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- •Contents
- •Contributors
- •Introduction to Learning Curves in Minimally Invasive Surgery
- •Future Direction
- •Transanal Approaches
- •Training in Minimally Invasive Rectal Surgery
- •Conclusions
- •References
- •Creating a Learning Curve
- •Differences in Minimally Invasive Colon and Rectal Surgery
- •Laparoscopic Rectal Resection
- •Single-Incision Laparoscopic Surgery
- •Hand-Assisted Laparoscopic Surgery
- •Robotic-Assisted Laparoscopic Surgery
- •Introduction
- •Indications and Contraindications
- •Benign Indications
- •Malignant Indications
- •T1 Rectal Cancer
- •T2 Rectal Cancer
- •Preoperative Nodal Staging
- •Pathologic Risk Factors for Lymph Node Metastases
- •Summary Statement for Treatment of Early-Stage Rectal Malignancy
- •Treatment of Recurrences
- •TES for Palliation
- •Carcinoid
- •Preoperative Workup
- •Operative Details
- •Postoperative Care
- •Possible Complications
- •Implications of Prior TEM on Radical Resection
- •Follow-Up
- •Tips and Tricks
- •Future Directions
- •References
- •Introduction
- •Indications and Contraindications
- •Preoperative Workup
- •Operative Details
- •Postoperative Care
- •Complications
- •Follow-Up
- •Tips and Tricks
- •Conclusions
- •References
- •Introduction
- •Indications and Contraindications
- •Preoperative Workup
- •Operative Details
- •Equipment
- •Patient Positioning and Preparation
- •Instrument Positioning and Port Insertion
- •Approach to and Division of the Inferior Mesenteric Vessels
- •Mobilization of the Lateral Attachments of the Rectosigmoid and Descending Colon
- •Mobilization of the Splenic Flexure
- •Rectal Mobilization
- •Rectal Division
- •Specimen Extraction and Anastomosis
- •Port Site Closure and Ileostomy
- •Postoperative Care
- •Complications
- •Follow-Up
- •Tips and Tricks
- •References
- •Background
- •Access Platforms and Equipment
- •Technical Pearls
- •Patient Positioning
- •Conduct of the Operation
- •SILS TME
- •Port Placement
- •Discussion
- •References
- •Introduction
- •The Evolution of APR
- •Extra-levator APR
- •Laparoscopic APR
- •Laparoscopic ELAPR
- •Indications and Contraindications
- •Indications
- •Contraindications
- •Preoperative Workup
- •Operative Details
- •Setup
- •Abdominal Phase
- •Laparoscopic Pelvic Dissection
- •Perineal Phase
- •Reconstruction of the Perineum
- •Perineal Reconstruction Using Tissue Flap
- •Perineal Reconstruction Using Mesh
- •Introduction
- •Indications and Contraindications
- •Preoperative Workup
- •Operative Details
- •Operating Room Organization
- •Positioning
- •Port Placement and Docking
- •Postoperative Care
- •Possible Complications
- •Operative Complications
- •Postoperative Complications
- •Follow Up
- •Tips and Tricks
- •Abdominal Phase
- •Perineal Phase
- •References
- •Laparoscopic Mobilization
- •Robotic TME
- •Anastomosis and Specimen Extraction
- •Creation of Ileostomy
- •Robotic Abdominoperineal Resection
- •Postoperative Care
- •Possible Complications
- •Follow Up
- •Tips and Tricks
- •References
- •Operative Details
- •Fully Robotic “Single-Stage” Technique
- •Fully Robotic “Dual-Stage” Technique
- •Indications and Contraindications
- •Bibliography
- •Introduction
- •Indications and Contraindications
- •Indications
- •Ulcerative Colitis
- •Indeterminate Colitis
- •Relative Contraindications
- •Contraindications
- •Preoperative Workup
- •Operative Details
- •Positioning
- •Port Placement
- •Colectomy
- •Proctectomy
- •Postoperative Care
- •Possible Complications
- •Conclusion
- •Suggested Readings
- •Introduction
- •Preoperative Planning
- •Surgical Procedure
- •Complications
- •Postoperative Management
- •Conclusions
- •References
- •Introduction
- •Indications and Contraindications for Transanal Endoscopic Proctectomy
- •Benign Indications
- •Rectal Cancer
- •Tumor Stage
- •Tumor Location
- •Anatomic Factors
- •Preoperative Workup
- •Operative Details
- •Hybrid Procedures
- •Transanal Endoscopic Completion Proctectomy, Proctocolectomy, and Apr
- •Transanal Endoscopic-Assisted Restorative Proctectomy
- •Robotic Transanal Dissection
- •Postoperative Care
- •Possible Complications
- •Follow-Up
- •Tips and Tricks
- •Procedural Training
- •Operating Teams
- •Smoke Evacuation
- •Anterior Dissection for a Very Low Rectal Tumor in a Male
- •References
- •Introduction
- •Current Laparoscopic Procedures for the Treatment of Rectal Prolapse
- •Suture Rectopexy
- •Frykman-Goldberg Procedure
- •Mesh Rectopexy
- •Laparoscopic Orr-Loygue Rectopexy
- •Laparoscopic Ventral Mesh Rectopexy
- •Laparoscopic Ripstein Technique
- •Wells’ Technique
- •Pelvic Organs Prolapse Suspension
- •Robotic Rectopexy
- •References
- •Introduction
- •Outcomes of Robotic Surgery for Rectal Prolapse
- •Ventral Rectopexy
- •Indications and Contraindications
- •Preoperative Workup
- •Operative Details
- •Positioning
- •Port Placement and Robotic Docking
- •Rectal Mobilization
- •Mesh Placement
- •Postoperative Care
- •Possible Complications
- •Recurrent Prolapse
- •Mesh Complications
- •Constipation
- •Fecal Incontinence
- •Treatment of Recurrent Rectal Prolapse
- •Conclusions
- •References
- •Introduction
- •Indications and Contraindications
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Preoperative Workup (Includes Imaging)
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Operative Details (with Photos)
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Postoperative Care
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Possible Complications
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Follow-Up
- •Rectourethral Fistula
- •Retrorectal Tumors
- •Tips and Tricks
- •Rectourethral Fistula
- •Retrorectal Tumors
- •References
- •Introduction
- •Indications and Contraindications
- •Preoperative Workup
- •Postoperative Care
- •Possible Complications
- •Follow-Up
- •Tips and Tricks
- •References
- •Index

Techniques in
Minimally Invasive
Rectal Surgery
Alessio Pigazzi
Editor
123

Techniques in Minimally Invasive Rectal Surgery

Alessio Pigazzi
Editor
Techniques in Minimally
Invasive Rectal Surgery

Editor
Alessio Pigazzi
Division of Colon and Rectal Surgery
University of California, Irvine
Orange, CA, USA
Videos can also be accessed at http://link.springer.com/book/10.1007/978-3-319-16381-9.
ISBN 978-3-319-16380-2 ISBN 978-3-319-16381-9 (eBook)
DOI 10.1007/978-3-319-16381-9
Library of Congress Control Number: 2017956212
© Springer International Publishing Switzerland 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents
1 Training and Learning Curve in Minimally Invasive
Rectal Surgery ......................................................................................... 1
Deborah S. Keller and Eric M. Haas
2 Transanal Approaches: Transanal Endoscopic Surgery ..................... 17
Traci L. Hedrick and Joshua Bleier
3 Transanal Approaches: Transanal Minimally Invasive
Surgery (TAMIS) .................................................................................... 39
John P. Burke and Matthew R. Albert
4 Laparoscopic Procedures: Laparoscopic Low
Anterior Resection .................................................................................. 53
Skandan Shanmugan and Bradley J. Champagne
5 Laparoscopic Procedures: Single-Incision Laparoscopic
Colorectal Surgery .................................................................................. 73
Daniel P. Geisler and Deborah S. Keller
6 Laparoscopic Procedures: Laparoscopic Abdominoperineal
Resection .................................................................................................. 81
Jake D. Foster and Nader K. Francis
7 Robotic Low Anterior and Abdominoperineal Resection:
Hybrid Technique ................................................................................... 101
Mark H. Hanna and Alessio Pigazzi
8 Robotic Low Anterior Resection: Fully Robotic Technique ............... 115
Fabrizio Luca and Paolo Bianchi
9 Minimally Invasive Techniques for Inflammatory Bowel Disease ...... 131
Michael A. Valente and Tracy L. Hull
v

vi
10 Natural Orifice Specimen Extraction in Laparoscopic
Colorectal Surgery: Transanal Approach ............................................. 143
Morris E. Franklin Jr. and Miguel A. Hernández
11 Natural Orifice Approaches in Rectal Surgery:
Transanal Endoscopic Proctectomy ...................................................... 151
Uma M. Sachdeva and Patricia Sylla
12 Minimally Invasive Surgery for Rectal Prolapse:
Laparoscopic Procedures ....................................................................... 177
Pierpaolo Sileri, Luana Franceschilli, Ilaria Capuano,
Federica Giorgi, and Gabriele Boehm
13 Minimally Invasive Surgery for Rectal Prolapse:
Robotic Procedures ................................................................................. 195
Joseph C. Carmichael and Zhobin Moghadamyeghaneh
14 Minimally Invasive Procedures for Rare Rectal Conditions:
Complex Rectourethral Fistulas and Retrorectal Tumors .................. 213
Alessio Vinci, Mark H. Hanna, and Alessio Pigazzi
15 Minimally Invasive Procedures for Rare Rectal Conditions:
Endometriosis .......................................................................................... 227
Vladimir Schraibman, Antonio Luiz de Vasconcellos Macedo,
Marina Gabrielle Epstein, and Camila Campos Padovese
Contents
Index ................................................................................................................. 233

Contributors
Matthew R. Albert, M.D., F.A.C.S., F.A.S.C.R.S. Department of Colon & Rectal
Surgery, Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
Paolo Bianchi, M.D. Division of General and Minimally Invasive Surgery,
Misericordia Hospital, Grosseto, Italy
Joshua Bleier, M.D., F.A.C.S., F.A.S.C.R.S. Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA
Gabriele Boehm, M.D. Department of Surgery, University of Rome Tor Vergata,
Policlinico Tor Vergata, Rome, Italy
John P. Burke, Ph.D., F.R.C.S.I. Center for Colon & Rectal Surgery, Florida
Hospital, Orlando, FL, USA
Ilaria Capuano, M.D. Department of Surgery, University of Rome Tor Vergata,
Policlinico Tor Vergata, Rome, Italy
Joseph C. Carmichael, M.D.
Irvine, Orange, CA, USA
Bradley J. Champagne, M.D., F.A.C.S., F.A.S.C.R.S. Division of Colorectal
Surgery, Department of Surgery, St. John Medical Center, Digestive Health Institute,
Community Gastroenterology and Quality Center, Cleveland, OH, USA
Marina Gabrielle Epstein, M.D. Department of General and Gastric Surgery,
Albert Einstein Hospital, São Paulo, SP, Brazil
Jake D. Foster Department of Surgery, Yeovil District Hospital NHS Foundation
Trust, Somerset, UK
Luana Franceschilli, M.D. Department of Surgery, University of Rome Tor
Vergata, Policlinico Tor Vergata, Rome, Italy
Department of Surgery, University of California,
vii

viii
Contributors
Nader K. Francis, Ph.D. Department of Surgery, Yeovil District Hospital NHS
Foundation Trust, Somerset, UK
Morris E. Franklin Jr., M.D., F.A.C.S. Department of Minimally Invasive
Surgery, Texas Endosurgery Institute, San Antonio, TX, USA
Daniel P. Geisler, M.D., F.A.S.C.R.S. Colorectal Physicians & Surgeons of
Pennsylvania, Saint Vincent Health Center, Allegheny Health Network, Erie, PA,
USA
Federica Giorgi, M.D. Department of Surgery, University of Rome Tor Vergata,
Policlinico Tor Vergata, Rome, Italy
Eric M. Haas, M.D., F.A.C.S., F.A.S.C.R.S. Division of Minimally Invasive
Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical
School at Houston, Houston, TX, USA
Mark H. Hanna, M.D. Department of Surgery, University of California, Irvine,
Orange, CA, USA
Traci L. Hedrick, M.D., M.S., F.A.C.S., F.A.C.R.S. Department of Surgery,
University of Virginia Health System, Charlottesville, VA, USA
Miguel A. Hernández, M.D. Department of Minimally Invasive Surgery, Texas
Endosurgery Institute, San Antonio, TX, USA
Tracy L. Hull, M.D., F.A.C.S., F.A.S.C.R.S. Department of Colorectal Surgery,
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
Deborah S. Keller, M.S., M.D. Colorectal Surgical Associates, LLP, Houston,
TX, USA
Fabrizio Luca, M.D., F.A.S.C.R.S. Division of Digestive Surgery, European
Institute of Oncology, Milan, Italy
Antonio Luiz de Vasconcellos Macedo, M.D.
Department of General and Gastric
Surgery, Albert Einstein Hospital, São Paulo, SP, Brazil
Zhobin Moghadamyeghaneh, M.D. Department of Surgery, University of
California, Irvine, Orange, CA, USA
Camila Campos Padovese, M.D. Department of General and Gastric Surgery,
Albert Einstein Hospital, São Paulo, SP, Brazil
Alessio Pigazzi, M.D., Ph.D. Division of Colon and Rectal Surgery, University of
California, Irvine, Orange, CA, USA
Uma M. Sachdeva, M.D., Ph.D. Department of Surgery, Massachusetts General
Hospital, Boston, MA, USA

Contributors
ix
Vladimir Schraibman, M.D., Ph.D. Department of General and Gastric Surgery,
Albert Einstein Hospital, São Paulo, SP, Brazil
Skandan Shanmugan, M.D. Division of Colon and Rectal Surgery, Perelman
School of Medicine, Pennsylvania Hospital, University of Pennsylvania,
Philadelphia, PA, USA
Pierpaolo Sileri, M.D., Ph.D. Department of Surgery, University of Rome Tor
Vergata, Policlinico Tor Vergata, Rome, Italy
Patricia Sylla, M.D., F.A.C.S., F.A.S.C.R.S. Division of Colorectal Surgery,
Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine,
Massachusetts General Hospital, New York, NY, USA
Michael A. Valente, D.O., F.A.C.S., F.A.S.C.R.S. Department of Colorectal
Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
Alessio Vinci, M.D., Ph.D. Division of Colon and Rectal Surgery, Department of
Surgery, University of California, Irvine, Orange, CA, USA

Chapter 1
Training and Learning Curve in Minimally
Invasive Rectal Surgery
Deborah S. Keller and Eric M. Haas
Introduction to Learning Curves in Minimally Invasive Surgery
The learning curve is a graphical demonstration of the number of cases a surgeon
must perform to become proficient.
When learning a new procedure, performance is expected to improve with experience, and graphically plotting performance against experience produces a learning
curve [1–3]. The concept of a learning curve, where inexperienced clinicians improve
with increasing experience, is particularly fitting for minimally invasive surgery,
which requires a high degree of special dexterity and technical skills, and learning
has potentially dramatic implications [4, 5]. The learning curve is a graphic representation of the individual surgeon’s experience performing a procedure versus outcome
variables of clinical interest, such as operative time, postoperative complications,
and conversion rates [6–9] (Fig. 1.1). A technically demanding technique, such as
minimally invasive rectal resection, is often termed as having a “steep learning
curve.” This term has been described as a misnomer, as complex techniques are more
likely to have gradual learning curves, with small improvements in outcome associated with each case, and expertise possible only after significant experience [4].
D.S. Keller, M.S., M.D.
Colorectal Surgical Associates, LLP, Houston, TX, USA
E.M. Haas, M.D., F.A.C.S., F.A.S.C.R.S. (
Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery,
The University of Texas Medical School at Houston,
7900 Fannin Street, #2700, Houston, TX 77054, USA
e-mail: ehaasmd@houstoncolon.com
A. Pigazzi (ed.), Techniques in Minimally Invasive Rectal Surgery,
DOI 10.1007/978-3-319-16381-9_1
*)
1© Springer International Publishing Switzerland 2018
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