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.

The robotic sigmoidectomy dissection was carried out in standard fashion, following which the descending colon and rectosigmoid junction were transected with electrocautery, allowing for a trans-anal specimen extraction. Preoperative bowel preparation limited intra-peritoneal contamination from these maneuvers. An end-to-end anastomotic stapler was introduced through the anus. The anvil was detached intra-corporeally, and both the anvil and stapler body were secured in their respective locations with endoloops prior to firing. Thus, the patient received a totally robotic sigmoidectomy with an intra-corporeal, end-to-end anastomosis, using a single stapler technique.
Indications to proceed with a totally robotic sigmoidectomy with an intra-corporeal, end-to-end anastomosis, using a single stapler technique includes recurrent diverticulitis without evidence of malignancy.
Malignancy extraction via this technique places the patient at risk for seeding along the extraction site.
Port placement for use with the daVinci XI system includes with 4 ports in a linear fashion spanning from the left upper quadrant to the right lower quadrant with the right lower quadrant being 12mm for the stapler. An additional 12mm AirSeal port is placed in the right upper quadrant for the bed-side assist.
Pre-operatively, mechanical and antibiotic bowel preparation is necessary.
Important anatomy to be aware of is the sigmoid and descending colon, the left ureter, the inferior mesenteric artery pedicle, and the left iliac vessels. Care must be taken during dissection to mobilize and free the inferior mesenteric artery pedicle while protecting the ureter and iliac vessels.
Advantages: Omitting an extraction incision can reduce pain, reduce the risk of hernia formation, and reduce hospital length of stay. A single stapler technique reduces procedural cost and eliminates potential intersecting staple lines. Disadvantages: This technique should not be used in cases of colon cancer, due to the risk of spreading malignancy upon extraction. In addition, this technique is technically more difficult than the standard 3 stapler technique.
Risks for this surgical procedure include, bleeding, infection, injury to surrounding structures, port-site hernias, adverse cardiac events, deep venous thrombosis, gas embolus, anastomotic leak, ureteral injury, adjacent bowel injury, sepsis, muti-system organ failure, and death.
None of the authors have any financial disclosures with any commercial interest.
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