Robotic sigmoid colectomy for diverticular disease

Introduction

Indications for robotic sigmoid colectomy in diverticular disease

Diverticular disease is common and increasing in incidence worldwide. The main site of disease in the Western world is the sigmoid, although diverticula can occur anywhere in the colon and right-sided diverticular disease is more common in Asian populations. Diverticular disease comprises a wide spectrum of disease ranging from mild inflammation that can be treated in an ambulatory setting to complicated disease (e.g., an acute free perforation, an inflammatory phlegmon, a pericolic abscess, a colovesical fistula, a colovaginal fistula, or a stricture). It is estimated that 30% of those with diverticular disease will ultimately require surgery. A minimally invasive approach to diverticular resection has been shown to improve quality of life outcomes. A laparoscopic approach has been well described, but has limitations with a relatively high conversion rate. ^, A robotic approach is increasingly recognized as an option in diverticular disease, with over 3800 cases reported in the literature and has been shown to have a lower conversion rate. Robotic colectomy may offer technical advantages with a stable platform and operator control of the camera, as well as improved definition and visualization, although at the cost of direct tactile feedback. Robotic surgery has been described across the spectrum of severity of diverticular disease. This chapter describes technical considerations for a robotic approach to robotic sigmoid colectomy in diverticular disease.

ICG, Indocyanine green; IMA, inferior mesenteric artery; IMV, inferior mesenteric vein.

KEY STEPS

Access —pneumoperitoneum, port placement
Dissection —the order of steps in dissection may vary
- Splenic Flexure
  - Positioning for splenic flexure takedown, and target to flexure, using flexure port layout ( Fig. 51.1 )
  - IMV high ligation for length of colonic conduit• Splenic flexure mobilization using a combination of three approaches: medial to lateral, superior to lateral, and lateral to medial
- IMA Dissection and Sigmoid Colon Mobilization
  - Position for vessel dissection, and sigmoid mobilization, using IMA port layout (see Fig. 51.1 )
  - IMA dissection and ligation; IMV second tie
  - Hypogastric nerve dissection and preservation
  - Lateral mobilization
  - Division of disease-free upper rectum
  - Undocking and delivery of colon
  - Sigmoid mesocolon hemostatic division
  - Division of proximal colon and removal of specimen
- Anastomosis
  - Preparation of conduit with anvil placement
  - Regain pneumoperitoneum
  - Vascularity check using ICG
    - End to end anastomosis using laparoscopic approach
  - Leak test ± flexible sigmoidoscopy for joint hemostasis
- Defunctioning and Closure
  - Terminal ileum identified and used to form a defunctioning loop ileostomy if deemed necessary—usually done laparoscopically
  - Port closure and tumor extraction site closure

Indications and contraindications to robotic sigmoid colectomy in diverticular disease

Indications for robotic colectomy in diverticular disease are given in Table 51.1 . Limiting factors in robotic approaches to sigmoid colectomy are robotic access for emergency cases, surgeon skill set, and how unwell the patient is/considerations for operative time for acute colectomy.

TABLE 51.1

Indications for Robotic Sigmoid Colectomy

Elective	Considerations
Recurrent acute diverticulitis	There is no absolute cutoff for when to intervene, and shared decision making with the patient is important.
Colovesical fistula	This may require an extended resection including a cuff of the bladder. Preoperative imaging should be carefully reviewed to determine the site of the fistula, (e.g., is the trigone or ureters at risk).
Colovaginal fistula	An extended resection including a cuff of vagina may be required.
Persistent phlegmon	This can involve ureters and other structures (e.g., small bowel).
Diverticular stricture	Surgery may be required due to either obstructive symptoms or diagnostic uncertainty (e.g., unable to exclude sigmoid cancer).
Emergency Acute perforated diverticulitis	Suitability for robotic approach depends on: Robotic availability in the emergency setting Severity of perforation (e.g., using Hinchey classification) Patient overall condition Surgeon technical level of comfort with a robotic approach

Preoperative assessment and preparation

Patients usually undergo a CT of the abdomen and pelvis with oral and IV contrast to delineate the extent of disease. For elective resection, colonoscopy is undertaken to rule out a colonic tumor. For those with fistulating disease, there may be a role for additional contrast studies to delineate anatomy, or for cystoscopy or hysteroscopy to clarify diagnosis and exclude other pathology. Patients should be seen by a stoma therapist preoperatively and marked and counseled regarding the possibility of a stoma. Bowel preparation, using a combination of oral antibiotics and mechanical bowel preparation, is often used for elective resection. For elective resection, preoperative optimization with review at the anesthetic preoperative assessment clinic is undertaken. Careful counseling of the patient of the risks, benefits, and alternatives to surgery is undertaken. In the elective setting, it is particularly important to emphasize functional outcomes and quality of life considerations to enable informed shared decision making and consent, particularly as this is an operation for benign disease.

Technical planning

There are specific considerations for technical aspects of sigmoid colectomy depending on the indication.

Operative sequence

There are a number of options in terms of the operative sequence. Options for approach include an IMA first approach with either medial to lateral or lateral to medial dissection of the IMA, or a vein first approach with dissection of the IMV and mobilization of the splenic flexure. The sequence of components of the operation varies depending on surgeon preference and patient anatomy. Flexibility of approach is important in diverticular resection, as inflamed tissue planes may render the normal “go to” approach less favorable. This flexibility is important in ensuring continuous progress, moving to another area if not progressing in one area.

Restorative versus nonrestorative sigmoid colectomy

In elective colectomy, often a primary anastomosis is performed. In the more emergency setting (for example, acute diverticulitis with perforation), traditionally a lot of resections are nonrestorative. However, there is increasing evidence that it is safe and reasonable to perform a primary anastomosis in selected patients. ^,

Mesocolic resection versus preservation

If the colectomy is for cancer, complete excision of the mesocolon is required for oncological reasons. However, in diverticular disease, mesenteric and IMA preservation is an option, in comparison to a standard oncologic approach with a high tie of the IMA. Preserving the mesentery has the disadvantage of not creating space as effectively when operating. It also is not good if there is any diagnostic uncertainty, in case there is an unexpected cancer. Going through the mesentery has the disadvantage of being out of plane, with the potential for increased bleeding from friable mesentery. There is also the potential for increased tension on the anastomosis as the IMA has not been divided. The advantage of sparing the mesentery is potentially avoiding retroperitoneal structures that might be pulled in near the IMA in inflammation such as the ureter. It may also render specimen extraction easier for a bulky inflamed specimen, as there is not the same burden of mesentery to extract. Preserving blood supply may reduce the risk of ischemia at the anastomosis. Data are contradictory with no clear evidence base to support either approach, and a tailored approach to the individual patient’s clinical picture is recommended.

Theater and port setup

Special equipment required is given in the box that follows. The approach given here is based on using the da Vinci Xi. Other platforms may require some modifications in approach.

NICE , N atural orifice i ntra c orporeal anastomosis with e xtraction; PDS, polyester pol(p-dioxanone).

SPECIAL EQUIPMENT

Robotic instruments
Tip-up grasper
Bipolar fenestrated grasper
30-degree camera
Monopolar scissors
Vessel sealer
Large clip applier
Mega needle driver (optional)
Sutures (optional, for second layer anastomosis)
2.0 Prolene for pursestring
If performing a second layer on the anastomosis:
3.0 Vicryl cut at 15 cm × 3
Alternatively, 3.0 V-Loc 180 30 cm
Staplers
Circular stapler of choice
Robotic stapler—SureForm 60 stapler with a green reload
Laparoscopic instruments
Bowel graspers (Johan and A-tract)
Suction irrigation
Laparoscopic scissors
Laparoscopic Hem-o-lok gold applicator
Disposable ports
12-mm AirSeal port (optional), or a 12-mm laparoscopic port
GelPOINT or Alexis for Pfannenstiel (or optical port if used instead)
Extras:
- Flexible sigmoidoscopy
Resolution clips
NICE approach
0 PDS Endoloop ×2
Small Alexis wound retractor
Large EndoCatch Babcock (optional)

Patient preparation and positioning

Once the patient is under general anesthetic, they are positioned in Lloyd-Davies position on the operating table. An antislip device is placed on the table prior to positioning the patient. Spontaneous pneumatic compression stockings are applied. Careful attention is placed when positioning in Lloyd-Davies to make sure that there is no pressure on peripheral nerves. Both arms are tucked in with careful attention to pressure areas and use of gel pads. A patient warming system (e.g., Bair Hugger) is applied to maintain normothermia intraoperatively. Abdominal hair is clipped, and anatomical landmarks are marked with a permanent marker. Rectal washout may be performed (optional—not usually performed if bowel preparation was used, but in the context of acute diverticulitis if bowel preparation was not tolerated this may be useful). Placement of ureteric catheters is recommended, and an indwelling urinary catheter is also placed. Preparation and draping are performed.

Ureteric catheters

Ureteric catheters are particularly useful in complex diverticular resections, in patients with significant inflammation where planes are much less clearly defined, and ureters may be drawn into the inflammatory process. Ureteric catheters are placed using cystoscopy and image guidance along with a urinary catheter. The evidence is mixed on whether traditional stents reduce injury, but data are skewed by selection bias of patients who undergo stents. Unlike in open surgery where ureteric catheters are inserted to facilitate identification by feel, in robotic surgery, indocyanine green is injected into the catheters to aide ureteric identification (see Fig. 51.4 ). White et al. describe inserting ureteric catheters to 20 cm and injecting 5 mL of 2.5 mg/mL indocyanine green (ICG). An alternative to injection of ICG is to use fluorescent stents. At the end of the case ureteric catheters are removed and the catheter replaced.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here