that studies the biology of head and neck cancer. He holds funding from the National Institute of Health, Department of Veterans Affairs and the “V” foundation.

Advanced Salivary Endoscopy: Challenging Cases Diagnosis & Treatment

The advanced course will assume a basic understanding of the procedure. It will include complex interventions including endoscopic and combined open (transoral and external procedures), complications and management of complications, approach to revision surgery, in-office procedures, advanced radiology, and will include case studies.

Meet the Course Directors!

Rohan R. Walvekar, MD

Assistant Professor in Head Neck Surgery

University of Pittsburgh/VA Medical Center

Rohan R. Walvekar, MD, earned his doctoral degree from the University of Mumbai. After graduating in 1998, he completed a residency in Otolaryngology and Head Neck Surgery at the TN Medical College & BYL Nair Charitable Hospital, Mumbai, India, with triple honors. Subsequently, he completed two head neck surgery fellowships, and trained at at the Tata Memorial Hospital, Mumbai, which is India's most prestigious cancer institute. After completing an Advanced Head Neck Oncologic Surgery fellowship at the University of Pittsburgh, he became an Assistant Professor in Head Neck Surgery within the Department of Otolaryngology Head Neck Surgery at the University of Pittsburgh/VA Medical Center, prior to joining the LSU Health Sciences Center in July 2008. His clinical interests are head neck surgery and salivary endoscopy. His research interests include evaluating prognostic markers and clinical outcomes of head and neck cancer therapy and treatment of salivary gland disorders.

Barry M Schaitkin, MD

Professor of Otolaryngology

UPMC Pittsburgh

Dr. Schaitkin specializes in the treatment of inflammatory and neoplastic conditions of the salivary glands. He practices at UPMC in the Department of Otolaryngology and is affiliated with UPMC branches all across the city of Pittsburgh. He completed his medical degree and residency at Pennsylvania State University College of Medicine.

Meet the Presenters!

Jolie Chang, MD

Associate Professor, Chief of Sleep Surgery and General Otolaryngology

University of California, San Francisco

Dr. Chang specializes in sleep apnea surgery and minimally invasive approaches to the salivary duct with sialendoscopy. She has interest in studying patient reported outcomes after sialendoscopy procedures.

Mark Marzouk, MD

Clinical Associate Professor of Otolaryngology - Head and Neck Surgery

SUNY Upstate Medical University

Dr. Marzouk completed his residency training in 2010 from the UPMC Department of Otolaryngology. He is currently the Division Chief of Head and Neck Oncologic Surgery in Syracuse. He is also the Associate Program Director of Residency Programs.

David W. Eisele, MD. FACS

Andelot Professor and Director - Department of Otolaryngology-Head and Neck Surgery

Johns Hopkins University School of Medicine

Dr. Eisele is the Past-President of the American Board of Otolaryngology- Head and Neck Surgery and a member of the NCCN Head and Neck Cancer Panel. He has served as a member of the Residency Review Committee for Otolaryngology, as Chair of the Advisory Council for Otolaryngology - Head and Neck Surgery for the American College of Surgeons, President of the American Head and Neck Society, and as Vice-President of the Triological Society. He served as President of the Maryland Society of Otolaryngology and is a former Governor of the American College of Surgeons.

M. Boyd Gillespie, MD, MSc, FACS

Professor and Chair

UTHSC Otolaryngology-Head and Neck Surgery

M. Boyd Gillespie is Professor and Chair of Otolaryngology-Head & Neck Surgery at University of Tennessee Health Science Center. He is a graduate of the Johns Hopkins University School of Medicine where he a completed residency and fellowship in Otolaryngology-Head & Neck Surgery. Dr. Gillespie earned a Masters in Clinical Research at the Medical University of South Carolina, and is board certified in Otolaryngology-Head and Neck Surgery and Sleep Medicine. He has published over 150 academic papers and is editor of the textbook Gland-Preserving Salivary Surgery: A Problem-Based Approach. He is a former Director of the American Board of Otolaryngology-Head & Neck Surgery (ABOHNS) and current member of the otolaryngology section of the Accreditation Council for Graduate Medical Education (ACGME).

M. Allison Ogden, MD FACS

Professor & Vice-Chair of Clinical Operations - Department of Otolaryngology

Washington University School of Medicine

Dr. Ogden is a Professor and Vice-Chair of Clinical Operations in the Department of Otolaryngology at Washington University School of Medicine. She graduated from the Washington University School of Medicine in 2002 and went on to complete her residency there as well in Otolaryngology in 2007. Her clinical interests include sialendoscopy, nasal obstructions, and hearling loss. In 2015 Dr. Ogden was listed in "Best Doctors in America", an honor that continues to this day.

Arjun S. Joshi, MD

Professor of Surgery

The George Washington University School of Medicine & Health Sciences

Arjun Joshi, MD is board-certified in Otolaryngology and Head & Neck surgery by both the American Board of Otolaryngology – Head and Neck Surgery and the Royal College of Physicians and Surgeons of Canada. Dr. Joshi received his medical degree from the State University of New York at Syracuse and completed his residency at The George Washington University Medical Center. His areas of expertise include: Head and Neck Cancer, Head and Neck Masses, Head and Neck Reconstruction, Thyroid and Parathyroid Surgery, and Salivary Endoscopy.

Henry T. Hoffman, MD

Professor of Otolaryngology / Professor of Radiation Oncology

University of Iowa Healthcare

Dr. Henry T. Hoffman is an ENT-otolaryngologist in Iowa City, Iowa and is affiliated with University of Iowa Hospitals and Clinics. He received his medical degree from University of California San Diego School of Medicine and has been in practice for more than 20 years.

David M. Cognetti, MD, FACS

Professor and Chair of Department of Otolaryngology-Head & Neck Surgery

Thomas Jefferson University

Dr. Cognetti received his BS in Biology from Georgetown University and his MD from the University of Pittsburgh School of Medicine. He completed a residency in Otolaryngology – Head and Neck Surgery at Thomas Jefferson University before completing a fellowship in Advanced Head and Neck Oncologic Surgery at the University of Pittsburgh Medical Center.  Dr. Cognetti returned to Jefferson, his professional home, as faculty in 2008.

Christopher H. Rassekh, MD, FACS

Professor in Department of Otorhinolaryngology - Head & Neck Surgery / Director of Penn Medicine Sialendoscopy Program

University of Pennsylvania

Christopher H. Rassekh, MD is Professor of Clinical Otorhinolaryngology-Head and Neck Surgery at Penn Medicine. He is the Director of the Penn Medicine Sialendoscopy Program, which provides evaluation of and minimally invasive surgery for diseases that cause swelling of the salivary glands including obstructive diseases such as salivary stones, salivary duct strictures and tumors. Dr. Rassekh sees patients with head and neck tumors including cancers of the mouth, throat, voice box, salivary gland, thyroid and neck and also was a very early adopter of Transoral Robotic Surgery (TORS) for tumors and salivary gland diseases, and is an expert in cranial base surgery. He also is co-chair of the Airway Safety Committee at the Hospital of the University of Pennsylvania.

Three Stage Management of the Single Ventricle

In this session our team of experts will discuss the three stages of single ventricle palliation including the Norwood procedure, the bidirectional Glenn shunt and the Fontan procedure.  Included in this webinar will be single ventricle pathophysiology, diagnostic studies/imaging, indications and contraindications for palliation, timing of surgical intervention, and overview of surgical goals and associated mortality.

Ventricular Septal Defects

As one of the most common congenital cardiac anomalies managed by pediatric cardiac teams, VSD’s often may present a challenge in optimal management.  Our team of experts will discuss pathophysiology, diagnostic studies, indications and timing of surgery, surgical management; along with the technical challenges/considerations of repairing each of the different anatomic variants of ventricular septal defects: perimembranous, conoventricular, supracristal (subpulmonary), inlet (atrioventricular canal type), and muscular.

The People Behind CSurgeries: Dr. Gerald Healy, CSurgeries Chief Surgical Officer

Meet Dr. Gerald Healy –
accomplished otolaryngologist and dedicated family man.
Learn more about his recipe for success and
how all surgeons can benefit from what he calls a
“House of Surgery”.

Q: What can you tell me about your role as Chief Surgical Officer, of CSurgeries? What are your main areas of focus?

A: First and foremost this really is a unique opportunity! There isn’t any other publication vehicle where all of the “House of Surgery” (as I like to call the surgical groups that are represented on CSurgeries) can present a compendium of information acceptable to all surgeons of all disciplines. As a specialty surgeon, I feel strongly that the surgical disciplines do not interact enough with each other. We have developed a silo mentality in medicine where we’re so focused on our own discipline, we fail to learn from the others. With CSurgeries, we have the ability to learn from surgeons in other disciplines. Even during my tenure as president of the American College of Surgeons, I worked to promote this “House of Surgery” concept ─a place where everyone lives and works together for the common goals of patient safety and quality care.

My primary role as Chief Surgical Officer, is to recruit the very best people we can find in the various surgical disciplines to be the Section Editors. We’ve welcomed some very well-known, accomplished surgeons (such as Dr. Britt who is our General Surgery editor and Dr. Shamberger who is our Pediatric Surgical Section Editor). The idea is to reach out to surgical leaders like these who can then go out and recruit the best videos. Our Section Editors are extremely well respected, recognizable names in their field. So much so that when they pick up the phone, you listen to what they have to say. People recognize that these individuals would only be affiliated with a valid journal that has something worthwhile to offer.

Q: What does CSurgeries have to offer learners of every type (trainees, patients, families, experienced surgeons) compared to other channels of surgical education?

A: CSurgeries is dedicated to serving all of those groups, and we will have to pay special attention to the development of a video library/process that addresses every viewer group. For example, the video presented to a lay person about a laparoscopic cholecystectomy might be completely different from the video we show an advanced surgeon who wants to simply see, “How does Dr. X take out gall bladder? I’d like to see the little tricks he uses when he’s in there”. Paying close attention to the viewing audience is critically important as we move forward- ensuring the production of educationally appropriate videos geared towards each viewer group or learner group.

Similarly, if we’re addressing a medical student audience, it would be acceptable to show them the same video of the gall bladder removal that we might also show a senior surgical professor. However, the audio portion (author explanation/narration) might be very different. Simply stated, the senior professor doesn’t need me telling him, “Put the scope here and look 30 degrees there”. He or she already knows that. What they want to know is, “What kind of a clamp does Dr. X use?” or “What kind of a clip, does he put on the gall bladder when he’s finished?” I expect those nuances would be differentiated through the video narration itself.

Q: Dr. Healy, your list of accomplishments are endless…You are an author, lecturer, scholar, and honorary society member (just to name a few). Where do find this motivation, what fuels you?

A: Like many people in many walks of life, I had a role model that I wanted to emulate. The short version is that when I was a small kid, I have this memory of my pediatrician who would come out in the middle of the night, in the snow, in the rain, and in the ice to see me because I was sick. Those visions stayed with me for my early life and drove me with a passion. I wanted to be like this guy. His name was Eli Friedman – an incredibly unique human being who actually has a lectureship at Boston Medical Center named in his honor because so many of his students over the years were so adoring of him. He’s what drove me.

I always knew I wanted to become a physician, but the question was whether or not I could achieve it. Could I get there? And once I got there, what was I going to do with it? The driving force behind my career really unfolded in three phases:

1. The first third of my career, I was a learner. I tried to absorb everything I could from everyone I met because I wanted to be the best surgeon I could be-helping patients with the very best of my ability.
2. The second part of my career, I made a concerted effort to try and share my experiences with others. I spent a lot of time giving talks, writing papers, presenting my material at various meetings and listening to the critiques.
3. The final third of my career, I decided to help as many as I could by becoming involved in medical organizations focused on driving the agenda so that we were always focused on what’s best for the patient and their quality of care.

*I’m also a passionate guy, who loves his family, always makes time for my wife and daughters and am driven to do the very best I can in all things.

Q: What advice would you give a medical student thinking about becoming a surgeon?

A: First and foremost, DO NOT look at medicine as a job. It’s a profession. Too many students today are looking at lifestyle choices. Being a surgeon is not an easy lifestyle. So, if you’re about working 8 am to 4pm and having all your nights and weekends off, don’t become a surgeon. But if you’re passionate about helping others, easing suffering, and changing things for the better, there is no part of our profession that’s more rewarding than surgery.

I often address medical students in and around Boston, and I let them know they are being given a unique privilege- the privilege of holding the life of another human being in their hands. It is an immense responsibility that you cannot take lightly. Once that person puts their trust in you and says, “Doctor, I need your help…” they need your help until the problem is solved. It’s not a job. It’s a profession and a calling.

1. How has medical teaching and surgical learning evolved over the years? Where do you see it going years from now?

Well, when I went to medical school, everything was pictures, book and journal reading and so forth. Now the electronic world has taken over. Visual learning, e-learning and interactive learning is the new norm. When it comes to surgery, people want to talk less and see more. That’ simply the world we live in. Today, simulation and the use of simulators is also extremely important.

I believe we are going to be heavily into robotic surgery. That’s a very important issue to think about because surgeons can easily make the mistake of becoming technicians and not doctors. By that I mean, operating, but having no relationship with the patient. Robots will replace you in the future if you enter surgery solely focused on being a technician and not an empathizing doctor. Let’s not forget about the importance of positive doctor-patient relationships…the very human side of surgery.

Have a question you would like to ask Dr. Healy? Feel free to post a comment or send him an email at Gerald.Healy@csurgeries.com