Robotic rectal cancer surgery

In this key lecture, Dr. Brunaud demonstrates the application of robotics in endocrine surgery, highlighting indications and contraindications.

Gastric bypass is one of the most common procedures in bariatric surgery. The main steps of this procedure are well codified, namely fashioning of a small-sized gastric pouch in contact with the esophagus, measuring of a biliary limb and of an alimentary limb, gastrojejunal anastomosis and jejunojejunal anastomosis at the foot of the loop. The Da Vinci™ robotic Surgical System is particularly suited for manual anastomoses. This video demonstrates the use of the robot to perform gastrojejunal and jejunojejunal anastomoses.

Introduction: Since the first robotic adrenalectomy by Piazza et al. in 1999, using both the ZEUS and AESOP systems, numerous series and case reports have been published describing both left and right adrenalectomies using both transperitoneal and retroperitoneal approaches. These studies demonstrate that the robotic approach is feasible and safe.
Methods: This is the case of a 43-year-old female patient who presented with weakness, muscular cramps and systemic arterial hypertension. Her blood tests revealed a high Na++, low K+, very low renin (inhibited) and high aldosterone dose levels. A CT-scan showed a unique adenoma within 2.6cm at the left adrenal gland. She was diagnosed with Conn’s syndrome.
Results: In this video showing a robotic left adrenalectomy, the patient was placed in a left lateral decubitus, jack-knife position. Four robotic arms were used. Dissection was performed by means of scissors and of a bipolar fenestrated forceps. Operative time took 95 minutes. No measurable bleeding was observed. No UCI stay was necessary and the patient was discharged 24 hours after the intervention.
Conclusion: In this case, adrenal surgery was performed using a robotic approach, which demonstrated that the procedure was feasible, safe, with a low morbidity and a short hospital stay.

Minimally invasive techniques were revolutionary and provided evident clinical benefits. Robotic-assisted surgery may be useful in advanced laparoscopic procedures such as pancreatic resections. In this lecture, Professor Giulianotti presents a robotic distal pancreatectomy.

The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

This is the case of a robotic pancreaticoduodenectomy for an intraductal papillary mucinous neoplasm (IPMN) performed in a 50-year-old patient discovered on pancreatic MRI after three episodes of acute pancreatitis.

Objective
Surgical treatment of bronchiectasis is often proposed in complicated situations [1]. The development of minimally invasive surgery should allow us to propose a surgical curative treatment with preventative purposes. In this video, we describe a lung-sparing surgery using a full endoscopic robotic segmentectomy as described by Dylewsky [2] to deal with localized bronchiectasis.
Case presentation
This is the case of a 40-year-old man with bronchiectasis, colonized by Pseudomonas aeruginosa with antibiotic resistance. The patient suffered from recurrent infections. Bronchiectasis is localized in the left basal segments on CT-scan. Basal segmentectomy was decided upon using a robot-assisted procedure. This kind of patient is usually treated medically with iterative antibiotherapy until a new complication occurs.
Results
There was no postoperative complication and the patient was discharged on postoperative day 4. The patient resumed work after one month without any complaint.
Conclusion
When using a precise resection, basal segmentectomy seems to be feasible using a robot-assisted procedure, without increasing perioperative morbidity. This procedure should be proposed as a preventative surgery as it is a relatively new approach for benign or infectious lung disease.
Bibliographic references
1. Agasthian T. Results of surgery for bronchiectasis and pulmonary abscesses. Thorac Surg Clin. 2012;22:333-44.
2. Dylewski MR, Ohaeto AC, Pereira JF. Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg. 2011;23:36-42.

Objective:
When small pulmonary lesions are discovered on CT-scan during cancer surveillance, the differentiation between primary cancer metastasis and another metachronous carcinoma is impossible on frozen section. In this context, segmentectomy as sparing-lung resection is probably a valuable option to treat both lesions. However, segmentectomy is a complex procedure when using video thoracoscopy. Robotic segmentectomy, as described by Ninan (1) and Melfi (2), could be a more accurate and easier approach. Our objective is to show this reproducible technique.

Bibliographic references:
1. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg 2010;38:231-2.
2. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
Materials and methods:
In 2006, a 78-year-old man was found with a medical history of asbestos exposure and colonic adenocarcinoma with lymph node metastasis treated by hemi-colectomy and adjuvant chemotherapy. During colon cancer surveillance, a centrimetric pulmonary mass of the left upper lobe was found on CT-scan in September 2012. In this context, the lesion was suggestive of metastasis, but primary lung cancer could not be ruled out (due to the patient’s history of smoking). As a result, trisegmentectomy of the left upper lobe was decided upon instead of wedge resection, for diagnosis and treatment of the lesion.
Results: The postoperative course was uneventful, with a medical discharge on the fourth day following trisegmentectomy. Pathological findings concluded to a primary lung carcinoma without lymph node invasion.
Conclusion: Complete and precise segmentectomy can be performed safely by means of the da Vinci™ robotic system, without using a utility thoracotomy. This diagnostic and therapeutic option must be considered in case of small pulmonary lesions occurring during cancer surveillance.

In this lecture, Dr. Katz presents the evolution of robotic surgery and its application in morbidly obese patients. Dr. Katz’s technique is also outlined.