A novel approach for robotic mobilization of the splenic flexure

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.

Minimally Invasive Management of Diverticular Disease

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Development and Implementation of a Novel Computer-Based Training Module for the Standardization of Splenic Flexure Mobilization

BACKGROUND

Computer-based training modules use various multimedia components such as text, graphics, animation, and videos that can theoretically facilitate the learning process. Splenic flexure mobilization (SFM) is a crucial step for tension-free colorectal/anal anastomosis that can be a technically demanding step. This study is designed to demonstrate our novel training module for SFM with high-vessel ligation during surgery and present the anatomical landmarks and embryological plans for SFM.

MATERIALS AND METHODS

A step-by-step educational video was prepared to standardize and teach the technical steps of the SFM. 3D animation was prepared and cadaveric dissection was performed in a step-by-step manner similar to minimally invasive surgery. This is followed by the laparoscopic technique. Since we have started this modular training program in our department, a consecutive of 100 patients underwent laparoscopic low anterior resection and coloanal anastomosis with covering stoma. Demographics, characteristics, and postoperative outcomes were evaluated.

RESULTS

Surgical anatomical planes and important vascular structures/variations are both shown by 3D animation, cadaveric dissection, and laparoscopic surgery. Out of 100 consecutive cases, there were no mortality, 5 anastomotic leakages 1 of which necessitates reoperation, and 2 splenic injuries which were managed conservatively.

CONCLUSION

This unique educational video module for SFM demonstrates surgical anatomical planes and important vascular structures/variations. The employment and implementation of time-independent multimedia components lead to effective training and can theoretically facilitate the learning process.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box

AIM

The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach.

METHODS

Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM.

RESULTS

First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access.

CONCLUSION

With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

Standardize the Surgical Technique and Clarify the Relevant Anatomic Concept for Complete Mobilization of Colonic Splenic Flexure Using da Vinci Xi® Robotic System

BACKGROUND

The present study is to set up a standardized approach for complete mobilization of colonic splenic flexure using da Vinci Xi^® robotic system, based on clarification of the mesenteric structures of distal transverse colon.

METHODS

The surgical outcomes and relevant anatomic structures of 104 consecutive patients undergoing robotic resection of primary colorectal cancer with the intent of complete mobilization of colonic splenic flexure using da Vinci Xi^® robotic system were retrospectively reviewed.

RESULTS

Complete mobilization of colonic splenic flexure can be efficiently performed by the Xi^® robotic system, as demonstrated by short operation time, minimal intra-operative blood loss, and few surgical complications. Xi^® robotic system has overcome the drawbacks of Si^® robotic system for the mobilization of colonic splenic flexure. The present study defined the following anatomic hallmarks for the colonic splenic flexure: (1) The transverse mesocolon distal to the inferior mesenteric vein adheres to the low border of pancreas by the avascular fibrous connective tissues, which have been inappropriately named as "mesenteric root"; (2) The colonic splenic flexure abuts closely to spleen with an acute angle in 78.85% (n = 82/104); (3) Only a minority of patients presented with the Riolan branch (15.38%, n = 16/104) or the Moskowitz artery (8.65%, n = 9/104).

CONCLUSION

With increased maneuverability of Xi^® robotic arms and the clarification of relevant anatomic concept, the surgical technique for the complete mobilization of colonic splenic flexure can be standardized; and the standardization of surgical technique is the first step toward the enhanced automation in the rapidly evolving robotic systems.

Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery

BACKGROUND

Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options.

METHODS

All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared.

RESULTS

There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03).

CONCLUSIONS

Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.