Colitis Cystica Profunda of the Hepatic Flexure: A Case Report.

A 72-year-old woman with a prior sigmoid resection for colon cancer underwent a right hemicolectomy after a colonoscopy revealed a mass in the hepatic flexure. A preoperative biopsy at colonoscopy showed tubulovillous dysplasia with high-grade neoplasm. The final specimen pathology revealed benign mucosal elements with mucin pools consistent with colitis cystica profunda (CCP). CCP is a benign lesion; no further treatment was necessary after resection. To our knowledge, this is the first reported case of CCP in the right colon, presenting atypically in the hepatic flexure. This case report brings to light the difficulty and importance of making an accurate diagnosis of CCP.

Robotic-Assisted and Laparoscopic Sigmoid Resection.

BACKGROUND AND OBJECTIVES: Published comparisons of minimally invasive approaches to colon surgery are limited. The objective of the current study is to compare the effectiveness of robotic-assisted and laparoscopic sigmoid resection. METHODS: A multicenter retrospective comparative analysis of perioperative outcomes from consecutive robotic-assisted and laparoscopic sigmoid resections performed between 2010 and 2015 by six general and colorectal surgeons, who are experienced in both robotic-assisted and laparoscopic surgical techniques and who had >50 annual case volumes for each approach. Baseline characteristics and surgical risk factors between the two groups were balanced using a propensity score methodology with inverse probability of treatment weighting. Mean standardized differences were reported, and in all instances, a p-value < 0.05 was considered statistically significant. RESULTS: Three hundred thirty-six cases (robotic-assisted, n = 211; laparoscopic, n = 125) met eligibility criteria and were included in the study. Following weighting, patient demographics and baseline characteristics were comparable between the robotic-assisted (n = 344) and laparoscopic (n = 349) groups. The laparoscopic group was associated with shorter operating room and surgical times. The robotic-assisted group had lower estimated blood loss and shorter time to first flatus compared to the laparoscopic group. Rates of complications post discharge to 30 d tended to be lower for the RA group: 5.1% vs 8.6% [p = 0.0657]. The RA group also had lower rates of readmissions and reoperations: 4% vs 8% [p = 0.029] and 0.5% vs 5.1% [p = 0.0003], respectively. CONCLUSIONS: Robotic-assisted sigmoid colon resection is clinically effective and provides a minimally invasive alternative to the laparoscopic approach with improved intraoperative and postoperative outcomes for colorectal patients.

Robotic-assisted ventral and incisional hernia repair with hernia defect closure and intraperitoneal onlay mesh (IPOM) experience.

BACKGROUND: The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM. METHODS: Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed. RESULTS: Mean age was 63.9 years old, with median BMI of 31.24 kg/m2. Median hernia area was 17 cm2. Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376). CONCLUSION: Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis.

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases.

BACKGROUND: In laparoscopic right hemicolectomy (LRC), extracorporeal or intracorporeal (ICA) anastomosis can be performed. Several authors have suggested advantages to ICA. This study reports our transition to and our experience with robotic right colectomy (RRC) with ICA. MATERIALS AND METHODS: From June 2009 to September 2012 we performed 58 consecutive RRCs, of which 52 were with ICA. Data were prospectively stored and retrospectively reviewed. RESULTS: Twenty-eight female and 30 male patients with a mean age of 71.6 ± 8.3 years (range, 52-89 years) were studied. Indications for surgery included adenocarcinoma (n=30), adenoma (n=20), diverticulitis (n=1), and Crohn's disease (n=1). For RRC with ICA (n=52), mean operative time (OT) was 193.2 ± 42.2 minutes (range, 123-239 minutes). Mean estimated blood loss (EBL) was 47.8 ± 59.5 mL (range, 5-300 mL). Mean length of hospital stay (LOS) was 3.7 ± 3.2 days (range, 1-21 days). Mean extraction-site incision size was 4.61 ± 0.78 cm (range, 2.5-6.5 cm). Mean lymph node harvest was 20.7 ± 8.2 (range, 6-40). Mean specimen length was 18.9 ± 7.2 cm (range 10-37). No intraoperative complications, conversions, or 30-day mortality occurred. Nine postoperative complications (19.1%) occurred, with one anastomotic leak (1.7%). For LRC with ICA as reported in the literature, OT ranges from 136 to 190 minutes, EBL ranges from 0 to 500 mL, median LOS ranges from 3 to 5 days, complication rates range from 6% to 15%, with ileus <22%, and conversion rates are <5%. CONCLUSIONS: RRC with ICA is safe and feasible. OTs and outcomes compare favorably with those published in the literature for LRC with ICA. The robot may facilitate transition to ICA, and if future studies confirm advantages of ICA, the role of RRC may gain importance.

Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction.

BACKGROUND AND OBJECTIVES: Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience. METHODS: We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up. RESULTS: The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications. DISCUSSION: The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.

Laparoscopic versus robotic right colectomy: a single surgeon's experience.

There is increased interest in robotic techniques for colon resection, but the role of robotics in colorectal surgery has not yet been defined. The purpose of this study was to compare our recent experience with robotic right colectomy to that with laparoscopic right colectomy. From November 2008 to June 2011, a total of 47 consecutive patients underwent elective, right colectomy: 25 laparoscopic right colectomies (LRC) and 22 robotic right colectomies (RRC). All procedures in this study were performed by a single, board-certified colon and rectal surgeon (H.J.L.). Main outcomes recorded included conversion rate, operative time (OT), estimated blood loss (EBL), length of extraction sites, length of stay (LOS), and complications. Data studied were prospectively recorded in a database and were retrospectively reviewed. Mean OT for LRC was 107 ± 36.7 min (median 98, range 48-207) and for RRC was 189.1 ± 38.1 min (median 185, range 123-288, P < 0.001). Mean total operating room time (TORT) for LRC was 158.6 ± 38.1 min (median 149, range 104-274) and for RRC was 258.3 ± 40.9 (median 251, range 182-372, P < 0.001). The tendency lines for both OT and TORT decreased over time for RRC. EBL for LRC was 70.2 ± 52.9 ml (median 50, range 10-200) and for RRC was 60.8 ± 71.3 ml (median 40, range 10-300, P = 0.037). The mean extraction site length for the laparoscopic group was 5.3 ± 1.3 cm (median 5, range 4-11) and for the robotic group was 4.6 ± 0.7 cm (median 4.5, range 3.5-6, p = 0.008). LOS was similar for both groups, as were complications. No cases were converted to open. No leaks occurred and there was no 30-day mortality. RRC is safe and feasible, with similar outcomes to LRC. Operative times were longer for RRC; however, they compare favorably with times for LRC published in the literature. Extraction site length and EBL were less for RRC. However, further study is necessary to demonstrate the clinical relevance of these findings. We are optimistic that OT and TORT will continue to improve.

Two-stage minimally invasive surgical management of colonic gallstone ileus.

Colonic gallstone ileus is an unusual cause of colonic obstruction. Management of these patients is not standardized and can be challenging. As these patients are often ill and frail at presentation, surgical management needs to be individualized to decrease morbidity and mortality. We report a case that was managed by staged minimally invasive techniques with an excellent outcome.

Laparoscopic management as the initial treatment of acute small bowel obstruction.

OBJECTIVES: We prospectively evaluated our experience with laparoscopic management of acute small bowel obstruction (SBO). METHODS: The study group included all patients requiring surgical intervention based on complete mechanical SBO by clinical assessment or who had failed conservative management. Patients with malignant causes were excluded. Experienced laparoscopic surgeons performed all operations. RESULTS: Between January 1998 to January 2003, 61 patients required operative intervention for acute SBO. Causes included adhesions, internal hernia, incarcerated incisional hernia, and inflammatory bowel disease. Laparoscopic techniques (LAP) alone were successfully used to complete 41 cases (67%). Twenty patients (33%) were converted (CONV) to either mini-laparotomy [7 patients (35%)] or standard midline laparotomy [13 patients (65%)]. A single band was identified in 25 patients (41%). Complications occurred in both groups. CONCLUSIONS: We believe all patients requiring surgery in the setting of acute small bowel obstruction should undergo a laparoscopic approach initially. By specifically identifying those patients with a single band as the cause of obstruction, a significant number of patients will be spared a large laparotomy incision. Conversion should not be viewed as failure, but rather, a sometimes necessary step in the optimal management of these patients.

Penetrating injuries of the subclavian artery.

BACKGROUND: Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS: A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS: The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS: Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.

Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up.

PURPOSE: The role of laparoscopic surgery in the cure of colorectal cancer is controversial. The aim of this study was to evaluate long-term survival after curative, laparoscopic resection of colorectal cancer. Specifically, we wanted to review those patients who now had complete five-year follow-up. METHODS: One hundred two consecutive patients (March 1991 to March 1996) underwent laparoscopic colon resections for cancer at one institution and now have complete five-year survival data. Charts were retrospectively reviewed and results compared with conventional surgery, i.e., open colectomy at our institution, and with the National Cancer Data Base during a similar time period. RESULTS: Fifty-nine male and 43 female patients with an average age of 70 (range, 34-92) years made up the study. Complications occurred in 23 percent of patients, and one patient died (1 percent). Forty-four laparoscopic right colectomies, 2 transverse colectomies, 36 laparoscopic left or sigmoid colectomies, 15 laparoscopic low anterior resections, and 5 laparoscopic abdominoperineal resections were performed. The average number of lymph nodes harvested was 6.6 +/- 0.61 (range, 0-22). Eight cases (7.8 percent) were "converted to open"; i.e., the typical 6-cm extraction site was lengthened to complete mobilization, devascularization, resection, or anastomosis, or a separate incision was required to complete the procedure. There was one extraction-site recurrence and one port-site recurrence; both occurred before the routine use of plastic-sleeve wound protection. The mean follow-up for laparoscopic colon resection patients was 64.4 +/- 2.8 (range, 1-111) months. According to the TNM classification system, 27 patients had Stage I cancer, 37 had Stage II, 23 had Stage III, and 15 had Stage IV. Similar five-year survival rates for laparoscopic and conventional surgery for cancer were noted. The five-year relative survival rates in the laparoscopic colon resection group were 73 percent for Stage I, 61 percent for Stage II, 55 percent for Stage III, and 0 percent for Stage IV. The five-year relative survival rates for the open colectomy and National Cancer Data Base groups were 75 and 70 percent, respectively, for Stage I, 65 and 60 percent for Stage II, 46 and 44 percent for Stage III, and 11 and 7 percent for Stage IV. CONCLUSIONS: Laparoscopic colon resection for cancer is safe and feasible in a private setting. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery. Prospective, randomized trials presently under way will likely confirm these results.