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
Specialty: Colorectal Surgery
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
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
Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis
Contributors: Justin A. Maykel MD
The following video demonstrates a laparoscopic sigmoid colectomy for the treatment of complicated sigmoid diverticulitis. The patient was initially managed with intravenous antibiotics and allowed three months for the acute inflammatory process to resolve. Subsequently she was taken to operating room electively for an uncomplicated sigmoid colectomy with a primary anastomosis.
DOI: http://dx.doi.org/10.17797/xq6fosqsh3
Editor Recruited By: Jeffrey B. Matthews, MD
Use of a Heineke-Mikulicz Like Stricturoplasty for Skin Level Anal Strictures in Children with Anorectal Malformations
Contributors:
Taiwo Lawal
Richard Wood
Victoria Lane
Alessandra Gasior
Karen Diefenbach
Marc Levitt
Anal strictures in children who have had anorectoplasties for anorectal malformation, although largely preventable, can be of two types; at the skin level or more extensive in nature. Skin level strictures are preventable and usually treatable by anal dilations but require surgery when intractable. We recently introduced a modification of the Heineke-Mikulicz technique to treat this problem, able to be performed in an ambulatory setting and without a protective colostomy. The aim of this article is to describe the technique and outcome in a series of patients.
DOI: http://dx.doi.org/10.17797/dvy3xhv1k0
Editor Recruited By: Robert C. Shamberger, MD
Laparoscopic Hepatic Left Lateral Sectionectomy
Contributors: David A Geller
Laparoscopic left lateral sectionectomy performed for a 14 cm hypervascular left lobe liver mass which is hypervascular during arterial phase and isodense to liver during venous phasem consistent with giant Focal Nodular Hyperplasia.
DOI: http://dx.doi.org/10.17797/yjare8xwt2
Editor Recruited By: Jeffrey B. Matthews, MD