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CASE SUMMARY A 54-year-old otherwise healthy woman presented for screening colonoscopy, during which 4 pedunculated 5- to 12-mm polyps distributed throughout the colon were found (Fig. 1). The 12-mm sigmoid polyp was removed with hot snare polypectomy in a nonpiecemeal fashion. Pathology demonstrated 3 tubular adenomas and a poorly differentiated invasive carcinoma in a sigmoid polyp without tumor budding, invading 0.8 mm into the submucosa, with lymphovascular invasion and with a deep margin of 0.6 mm. The next week, she underwent repeat flexible sigmoidoscopy with tattooing of the polypectomy site. She had a normal staging CT chest/abdomen/pelvis as well as CEA level and later underwent uneventful laparoscopic sigmoid resection, which included the area of endoscopic tattoo. Final pathology confirmed the presence of the tattooed area and polypectomy scar and showed no residual primary tumor and 2/18 positive lymph nodes (Fig, 2). She was referred to medical oncology for adjuvant chemotherapy.

Highlights • The precise localization of the fractured rib on the patient’s skin can facilitate rib plating. • Electromagnetic navigation can identify the precise location of the fracture on the skin., Introduction The precise localization of fractured ribs represents one of the primary challenges of surgical rib fixation. Computed tomography (CT) provides the facture’s general location, but it is difficult to use the imaging alone to properly place a surgical incision. We used electromagnetic navigation to identify the exact location of the fracture on the patient’s skin. Presentation of case A 64-year-old man fell and suffered multiple left-sided nonunion rib fractures (4th to 9th). He was initially treated with a chest tube and analgesia, but he developed chronic pain from the injury. On the CT scan of the chest, the rib fractures were displaced and on exam, the ribs were mobile with reproducible pain and clicks on palpation. We used electromagnetic navigation to determine the fracture’s exact location on the skin during the operation, which aided in the location of the incision. The patient had open reduction and internal fixation of the broken ribs using rib plates. The patient had relief from his chronic pain after the surgery. Discussion The localization of the rib fracture on a patient’s skin can be performed using a physical exam, landmarks from the CT scan, or video-assisted thoracic surgery (VATS) procedure. Each of the techniques sacrifices either time or accuracy during the operation. The electromagnetic navigation can provide precise localization of the fracture without sacrificing too much time during the operation. Conclusion The use of electromagnetic navigation to identify the fracture on a patient’s skin provides quick and accurate intraoperative localization for surgical rib fixation.

Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA.A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group.A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p 0.001).Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.

Laparoscopic surgery is now considered by many experts as the approach of choice for the surgical treatment of both benign and malignant colonic diseases. In contrast, robotic-assisted laparoscopic surgery is gaining acceptance and use in the colorectal surgery field. Currently, enthusiasm for the robotic platform, as a minimally invasive approach, has gained most interest for cases involving rectal surgery and pelvic anatomy. The robotic technique offers enhanced optics and mechanical instrumentation, which were designed to greatly improve visualization, exposure, and dissection in confined spaces such as the pelvic cavity. Nevertheless, during robotic surgery, attention to adjacent or distant operative field usually requires cumbersome repositioning of the camera and robotic arms. Thus, the robotic platform is best suited for surgical approach in a confined visual field and optimizes optics, fine tissue handling, and intracorporeal suturing technique, whereas laparoscopic surgery may be best suited for wider operative field of view and gross manipulation and dissection, requires smaller and fewer ports, and affords ready adaptation to various surgical maneuvers. In regard to colon resection, robotic surgery results in comparable short-term outcomes as compared with laparoscopy, although with longer operative time and higher expenses. Thus, the routine use of the robotic platform is not currently supported. However, robotic sigmoid colectomy may be beneficial for cases of complex diverticulitis. In addition, robotic sigmoid colectomy may be used in the teaching/training setting as a learning curve procedure before performing more challenging pelvic procedures. Robotic-assisted laparoscopic rectal resection represents the main indication of the use of the robotic platform in colorectal surgery. In this setting, its optical and operative attributes are actualized, whereas the laparoscopic pitfalls are maximally exposed. Although many rectal resections may be successfully accomplished using conventional laparoscopy, it requires extensive surgical expertise. Randomized controlled trials comparing laparoscopy with robotic technique for the treatment of rectal cancer are currently being conducted, and it will not be until the results of such studies are available that we can draw solid conclusions regarding the role of robotic-assisted laparoscopic surgery in the treatment of rectal cancer. Laparoscopic and robotic-assisted surgeries are safe and viable techniques for the treatment of essentially all colorectal conditions requiring surgical intervention. To determine a suitable minimally invasive surgical approach, it is important to recognize that both laparoscopic and robotic surgeries present benefits and limitations as compared with each other. Hence, the ideal approach should ultimately result in the use of the technique most appropriate for the specific surgical indication, thus realizing the benefits and avoiding the drawbacks of the approach.

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques.Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed.Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n=33) and anterior resections (n=12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups.Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques.

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations.Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge.Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58–83), mean BMI of 26.4 ± 3.4 kg/m2(range: 21.3–30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma(n=3)or thermal injury(n=2)and were localized to the sigmoid(n=4)or cecum(n=1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3–5). There were no readmissions or reoperations.Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes.

Background Colonic perforation during colonoscopy is a rare complication and is usually considered a surgical emergency. Traditionally, such perforations have required laparotomy with repair or resection. Minimally invasive approaches have recently been successfully implemented. We describe our initial experience with a robotic-assisted laparoscopic technique for primary colorrhaphy following colonoscopic perforation. Methods An 84 year-old female presented with an acute sigmoid perforation identified during colonoscopy. Laparoscopic exploration revealed a full-thickness tear into the sigmoid mesentery, which was primarily repaired using robotic-assisted technique. Results The procedure was successfully completed in 135 min with an estimated blood loss of 25 ml. There were no intraoperative complications or need for open conversion. The patient was discharged after 4 days without further hospitalization or secondary surgical intervention. Conclusion In the presented case, robotic primary colorrhaphy was demonstrated to be a safe and feasible alternative for the management of acute colonoscopic perforation and may warrant consideration in the emergency setting. Copyright © 2012 John Wiley & Sons, Ltd.

Background Single-incision laparoscopic surgery is an emerging approach in the field of minimally invasive colon and rectal surgery. This modality utilizes a ‘scarless’ incision concealed within the umbilicus, and results in improved cosmesis with the potential for reduced trauma, pain and length of hospital stay. However, unique technical challenges have curbed its adaptation. Robotic-assisted technique may help overcome these limitations when applied to the single-incision approach. Methods A robotic-assisted single-incision laparoscopic partial cecectomy was performed using the da Vinci® robot and the GelPOINT™ access device. Modifications of the robotic set-up were utilized to optimize the technique. The robotic instruments were crossed below the abdominal wall to minimize internal conflict and maximize range of motion. Control of the robotic arms was reassigned on the robotic console to create a more intuitive surgical approach. The robotic camera was rotated and positioned vertically to reduce external conflict and enhance visualization. Results Robotic-assisted single-incision laparoscopic partial cecectomy was performed in a 53 year-old male without complication or need for conversion. The procedure required 120 min with an estimated blood loss of < 50 ml. Pathology revealed a sessile tubular adenoma of the cecum. The length of hospital stay was 2 days and no complications were encountered. The patient returned with a well-healed 2.5 cm incision and no postoperative complications at 6 weeks follow-up. Conclusions With appropriate modifications, robotic-assisted single-incision laparoscopic surgery may be applicable as a minimally invasive modality for partial colectomy. Further studies are warranted to establish the safety, efficacy, benefits, and limits of this technique. Copyright © 2010 John Wiley & Sons, Ltd.

Our objective was to assess clinical and financial outcomes with long-acting liposomal bupicavaine (LB) in laparoscopic colorectal surgery.Patients that received local infiltration with LB were strictly matched to a control group, and compared for postoperative pain, opioid use, length of stay (LOS), hospital costs, and complication, readmission, and reoperation rates.A total of 70 patients were evaluated in each cohort. Operative times and conversion rates were similar. LB patients had lower post-anesthesia care unit pain scores (P = .001) and used less opioids through postoperative day 3 (day 0 P.01; day 1 P = .03; day 2 P = .02; day 3 P.01). Daily pain scores were comparable. LB had shorter LOS (mean 2.96 vs 3.93 days; P = .003) and trended toward lower readmission, complication, and reoperation rates. Total costs/patient were $746 less with LB, a savings of $52,200 across the cohort.Using local wound infiltration with LB, opioid use, LOS, and costs were improved after laparoscopic colorectal surgery. The additional medication cost was overshadowed by the overall cost benefits. Incorporating LB into a multimodal pain regiment had a benefit on patient outcomes and health care utilization.

Single-port laparoscopic techniques are utilized for various colorectal procedures. In this chapter, we will be describing the operative steps and differences to the multiport technique of a laparoscopic sigmoid resection and Hartmann`s reversal.

Following the overview of laparoscopic techniques to sigmoid resection and Hartmann’s reversal in the previous chapters, we will expand on the utilization of the da Vinci robotic system for this procedure. Certain operative steps described in this chapter are part of a total robotic low anterior resection and proctectomy described in a later chapter for this book.

Laparoscopic intervention for colorectal emergencies depends on both patient and surgeon factors. While mainly used for surgery complications of diverticulitis and cancer, a wide spectrum of applications is possible. Emergent laparoscopic colorectal surgery is safe and feasible in many cases, and permits exploration while limiting incision size, reducing overall morbidity. The ultimate success of emergent laparoscopic colorectal surgery lies in proper patient selection. In this chapter, we address the trends in utilization, indications, technical considerations, and pitfalls of emergent laparoscopic colorectal resection.

Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes.Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1)initial baseline phase; (2)rapid contraction phase; (3)tonic contraction and endurance phase; and (4)late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1)down-training; (2)accessory muscle isolation; (3)discrimination training; (4)muscle strengthening; (5)endurance training; and (6)electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications.Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course.

Robotic hybrid rectal resection is a safe and feasible surgical technique for the management of benign and malignant rectal diseases. In general, available data demonstrate that the robotic hybrid approach results in similar clinical and pathological outcomes as compared to conventional laparoscopy. While totally robotic rectal surgery, also referred to as single-stage robotic rectal surgery, has demonstrated to be a viable approach for the management of rectal diseases, we tend to approach the majority of the robotic rectal resections with a hybrid technique. Our preference for the hybrid technique is based on several factors, which will be discussed in this chapter; however, it is important to recognize that the approach may be altered based on individual case characteristics.

Background: Obesity is associated with increased surgical risk and major abdominal procedures performed in morbidly obese patients may prove challenging when compared with normal weight patients. There are limited data regarding outcomes after minimally invasive colorectal surgery in morbidly obese patients. The aim of this study was to compare the outcomes between morbidly obese and normal weight patients. Materials and Methods: Forty morbidly obese were matched to three normal weight patients (n=120), based on type of surgical approach and procedure. The patients underwent minimally invasive colorectal surgery by one of two colorectal surgeons. Patients were considered morbidly obese or normal-weight based on body mass index. Demographic data and operative outcomes were compared. Results: Mean body mass index differed significantly between the morbidly obese (median 43.9 kg/m2) and normal weight (median 22.7 kg/m2) groups, p

Traditionally, patients with colonic polyps not amenable to endoscopic removal require open colectomy for management. We evaluated our experience with minimally invasive approaches including endoscopic mucosal resection (EMR), laparoscopic-assisted endoscopic polypectomy (LAEP), and laparoscopic-assisted colectomy (LAC). Patients referred for surgery for colonic polyps were selected for one of three minimally invasive modalities. A total of 123 patients were referred for resection of “difficult” polyps. Thirty underwent EMR, 25 underwent LAEP, and 68 underwent LAC. Of those selected to undergo EMR or LAEP, 76.4% were successfully managed without colon resection. The remaining 23.6% underwent LAC. Nine complications were encountered, including two requiring reoperative intervention. Of the 123 patients, three were found to have malignant disease on final pathology. Surgical resection can be avoided in a significant number of patients with “difficult” polyps referred for surgery by performing EMR and LAEP. In those who require surgery, minimally invasive resection can be achieved.

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.

Background Single-incision laparoscopic right hemicolectomy has been shown to be safe and feasible; however, it remains technically demanding. We present a single-incision laparoscopic right hemicolectomy with an inferior-to-superior approach with intracorporeal anastomosis. This approach may help overcome some of the technical challenges of the conventional technique. Technique With the patient in steep Trendelenburg and right-side elevated, a single-incision device is placed at the umbilicus. The small bowel is mobilized out of the pelvis, exposing the ileocolic peritoneal attachments. The peritoneum is divided and the retroperitoneal plane is established in a cranial and medial fashion until the duodenum is exposed. The ileocolic pedicle is readily identified and divided. Further exposure of the retroperitoneal plane is developed and the right branch of the middle colic vessel is isolated and divided. Attention is drawn to the remaining attachments of the hepatic flexure, which is then taken down. The resection margins of the transverse colon and terminal ileum are identified and a side-to-side intracorporeal anastomosis using a double-stapled technique is performed. Conclusions Technical challenges of the single-incision laparoscopic right hemicolectomy may be overcome utilizing an inferior-to-superior approach with intracorporeal anastomosis by affording optimal exposure, retraction, and dissection of the tissue planes.