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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 Sigmoid Resection with Intracorporeal Anastomosis. Post-operative course: Enhanced Recovery principles that include goal directed fluids, multimodal pain management, early feeding, and early mobilization were instituted. She was discharged after satisfying discharge criteria on postoperative day 2.
benign and malignant diseases of the sigmoid colon
Indications and Contraindications are the same for laparoscopy and robotic platforms and standard for segmental colectomy. Contraindications include inadequate windows for minimally invasive approach and hypercarbia from carbon dioxide insufflation.
Patient is placed in Trendelenburg position with left to right rotation. Extremities are padded. Si robot is docked over left hip.
Standard workup for diverticulitis - colonoscopy when disease quiescent and CT imaging during disease exacerbation. Preoperative assessment includes Enhanced Recovery counseling with attention to optimizing comorbidities, CT imaging, and colonoscopy when possible.
Sigmoid and descending colon, ureter on left, rectosigmoid junction
The sigmoid resection is conducted by combination medial to lateral and lateral to medial dissection of mesentery off the retroperitoneum with identification of the left ureter early in the dissection. The inferior mesenteric artery is clipped and divided with the vessel sealer. The mesorectum is divided with the Vessel Sealer. The intracorporeal anastomosis is then done as described in the video. Operative time was about the same or a little less less than the extracorporeal approach.
Same for open, laparoscopic, and robotic colectomy - bleeding, infection, anastomotic leak, abscess, injury to ureters, bowel, blood vessels, possibility of stoma temporary or permanent, deep venous thrombosis, pulmonary embolus, myocardial infarction, sepsis, multiorgan system failure, possible death, functional bowel disturbances
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Tam MS, Kaoutzanis C, Mullard AJ, Regenbogen SE, Franz MG, Hendren S, Kraphol G, Vandewarker JF, Lampman RM, Cleary RK. A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc 2016;30:455-463; DOI 10.1007/s00464-105-4218-6 PMID: 25894448 Bhama AR, Obias V, Welch KB, Vandewarker JF, Cleary RK. A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons � National Surgical Improvement Program (ACS-NSQIP) database. Surg Endosc 2016;30:1576-84; DOI 10.1007/s00464-015-4381-9 PMID 26169638

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