Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported?

Background: Given the importance of operative documentation, we reviewed operative notes for surgeries that required splenic flexure mobilization (SFM) to determine their accuracy. Materials and Methods: We performed a retrospective review of 51 operative notes for complete SFMs performed at a single institution from January 2015 to June 2020. Results: None of the operative notes reported a rationale for performing SFM, use of preoperative imaging to guide technical approach, reasoning for the operative method and mobilization approach used, or specific steps taken to ensure that SFM was done safely. Most reports did not include technical details, with one-third of the notes merely reporting that "the splenic flexure was mobilized." Conclusions: Increased awareness about the lack of operative documentation of the critical aspects of the SFM could stimulate initiatives to standardize the SFM method and improve the quality of operative notes for SFM.

Efficient and Safe Method for Splenic Flexure Mobilization in Laparoscopic Left Hemicolectomy: A Propensity Score-weighted Cohort Study

Supplemental Digital Content is available in the text.

Because methods of performing laparoscopic left hemicolectomy differ between surgeons, standardizing the procedure is crucial to reduce complications and secure good oncologic outcomes.

Robotic right colonic resection. Is the robotic third arm a game-changer?

BACKGROUND

Minimally invasive surgery (MIS) approaches have produces relevant advancements in the pre/intra/postoperative outcomes. The conventional laparoscopic approach presents similar oncological results in comparison to laparotomic approaches. Despite these evidences, a considerable part of the colorectal operations are still being performed in an open way. This is in part because traditional laparoscopy may have some hurdles and a long learning curve to reach mastery. The robotic technology may help in increasing the MIS penetrance in colorectal surgery. The use of the R3 can potentially increase the number of surgical options available.

METHODS

In this retrospective case series, after a long robotic colorectal experience connected to a robotic program started by Giulianotti et al. in October 2000, we present our results regarding a subset of colorectal patients who underwent robotic right colonic resections performed, all by a single surgeon (P.C.G.), using the R3 according to our standardized technique.

RESULTS

Out of all the robotic colorectal operations performed, this sub-sample sample included 33 patients: 21 males and 12 females. The age range was between 51 and 95 years old. The Body Mass Index (BMI) was between 21.6 to 43.1. The conversion rate to laparoscopy or to open surgery has been 0%. No intraoperative complications have been registered. The postoperative complications rates are reported in this manuscript. The perfusion check of the anastomosis by Near-infrared ICG (Indocyanine Green) enhanced fluorescence has been used. In 11.2% of the sample, the site of the anastomosis has been changed after ICG-Test. Moreover, when the ICG perfusion test has been performed no leakage occurred.

CONCLUSIONS

This subset of patients suggests the potential role of R3 and the benefits correlated to robotic surgery. In fact, the laparoscopic approach uses mostly a medial to lateral mobilization. Indeed, during laparoscopic surgery an early right colon mobilization may create problems in the surgical field visualization. In robotic surgery, R3 can lift upwards the cecum/ascending colon/hepatic flexure exposing, in doing so, the anatomical structures. Hence, we can use also the same approach of the open surgery (where the first step is usually the mobilization of the ascending colon mesentery). In other words, the R3 offers more operative options in terms of surgical pathways maintaining at the same time good perioperative outcomes. However, more studies are needed to confirm our findings.

Surgical technique in robotic right colonic resection. How we do it: operative steps and surgical video

Minimally invasive surgery (MIS) has produced an important improvement in terms of peri-operative outcomes. Laparoscopic colorectal surgery presents comparable outcomes vs. open approach from an oncological standpoint. However, there are some technical challenges/hurdles that laparoscopy may have. Worldwide there are still too many colonic/rectal operations carried out by the open approach. The robotic technology may be useful in solving some of the potential laparoscopic issues and potentially it may increase the number of procedures performed in a minimally invasive way. This is a description of our standardized operative technique for Robotic Right Colonic Resection. Conceivably, this manuscript may be useful to collect more repeatable data in the future. Moreover, it might be a guide to learn the robotic technique and also for the expert surgeons as an additional tool which they may find useful during their teaching activity. In this manuscript, taking advantage of the long and extensive expertise in minimally invasive colorectal resections, connected to a robotic experience started by Giulianotti in October 2000, we present our standardized technique for the robotic right colonic resection. The currently available literature data have proven that robotic colorectal surgery is safe/feasible. From the literature data, and from our experience as well, we think that these are the following main points: 1) the right colectomy is often an operation which can be performed in a relatively simple way even with traditional laparoscopy. However, the robotic approach is easier to standardize and this operation is very useful from a teaching standpoint in order to master multiple robotic surgical skills (that can be applied in more complex colorectal operations); 2) the robotic surgery may increase the MIS penetrance in this field. 3) the robotic third arm (R3) is an important technical advantage which can potentially increase the range of surgical options available; 4) the robotic technology is relatively recent. Most of the available data are retrospective and there is literature heterogenity (this affects also the conclusions of the currently available meta-analysis results, which sometimes are conflicting); 5) we need more data from prospective randomized well-powered studies (with standardized technique). Achieving a standardized technical approach will be essential in robotic colorectal surgery.

Operative technique in robotic left colonic resection

Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those findings have been proven by prospective randomized multicenter trials and systematic reviews. However, some colorectal operations are still being performed by the open approach. This is partially related to the technical hurdles of the laparoscopic approach (particularly for more complex cases). Robotic surgery can be beneficial in overcoming the laparoscopic hurdles and limitations. Indeed, given the improved dexterity, the 3D stereotactic magnified view (with the camera controlled directly by the surgeon), the tremor filtering technology and the 7 degrees of liberty of the surgical instruments can guarantee a more accurate surgical dissection and tissue manipulation. Herein, after a large robotic experience in this field connected to a robotic program started by Giulianotti et al. in October 2000, we present our approach to robotic left colonic resection with routine splenic flexure mobilization. This approach may be helpful to get more reproducible results, it may be a technical guide and also an additional training tool for surgical residents.

Operative technique in robotic rectal resection

A still too high percentage of the colorectal resections are currently performed by open technique. This in part because laparoscopy has some technical hurdles: not ideal ergonomics, poor control on the traction exerted by the Assistant, long/steep learning curve, confined dexterity, low tactile feedback, hand-tremor and 2D vision with a not completely stable camera. The robotic approach, given the increased surgical dexterity and the better surgical view, may be used to solve the laparoscopic downsides (in particular in the most complex cases). In the present work, after an extensive robotic experience and a robotic program started by Giulianotti et al. in October 2000, we show our operative steps for the robotic rectal resection. The aim is to propose a model to standardize the surgical technique and potentially pave the way for the acquisition of more reproducible data among different centers. This proposal may be also a technical guide to learn the robotic way and also for the expert surgeons as an adjunct in the teaching strategy.

Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study

BACKGROUND

The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy.

METHODS

Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.).

RESULTS

We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript.

CONCLUSIONS

In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.