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m
Bare area &
18 Laparoscopic Left andSigmoid Colectomy: Options forColonic andColorectal…
window in mesentery
Ileocolic
pedicle
Terminal ileu
Cecum
285
Rectum
EEA stapler
Fig. 18.7 When there is difculty getting the proximal colon to reach easily into the pelvis, the
colon can be brought down the right side and passed through a window on the ileal side of the
ileocolic pedicle
retrospective study designs, relatively low incidence of anastomotic leaks, varying
denitions of a leak, and selection bias based on inability to account for surgeon
decision of when not to create an anastomosis. Having said all of that, there are a
handful of factors that have consistently been shown to impact the rate of anastomotic leak (Box 18.1). The site of the anastomosis does have an impact. Any anastomosis of the colon to the rectum has a higher rate of leak when compared to
ileocolic anastomosis and small bowel anastomosis [5]. Additionally, the level of
the anastomosis from the anal verge has an impact as anastomoses <5cm from the
anal verge have a six times greater risk of an anastomotic leak than anastomoses
286
a
Cecum
m
M. G. Mutch
Rotate
Rotate
Rotate
Middle colic
vessels ties
Ileocolic
vessels
intact
Te rminal ileum
b
Cecum
Te rminal ileu
Ileocolic
vessels intact
Middle colic
vessels ties
Rectum & EEA
stapler
Fig. 18.8 (a, b) The Deloyer’s technique. (a) The right colon and transverse colon are in situ with
the middle colic vessels have been ligated. The arrows demonstrate that the end of the colon and
cecum are rotated counterclockwise 180. (b) The right colon and transverse colon are completely
mobilized and rotated counterclockwise 180. This results in placing the cecum in the RUQ and the
end of the colon in the pelvis
18 Laparoscopic Left andSigmoid Colectomy: Options forColonic andColorectal…
Box 18.1 Risk Factors for an Anastomotic Leak
287
Site of anastomosis:
Colorectal > ileorectal > ileocolic > small bowel
Height of colorectal anastomosis:
<5cm from anal verge
Male gender
BMI >30
Complexity of procedure:
Combined procedures
Excessive operative time
Excessive blood loss
Intraoperative adverse event
Malnutrition
Smoking
Crohn’s disease
Failure to perform an air leak test
above that level [6]. The complexity of the patient and operative procedure inuences the risk of an anastomotic leak. For example, prolonged operative times of
>200minutes, combined procedures, and need for blood transfusions have been
shown to be associated with an increased risk of leak by factors of 3.4, 3.7, and 3.1
times, respectively [7]. Specic patient-related factors that have been found to
increase the risk of anastomotic leak include male gender, a body mass index
(BMI) >30 who are having an anastomosis below the peritoneal reection, steroid
use, and smoking [8, 9]. Based on the German Rectal Cancer Trial that compared
preoperative vs postoperative radiation therapy, there was no difference in the rate
of anastomotic leak between the two groups [10]. After the introduction of early
recovery after surgery protocols, there has been a urry of articles examining the
association between NSAID usage and anastomotic leaks [11–14]. There does
appear to be some associated increased risk, but these studies have been retrospective. As a result, they lack detailed information such as accurate usage from a timing and dosage perspective, and there are many confounding factors in the study
populations such as comorbidities, steroid use, and emergent and elective surgery.
Thus, it is difcult to draw rm conclusions, so routine usage in ERAS protocols
remains common practice. Finally, one of the most effective preventative measures
for anastomotic leak is the use of preoperative bowel preparation with a mechanical component and oral antibiotics. Using colon and rectal surgery-specic NSQIP
(National Surgical Quality Improvement Program) data, Scarborough and colleagues demonstrated a signicantly lower rate of leak with a mechanical and oral
antibiotic prep (2.8%) compared to mechanical prep only (4.2%), oral antibiotics
only (5.5%), and no prep (5.7%) (p= 0.001) [15]. Therefore, it is recommended
that all patients undergoing elective colon and rectal surgery receive a mechanical
and oral antibiotic preparation.
288
M. G. Mutch
Anastomotic Assessment
Anastomotic assessment at the time of surgery is critical for a successful anastomosis. There are two components to the assessment. Air leak testing assesses that the
staple line is airtight, and direct visualization provides the ability to conrm an
intact staple line, gross perfusion to both ends of the bowel, and to manage bleeding
from the staple line. The benet of routine anastomotic testing is a decrease in the
chances that the anastomosis leaks. The state of Washington through their Surgical
Care and Outcomes Assessment Program demonstrated a 75% reduction in the
anastomotic leak rate for hospitals that performed routine testing (dened as >90%
of cases) compared to hospitals that did not routinely test their anastomosis [OR
0.23 (95% CI 0.05–0.99] [16]. Management of specic anastomotic complications
is discussed above. The assessment can be performed with either exible endoscopy
or rigid proctoscopy, and some will advocate instilling the rectum with betadine
versus air. It is also essential to clearly document your ndings in the operative note.
Bowel Function forReconstruction After Low Anterior Resection
Bowel function changes signicantly for patients after proctectomy. Low anterior
resection syndrome (LARS) occurs in 25–80% of patients and is characterized by
stool frequency, urgency, clustering, and/or emptying problems. In order to improve
bowel function after proctectomy for anastomosis within 5cm of the anal verge,
surgeons have utilized all of the reconstruction techniques described above. In 2007,
Fazio and colleagues published the rst results from a prospective randomized trial
comparing colonic J pouch, transverse coloplasty, and straight coloanal anastomosis
[4]. They reported that the colonic J pouch had signicant improvement in number
of bowel movements, fragmentation, and incontinence, but there was no difference
between coloplasty and straight anastomosis. However, after 2years there was no
difference in quality of life score between all three groups. In a more recent multicenter prospective randomized trial comparing end to side, colon J pouch, and
straight anastomosis, it demonstrated no difference in composite evacuation and
incontinence scores at any time point [17]. The composite evacuation score included
data on the use of medications, difculty emptying, need for digitation to empty,
feeling of incomplete evacuation, need for straining, and time required to evacuate.
Putting these studies together, the determination for the type of reconstruction after
proctectomy remains up to surgeon preference. There does appear to be some early
benet for the use of a colonic J pouch, but any difference is lost after 2years.
Therefore, patients with concern for difculty managing their bowels, fecal incontinence, or an anastomosis below 5cm may be best served by a colonic J pouch.
Temporary Fecal Diversion
Utilization of fecal diversion for high-risk anastomoses is benecial in reducing the
incidence of leak and managing the leak when it occurs. There are several
18 Laparoscopic Left andSigmoid Colectomy: Options forColonic andColorectal…
289
multicenter, prospective randomized trials demonstrating a decreased leak rate after
low anterior resection for rectal cancer. In 2007, a trial from Sweden reported a
reduced leak rate with either a diverting ileostomy of colostomy of 10.3% or 28%
without diversion (p<0.001) for anastomosis below 5cm [18]. These ndings have
been conrmed by more recent study by Mrak and colleagues [19]. They demonstrated improved leak rate for those patient with diverting stomas [5.8% compared to
16.3% (p=0.04)]. Both studies also demonstrated a decreased rate of urgent reoperation when a leak does occur, thus suggesting greater ease of managing a leak.
Diversion with either a loop ileostomy vs loop colostomy is acceptable. Each
type of stoma has positives and negatives. Loop ileostomies are easy to manage and
easy to reverse but have a higher rates of dehydration and pouching difculties [20].
In contrast, loop colostomies have a higher rate of prolapse, herniation, and morbidity after closure. It remains surgeon preference for utilizing a diverting ileostomy
versus colostomy. For more details on optimizing stoma function and quality of life,
please refer to Chap. 36 on best practices in planned and unplanned stoma
creation.
Conclusion
Anastomotic creation after left-sided colon or rectal resection is technically demanding and its critical aspect of a successful operation. The principles of a healthy
anastomosis include utilization of healthy bowel, adequate perfusion to the bowel,
adequate mobilization of the colon to ensure no tension, and assessment of the anastomosis. The type of reconstruction for the anastomosis is up to surgeon discretion
as there appears to be little benet of one type of reconstruction over another.
Surgeons should be familiar with potential risk factors associated with leaks and
capable of identifying and managing intraoperative anastomotic complications as
their decision-making at the time of the operation is critical for a successful
outcome.
References
1. Rojas-Machado SA, Romero-Simó M, Arroyo A, Rojas-Machado A, López J, Calpena
R.Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index
PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational
studies of risk factors. Int J Color Dis. 2016;31(2):197–210.
2. Jim JH, Kim HY, Lee IK, Oh ST, Kim JG, Lee YS.Intra-operative double-stapled colorectal
or coloanal anastomosis complications of laparoscopic low anterior resection for rectal cancer:
double-stapled anastomotic complication could result in persistent anastomotic leakage. Surg
Endosc. 2015;(11):3117–24.
3. Cheng KP, Roslani AC, Sehha N, Kueh JH, Law CW, Chong HY, etal. ALEXIS O-Ring wound
retractor vs conventional wound protection for the prevention of surgical site infections in
colorectal resections(1). Color Dis. 2012;14(6):e346–51.
4. Fazio VW, Zutshi M, Remzi FH, Parc Y, Ruppert R, Fürst A, etal. A randomized multicenter
trial to compare long-term functional outcome, quality of life, and complications of surgical
procedures for low rectal cancers. Ann Surg. 2007;246(3):481–8.
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5. Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk factors for anastomotic leak following
colorectal surgery: a case-control study. Arch Surg. 2010;145(4):371–6.
6. Lipska MA, Bissett IP, Parry BR, Merrie AE.Anastomotic leakage after lower gastrointestinal
anastomosis: men are at a higher risk. ANZ J Surg. 2006;76(7):579–85.
7. Buchs NC, Gervaz P, Secic M, Bucher P, Mugnier-Konrad B, Morel P. Incidence, conse-
quences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective
monocentric study. Int J Color Dis. 2008;23(3):265–70.
8. Gendall KA, Raniga S, Kennedy R, Frizelle FA.The impact of obesity on outcome after major
colorectal surgery. Dis Colon Rectum. 2007;50(12):2223–37.
9. Midura EF, Hanseman D, Davis BR, Atkinson SJ, Abbott DE, Shah SA, etal. Risk factors and
consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum.
2015;58(3):333–8.
10. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, etal. Preoperative ver-
sus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731–40.
11. Hakkarainen TW, Steele SR, Bastaworous A, Dellinger EP, Farrokhi E, Farjah F, et al.
Nonsteroidal anti-inammatory drugs and the risk for anastomotic failure: a report from
Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP). JAMA Surg.
2015;150(3):223–8.
12. Saleh F, Jackson TD, Ambrosini L, Gnanasegaram JJ, Kwong J, Quereshy F, etal. Perioperative
nonselective non-steroidal anti-inammatory drugs are not associated with anastomotic leakage after colorectal surgery. J Gastrointest Surg. 2014;18(8):1398–404.
13. Kotagal M, Hakkarainen TW, Simianu VV, Beck SJ, Alfonso-Cristancho R, Flum DR.Ketorolac
use and postoperative complications in gastrointestinal surgery. Ann Surg. 2016;263(1):71–5.
14. Bakker N, Deelder JD, Richir MC, Cakir H, Doodeman HJ, Schreurs WH, etal. Risk of anas-
tomotic leakage with nonsteroidal anti-inammatory drugs within an enhanced recovery program. J Gastrointest Surg. 2016;20(4):776–82.
15. Scarborough JE, Mantyh CR, Sun Z, Migaly J.Combined mechanical and oral antibiotic
bowel preparation reduces incisional surgical site infection and anastomotic leak rates after
elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP. Ann Surg.
2015;262(2):331–7.
16. Kwon S, Morris A, Billingham R, Frankhouse J, Horvath K, Johnson M, etal. Routine leak
testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program. Arch
Surg. 2012;147(4):345–51.
17. Marti WR, Curti G, Wehrli H, Grieder F, Graf M, Gloor B, etal. Clinical outcome after rec-
tal replacement with side-to-end, Colon-J-Pouch, or straight colorectal anastomosis following
total mesorectal excision: a Swiss prospective, randomized, multicenter trial (SAKK 40/04).
Ann Surg. 2019;269(5):827–35.
18. Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R.Defunctioning stoma reduces
symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14.
19. Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, etal. Diverting ileos-
tomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery. 2016;159(4):1129–39.
20. Rondelli F, Reboldi P, Rulli A, Barberini F, Guerrisi A, Izzo L, et al. Loop ileostomy versus
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M. G. Mutch
Robotic Left-Sided Colon Resections:
Unique Considerations andOptimal
19
Setup
MarkKaramSoliman andOvuncBardakcioglu
Introduction andRationale
It is widely accepted that compared with open operations, minimally invasive abdominal surgery is superior in nearly every aspect: reduced pain, faster return of bowel function, reduced length of hospital stay, lower overall cost of care, improved cosmesis,
lower hernia rates, and quicker return to work [1]. This holds true for most laparoscopic
operations and is therefore the reason that the laparoscopy has become the gold standard for a large part of elective and emergent operations. The same clinical benets are
seen in patients undergoing minimally invasive colorectal operations but with the
added benet of equivalent oncologic benets and a trend towards improved cancerrelated survival in at least one randomized controlled trial (RCT) comparing open and
laparoscopic resection for colon cancer [2]. However, despite the known benets and
widespread availability of laparoscopy [3], adoption has remained relatively low, with
rates of laparoscopic colectomy reaching 55.4% based on the most recent data from the
National Inpatient Sample database [4, 5]. The adoption is low even considering an
increase in worldwide prevalance of left-sided colonic pathology [6]. Slow adoption
can be partly explained by the complexity of colorectal operations, which require control and ligation of one or more major vascular pedicles, mastery of the relevant anatomical landmarks, careful dissection and manipulation of tumor specimens, and
familiarity with all the steps required to construct an adequate anastomosis.
M. K. Soliman (*)
Colon and Rectal Clinic of Florida, University of Florida, Orlando, FL, USA
Colorectal Surgery, AdventHealth Central Florida, Orlando, FL, USA
e-mail: mark.soliman@crcorlando.com
O. Bardakcioglu
Division of Colorectal Surgery, Department of Surgery, University of Nevada at Las Vegas
School of Medicine, Las Vegas, NV, USA
e-mail: ovunc.bardakcioglu@unlv.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_19
291
292
Continued advances in minimally invasive technologies have led to the development of robotic platforms in the hope that the ergonomic benets of a robotic platform, combined with wristed instruments and 3D visualization, would help mitigate
some the technical challenges of laparoscopy, thereby increasing adoption of minimally invasive surgery (MIS) while reducing conversion rates. This rise in pathology has likewise encouraged surgeons to incorporate instruments and technology to
bridge the gaps that laparoscopic surgery was unable to ll.
This chapter will describe various techniques and strategies for robotic left-sided
colonic resections, with emphasis on best practices based on tumor location and
tumor pathology.
M. K. Soliman and O. Bardakcioglu
Indications andContradictions
There are no absolute contraindications to a robotic approach for left-sided colorectal
resection. In fact, in recent years, absolute contraindications to minimally invasive
approaches in “high-risk” patients have been challenged, such as prior abdominal
surgery and obesity [7]. Authors now advocate for the use of minimally invasive
surgery when possible, even in “high-risk” patients based on the benets derived
from reduced physiologic stress and postoperative morbidity. Similarly, robotic
colorectal operations may also be offered to all patients undergoing left- sided colon
resections. Relative contraindications to robotic surgery include the following:
• Hemodynamic instability
• Inability to tolerate insufations: e.g., due to cardiopulmonary disease
• Inability to access the abdominal cavity safely: e.g., intense adhesive burden
from previous surgery, intraperitoneal mesh placement
• Inability to adequately insufate: e.g., abdominoplasty, bowel obstruction caus-
ing over distension of bowel
• Tumor-related issues: e.g., size of tumor larger than incision required for lapa-
rotomy, local extension into adjacent structures that would require a multidisci-
plinary approach where other surgical teams are not procient in reconstructive
procedures using a minimally invasive approach
Principles andQuality Benchmarks
The critical steps to be completed during minimally invasive resection of malignant
and benign left-sided pathology are outlined below.
Malignant Diseases
1. Dissection along embryologic planes of the parietal and visceral peritoneal layer
to the root of the mesentery and avoiding retroperitoneal structures and the left
ureter (complete mesocolic excision)
19 Robotic Left-Sided Colon Resections: Unique Considerations andOptimal Setup
293
2. Identication and dissection of the inferior mesenteric artery (IMA) with selec-
tive ligation of the IMA at its origin or just distal to the junction of the left colic
artery resulting in adequate lymph node yield for malignant diseases (minimum
of 12 lymph nodes)
3. Adequate proximal and distal tumoral margins of healthy, non-affected colon of
5–10cm
4. Adequate colonic mobilization with technical ability for complete splenic ex-
ure mobilization and high ligation of the inferior mesenteric vein (IMV) if neces-
sary for a tension-free anastomosis
Benign Diseases
1. Denition of the appropriate extent of the resection as dened by the nature of
the disease: for example, for a resection in diverticulitis cases, it is necessary to
precisely identify and divide the colon at the rectosigmoid junction (coalescence
of the teniae) to avoid retaining distal sigmoid colon with an increased risk of
recurrent diverticulitis.
2. Proximal division of the colon where the bowel is healthy.
3. Denition of an appropriate degree of devascularization: Unless there is strong
conrmation about the benign nature of the disease, the same oncological vascu-
lar dissection should be performed as for known malignant disease; if the disease
is conrmed to benign, a less aggressive and blood supply-sparing dissection
may be sufcient as the lymph node harvest is not of relevance.
Preoperative Planning, Patient Workup, andOptimization
Patients with left-sided pathologies are– like for any major surgical intervention–
evaluated for relevant comorbidities and optimized accordingly. Special attention is
paid to obese patients, where a thorough pulmonary evaluation is needed to rule out
underlying diseases such as chronic obstructive pulmonary disease which can be
associated with difculties with ventilation during prolonged periods in
Trendelenburg position.
Computer tomography of the chest, abdomen, and pelvis is obtained for tumor
staging. It further provides important strategic information about pathology itself as
well as about the conguration of the colon, its redundancy, and the level of the
splenic exure.
Preoperative complete colonoscopy or alternative colon evaluation is necessary
to exclude secondary pathology and possible for tattooing if the tumor location is
not otherwise reliably dened.
Individual hospital and institutional specic enhanced recovery protocols determine further preoperative optimization. These frequently include prehabilitation,
nutritional supplements, patient education, and bowel preparation with oral
antibiotics.
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M. K. Soliman and O. Bardakcioglu
Operative Setup
Patient Positioning
The patient is placed in the modied lithotomy position with both arms tucked in
neutral position along the torso. The legs are placed in stirrups such that they can be
moved from a 0-degree angle at the hip level to an elevated position when access to
the anus is needed.
To minimize sliding when the patient is placed in steep Trendelenburg position,
an anti-sliding pad should be used. Alternatively, a beanbag with respective external
stabilizers may be helpful. Shoulder brackets should be used with caution to avoid
damage to the brachial plexus. The patient is further secured to the table by means
of safety straps across the upper chest. Testing the various positions before prepping
the patient may be helpful to identify instabilities.
Room Setup
It is important to optimize the limited space and arrange the various items in the
room, such as operating table, towers, robot, accessory equipment, room lights,
anesthesia equipment, sterile trays, colonoscopy cart, etc. The arrangement needs
coordination in such a fashion that adequate space is available to access the robotic
arms and execute an unrestricted and sterile exchange of instruments once the
patient is prepped and draped.
The assistant surgeon will be on the right side of the patient and can help with
instrument changes, retraction, suctioning, and irrigation as needed. The scrub tech
is also on the right side next to the assistant surgeon.
Operative Technique
Trocar Placement
Planning the trocar outline should take into consideration the extent of the planned
colon dissection, the midpoint between the most proximal and the most distal point,
the optimal site for an accessory port as well as the specimen extraction site. Trocar
sites should be marked onto the patient’s skin using a sterile pen after draping.
Abdominal access, CO
insufation and initial camera insertion are completed in
2
the usual fashion using safe practice guidelines.
Si® Robot (Intuitive Surgical, Sunnyvale, CA, USA)
When using the Si system, the ports should be placed along a curve and be approximately 20cm away from the target and 10cm apart in order to avoid clashing of the
robotic arms. The ports/arms are labeled C for the camera and 1, 2, and 3 for trocars
going right to the left. The specimen extraction and anvil insertion site may be