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fashioninganend-to-sideanastomosis.Notetheside limbshouldbeabout3cm.
TestingtheAnastomosis
Theanvilandspikeareseparatedonwithdrawalofthestapler,andthe resectedendsoftheanastomosisshouldbeinspectedtoconfirmthe
muscularwallisintact. Thecolonproximaltotheanastomosisshouldbegentlyoccludedwith
anatraumaticclamp,thepelvisshouldbefilledwithsaline,andthe anastomosisshouldbegentlysubmerged.
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p.131
Usingflexiblesigmoidoscopy,theanastomosisshouldbedirectly visualizedtoconfirmanintactstapleline,hemostasis,andviabledistal
andproximalmucosa.Thepelvisshouldbecheckedforextravasationof airfromtheleaksintheanastomosisintothesaline-filledpelvis.
Fluorescenceimagingtechnologycanalsobeusedtoassessperfusionto theanastomosis.Intravenousindocyaninegreenisinjectedandthe
anastomosisisexternallyandtransanallyvisualized.Achangeoftissue colortogreenthroughfluorescenceangiographycanconfirmperfusion. Inarecenttrial,thistechnologywasfoundtochangeoperativeplansin 8%ofpatientswithfindingsofinadequateperfusion.Therewereno anastomoticleaksinthesepatients.
DrainPlacement
Theuseofpelvicdrainsiscontroversial. Althoughinitiallythoughttodecreasetheriskofanastomotic
complicationsbypreventingtheaccumulationoffluidandbloodinthe pelvis,thishasnotbeenborneoutintheliterature.Mostrandomized controlledtrailsandmeta-analyseshavenotshownanyharmorbenefit intheprophylacticplacementofpelvicdrains.
Theseauthorsroutinelydrainalllowpelvicanastomoses.
POSTOPERATIVEMANAGEMENT
Thelast10yearshaveseenmarkedadvancesinthepostoperative managementofcolorectalpatientsundergoingmajorabdominal
resection.Theroutineuseoftheadvancedrecoverypathwayhasreduced lengthofstaybymorethan30%anddecreasedpostoperative complicationsbyupto50%.
Factorsofperioperativecarethatdemonstratebenefitinclude:
inflammatorydrugs,muopioidantagonist,andgamma-aminobutyric acidantagonists
magnesiumoxide

COMPLICATIONS

Postoperativecomplicationsareusuallyrelatedtotechnicalfactorsor patient-relatedfactors.Allattemptsshouldbemadetoassessand optimizethesefactorsbeforeandduringsurgery.Careshouldbetakento createatension-freeanastomosisanddivertproximallywhenindicated.
AnastomoticBleeding
Postoperativebleedingcanpresentonaspectrumrangingfrom insignificanthematocheziatoseverehemorrhagewithhemodynamic instability.Patientswillusuallycomplainofbloodperrectumfollowing thefirstbowelmovementandmayexperienceadropinserum hemoglobin.Typically,bleedingisself-limitedandwillstopwithin24–72 hours.Rarely,bleedingcanbemassiveandrequiretransfusioninwhich caseendoscopicortransanalcontrolshouldbeattempted.Endoluminal maneuversmayincludeinjectionoftheanastomosiswith1:10,000 epinephrine,cauterization,clipapplication,orsutureligation.These authorsfavorflexiblesigmoidoscopyaftercompletionofanyanastomosis tocheckforhemostasisandsutureligateorclipareasofsignificant bleedingunderdirectvisualization.
AnastomoticLeak
Anastomoticleakisadevastatingcomplicationthatoccursin approximately5–8%ofallanastomoses,withanincidenceofover20%in lowpelvicanastomosis.
Randomizedhead-to-headcomparisonofEEAandside-to-end anastomosishasshownasignificantlylowerleakratewithaside-to-end anastomosis(29.2%vs.5%).Althoughnotproven,thisisfelttoberelated toamorereliablebloodsupplyoftheside-to-endanastomosis.Similarly, colonicJ-pouchhasbeenfoundtohavethelowestleakrateswhen comparedtobothend-to-endcoloanalanastomosisandtransverse coloplasty.
p.131
p.132
Thepresentationofleaksoccursonaspectrumandmanagement requiresathoughtfulapproachbythesurgeon.Clinicalmanifestations andradiographicfindingscanvarywidelyamongpatients,andtreatment shouldbebasedaroundthesefindings.
Diagnosisshouldbesuspectedwiththedevelopmentofabdominal pain,ileus,fever,tachycardia,leukocytosis,orentericcontentsfrom incisionsitesordrains.Computedtomographyscanshouldbeobtained lookingforabscessformation,phlegmon,sinus,freefluid,freeair,or contrastextravasation.
Patientswithcontainedleaksdefinedasaperianastomoticphlegmon, sinus,orabscesswithnoevidenceofperitonitiscanbetreatedwithbroad spectrumIVantibioticsandserialexaminations.Allintra-abdominal collectionamenabletopercutaneousinterventionshouldbedrained underimageguidance.Patientswithperitonitisorsystemicsignofsepsis suchashemodynamicchanges,multiorgansystemfailure,andmetabolic acidosisshouldbeconsideredforoperativeinterventionafter resuscitationandadministrationofantibiotics.Operativeintervention canincludewashoutwithdrainplacementandproximaldiversion, revisionoftheanastomosis,orHartmann’scolostomy.Leakscanalsobe asymptomaticintheacutesettingmostcommonlyseenwithprophylactic divertingloopileostomyandmaypresentlateinthepostoperativeperiod withstricturesorfistulas.
Preventionofleaksshouldbetheprimaryaimintheconstructionof anyanastomosis.Techniquestoreducetensionontheanastomosis includecompletemobilizationoftheproximalcolonfromthelateral attachmentsandhighligationoftheinferiormesentericarteryandvein attheinferiorborderofthepancreas.Ensuringgoodbloodsupplyto anastomosisisofparamountimportance.Pulsatilebleedingfromthe marginalarteryshouldbedemonstratedthroughpalpationorDoppler signal.Endoscopicexaminationshouldalsoconfirmviabilityofthebowel byrevealingpinkandwell-perfusedmucosa.Patient-relatedfactorsthat havebeenassociatedwithleakincludemalnutrition,exposureto radiation,immunosuppression,smoking,andanemia.
RESULTSOFLONG-TERMFUNCTIONAL OUTCOMES
TheliteratureincludesmultiplecomparisonsofEEAwithdifferent reconstructivetechniquesafterLARincludingcolonicJ-pouch, transversecoloplasty,andside-to-endanastomosis.
In2016,arandomizedcontrolledtrialof86patientsaimedtocompare surgical,functional,physiologic,andqualityoflifeoutcomesafterLAR withside-to-endorstraightcolorectalanastomosis.Outcomemeasures includednumberofbowelmovements,nocturnalincontinence,urgency, Wexnerscore,fecalIncontinenceQualityofLifeScale,andtheuseof antidiarrhealmedicine,laxatives,enemas,andpads.Physiologic assessmentsusinganalmanometryandvolumetricanalysiswerealso performed.Overallmorbidityofeachgroupwasequivalent,andat6 monthsoffollow-up,theonlybenefitofside-to-endanastomosiswasa lowernumberofbowelmovements.
Similarly,meta-analysishasshowncolonicJ-pouchtobesuperiorto EEAinfrequency,urgency,andfecalincontinence,withadecreaseduse ofantidiarrhealmedications.However,therewasnosignificant differencefoundwhencomparingcolonicJ-pouchtotransverse coloplastyorside-to-endanastomosis.
Theoptimallengthofthesidelimboftheside-to-endanastomosishas alsobeenstudied.Arandomizedstudyexaminingfunctionaftershort(3 cm)versuslong(6cm)sidelimbsshowedsimilarclinicalresultsbutan increaseofevacuatorydysfunctionseenofdefecographyinthelonglimb group.
ItisimportanttonotethatpatientswhoundergoAPRhavean equivalentqualityoflifewhencomparedtopatientswhoundergo coloanalanastomosis,andelectingforpermanentstomashouldnotbe consideredfailureinpatientswhoseexpectedpostoperativefunctionmay becompromised.

CONCLUSION

Aside-to-endlowcolorectalanastomosisisasimplealternative techniquetoastraightEEAthatmaybeusedpreferentiallytoimprove function.Importantpreoperativecounseling,advancedrecovery initiatives,andtheearlyidentificationofpostoperativecomplicationsare allkeycomponentstoqualitysurgicalcare.
RECOMMENDEDREFERENCESAND READINGS
BessonR,ChristidisC,DenetC,etal.Managementofpostoperativebleedingafterlaparoscopic
leftcolectomy.IntJColorectalDis2016;31:1431–6. BrisindaG,VanellaS,CadedduF,etal.End-to-endversusend-to-sidestapledanastomosesafter
anteriorresectionforrectalcancer.JSurgOncol2009;99:75–9. BrownCJ,FenechD,McLeodRS.Reconstructivetechniquesafterrectalresectionforrectal
cancer.CochraneDatabaseSystRev2008;(2):CD006040. DigennaroR,TondoM,CucciaF,etal.Coloanalanastomosisorabdominoperinealresectionfor
verylowrectalcancer:whatwillbenefit,thesurgeon’sprideorthepatient’squalityoflife?Int
JColorectalDis2013;28:949–57. JafariMD,WexnerSD,MartzJE,etal.Perfusionassessmentinlaparoscopicleft-sided/anterior
resection(PILLARII):amulti-institutionalstudy.JAmCollSurg2015;220:82–92. JesusEC,KarliczekA,MatosD,CastroAA,AtallahAN.Prophylacticanastomoticdrainagefor
colorectalsurgery.CochraneDatabaseSystRev2004;(4):CD002100. RybakovEG,PikunovDY,FomenkoOY,ChernyshovSV,ShelyginYA.Side-to-endvs.straight
stapledcolorectalanastomosisafterlowanteriorresection:resultsofrandomizedclinicaltrial.
IntJColorectalDis2016;31:1419–26. SteeleSR,HullTL,ReadTE,etal.Anastomoticcomplications.In:UmanskiyK,ed.TheASCRS
TextbookofColonandRectalSurgery.Arlington,IL:SpringerInternationalPublishing,
2016:161–71. TilneyHS,HeriotAG,PurkayasthaS,etal.Anationalperspectiveonthedeclineof
abdominoperinealresectionforrectalcancer.AnnSurg2008;247:77–84. TsunodaA,KamiyamaG,NaritaK,WatanabeM,NakaoK,KusanoM.Prospectiverandomized
trialfordeterminationofoptimumsizeofsidelimbinlowanteriorresectionwithside-to-end
anastomosisforrectalcarcinoma.DisColonRectum2009;52:1572–7. UrbachDR,KennedyED,CohenMM.Colonandrectalanastomosesdonotrequireroutine
drainage:asystematicreviewandmeta-analysis.AnnSurg1999;229:174–80. VaradhanKK,NealKR,DejongCH,FearonKC,LjungqvistO,LoboDN.Theenhancedrecover
aftersurgery(ERAS)pathwayforpatientsundergoingmajorelectiveopencolorectalsurgery:a
meta-analysisofrandomizedtrials.ClinNutr2010;29:434–40. ZhangHY,ZhaoCL,XieJ,etal.Todrainornottodrainincolorectalanastomosis:ameta-
analysis.IntJColorectalDis2016;31:951–60.
Chapter17
HybridRoboticandFully RoboticProcedure
CigdemBenliceandEmreGorgun

INDICATIONS/CONTRAINDICATIONS

Sincetheintroductionoflaparoscopiccolectomy,colorectalsurgery practicehasdramaticallychangedoverthepastthreedecadesbygrowing useofminimallyinvasivetechniques.Minimallyinvasivetechniqueshave improvedpostoperativerecoveryandreducedmorbidityandlengthof hospitalstayaftercolorectalsurgerycomparedtoopensurgery.
Surgicalresectionremainsthemostimportanttreatmentmodalityin themanagementofrectalcancerintermsofcurativeresection,staging, prognosis,andsubsequenttherapeuticdecisions.However,rectalcancer surgeryistechnicallychallengingbecauseofthelimitedboundariesand thecomplexnatureofthepelviswithcloseproximitytothepresacral veinsandautonomic,sexualnervesandorgans.Challengesduringrectal surgery,however,arelikelymagnifiedwhentheadditionaldifficultiesof thelaparoscopictechniqueareaddedtotheprocedurebecauseofthe ergonomiclimitationsoftheinstruments.Thelaparoscopicsurgeonis requiredtoundertakethesamemulti-quadrantoperationsasopen surgerybutwithlimitedtactilefeedbackunderthetwo-dimensional visualizationthatreducesin-depthperceptionaswellashand–eye coordination.
Accordingly,tworecentrandomizedtrials,theAmericanCollegeof SurgeonsOncologyGroup(ACOSOG)Z6051andAustralasian LaparoscopicCanceroftheRectum(AlaCaRT),failedtoprovenon­inferiorityofthelaparoscopictechniqueforrectalcancer.Interestingly, Fleshmanetal.statedinthediscussionoftheACOSOGtrialthatone explanationfortheirfindingsisthatproctectomyischallengingat baseline,anditcanbeevenmoredifficulttoworkinthedeeppelviswith in-linerigidinstrumentsfromanglesthatrequirecomplicatedmaneuvers
toreachtheextremesofthepelvis.Theyalsocontinuedtostatethatitis possiblethatmodificationofinstrumentsoradifferentplatformsuchas roboticswillimproveefficacyofminimallyinvasivetechniques. Furthermore,theyindicatedthatwristedinstrumentsmayprovidethe neededcontrolinthedeeppelvisandplacementofinstrumentsinline withsidewallsofthepelvisandremotecontroloftheseinstruments provideergonomicfeasibilitytoperformminimallyinvasiveresection. Essentially,thesearecharacteristicsoftheexistingroboticplatformand thisjustifiesfurtherinvestigationinthefield.
Indeed,theroboticapproachisanemergingtechniqueinthesettingof colorectalsurgery.Three-dimensionalvisualization,endo-wristed instrumentations,tremorreduction,ergonomics,andphysicalcomfort forthesurgeonareseveraladvantagesofroboticsurgery(RS)over laparoscopy.
Thereisstilldebatewhetherthistechnologywilltranslateintoclinical efficiencyandvalueofcare.Thischapterdiscussestheroleofrobotic approachonlowanteriorresectionbyfocusingonrectalcancersurgery anddescribesvariousapproachesinroboticrestorativeproctectomy.
PREOPERATIVEPLANNING
Properpatientselectioniscrucialtopreoperativeplanning,andpatients shouldbebothmedicallyfitandabletotolerateminimallyinvasive surgery.Allpatientsshouldundergoadetailedhistoryandphysical examination.Preoperativefullcolonoscopyisrecommendedforall patientswithrectallesions,especiallyforidentificationoftumorlocation andpossiblesynchronouscolorectallesions.Aspartofthepreoperative preparationforrectalsurgery,patientsshouldundergoamechanical bowelpreparationwithoralantibiotics.Inourpractice,mechanical bowelpreparationandoralantibioticsarecompulsorytosustainlow postoperativesurgicalsiteinfection.Preoperativebroad-spectrum intravenousantibioticsaregivenwithin60minutesoftheincisiontime, toensureadequateconcentrationattheoutset.Deepvenousprophylaxis shouldincludetheuseofsequentialcompressiondevices,aswellas chemicalprophylaxis(preoperativeheparin).
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PreoperativeantibioticsareadministeredonthebasisoftheSurgical CareImprovementProject–relatedmeasures.Rectalirrigationand washoutwithsalineisperformedinrectalcancercases.AFoleycatheter andanintraoperativeorogastrictubeareplacedinallcasesduringthe operation.
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