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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1369_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 12.3 Identification of the ureter (black arrow) and left common iliac (blue arrow) before
dividing the inferior mesenteric artery
M. DeLeon and C. Rezac
Fig. 12.4 Window created around inferior mesenteric artery that will be ligated with the robotic
vessel sealer seen to the right of the photo
colon are taken down. This allows elevation of the sigmoid colon to identify the inferior mesenteric vascular bundle. Dissection then proceeds medial to lateral, underneath the inferior mesenteric artery (IMA), over the left common iliac, identifying the
left ureter (Fig. 12.3). A window is made around the IMA and divided with the robotic
vessel sealer device (Fig. 12.4). The dissection is continued until the peritoneal
12 Robotic Surgery for the Treatment of Inflammatory Bowel Disease
Fig. 12.5 Posterior TME dissection. The rectum is elevated to the top of the photo, while the hook
cautery is used for the TME dissection
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Fig. 12.6 Anterior rectal dissection. The blue arrow indicates the seminal vesicle seen while tak-
ing down the anterior peritoneal reflection. The rectum is retracted down and out of the pelvis for
maximal exposure
reflection is taken down up to the splenic flexure. The pelvic dissection is then initiated, going posteriorly over the sacral promontory in a total mesorectal excision
(TME) plane down to the tip of the coccyx (Fig. 12.5). The lateral stalks are divided.
Lastly, the anterior peritoneal reflection is taken down, identifying the seminal vesicles (Fig. 12.6). A digital rectal exam is then performed to ensure that the dissection
160
Fig. 12.7 The left mesocolon is divided with the robotic vessel sealer up to the splenic flexure
M. DeLeon and C. Rezac
Fig. 12.8 The omentum is dissected off of the transverse colon with the robotic hook cautery to
enter the lesser sac. The omentum is retracted toward the top of the photo and the transverse colon
is below
is completed up to 1–2 cm above the dentate line. After this is confirmed, the robotic
stapler is used to divide the distal rectum. The mesocolon is then taken with the
robotic vessel sealer device up to the splenic flexure (Fig. 12.7). At this point,
the robotic arms are undocked and repositioned to access the transverse colon.
12 Robotic Surgery for the Treatment of Inflammatory Bowel Disease
Fig. 12.9 Total proctocolectomy specimen
161
Fig. 12.10 Critical view of mesentery obtained before formation of J pouch to ensure the mesentery is properly aligned. Photo shows no small bowel to the right of the ileocolics. The blue arrow
highlights the duodenum
The patient is then placed in reversed Trendelenburg and the splenic flexure is taken
down. The omentum is dissected off of the transverse colon opening up the lesser sac
(Fig.12.8). The mesentery of the transverse colon is divided with the robotic vessel
sealer device going past the midline toward the ascending colon. The robotic arms
are then undocked again and repositioned to access the ascending colon and hepatic
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Fig. 12.11 Extracorporeal creation of J pouch using double-stapled technique
Fig. 12.12 Final incisions
and ileostomy placement
M. DeLeon and C. Rezac
12 Robotic Surgery for the Treatment of Inflammatory Bowel Disease
163
flexure. At this point the patient is placed left side down for better exposure. The
hepatic flexure and ascending colon are dissected off of the duodenum, being sure to
identify the right ureter. The ileocolic vessel is then isolated. After the entire right
colon is fully mobilized, the suprapubic port is opened approximately 4 cm and an
Alexis wound retractor is placed. The entire specimen is delivered through this port
site. A handheld LigaSure is used to divide the terminal branches of the ileocolic vessels flushed to the right colon. The terminal ileum is divided with a GIA stapler and
the specimen is removed (Fig. 12.9). Before the terminal ileum is exteriorized to form
the J pouch, the surgeon must make sure that the small bowel mesentery is not
twisted. This is confirmed when the mesentery is configured so that only the duodenum and no small bowel is seen to the right of the ileocolics (Fig. 12.10). The terminal ileum is then prepared. Thirty cm of the distal ileum is folded on itself to make a
pouch of 15 cm in length using the Echelon stapler (Fig. 12.11). An EEA stapler is
then used to create the ileoanal anastomosis. Care is taken not to rotate the pouch and
to ensure there is no tension on the anastomosis. A protective loop ileostomy is then
created in the right lower quadrant (Fig. 12.12).
Total Proctocolectomy with IPAA: Laparoscopic, Robotic-Assisted Approach
In this technique, there is only one docking of the robotic arms, and it is used only for
the rectal dissection. This method is preferred at centers where the da Vinci Xi system
is not available. The patient is placed in dorsal lithotomy position. A 13 mm trocar is
placed in the right lower quadrant, a 5 mm trocar is placed in the right upper quadrant,
and two 8 mm trocars are placed in the left lower and left upper quadrants. A 6 cm hand
port is placed 2 cm above the symphysis pubis as the extraction site. The patient is
placed in Trendelenburg with the left side up allowing the small bowel to be delivered
outside of the pelvis. The procedure begins laparoscopically. Similar to the complete
robotic approach, the inferior mesenteric vascular bundle is identified. Medial-tolateral dissection commences, identifying the left common iliac and left ureter. A window is made around the inferior mesenteric vessels and is divided with an endovascular
stapler. The gonadal vessels are isolated. The peritoneal reflection is then taken down
with the hook cautery up to the splenic flexure. At this point the da Vinci robot is
docked to the left of the patient and the pelvic dissection begins posteriorly over the tip
of the sacral promontory. The lateral stalks are then divided, followed by the anterior
peritoneal reflection. Dissection is then continued toward the anus. A rectal exam is
done to ensure that dissection is completed 1–2 cm above the dentate line. The rectum
is then transected using the robotic stapler. The robot is undocked and the mesentery
on the left side is taken down laparoscopically up to the splenic flexure with the
LigaSure device. The lesser sac is opened, preserving the omentum, allowing continued dissection of the transverse colon toward the hepatic flexure, making sure to clearly
identify the duodenum and keep it out of harms way. The right colon is then mobilized
along the white line of Toldt. Finally the hepatic flexure is taken down, again making
sure to visualize and protect the duodenum. The rest of the mesentery from the splenic
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M. DeLeon and C. Rezac
flexure to the ileocolic vessels is taken down with the LigaSure device, preserving the
ileocolic vessels. The specimen is delivered into the operative field through the hand
port. The ileocolic vessels are then divided with the LigaSure and the GIA stapler is
used to transect the terminal ileum. The J pouch and ileoanal anastomosis are then
performed as described in the completely robotic approach.
Robotic-Assisted Completion Proctectomy
First, the ileostomy is taken down, stapled off, and returned to the abdominal cavity. The fascia is sutured closed. Trocar and hand port placement are identical to the
setup described in the laparoscopic robotic-assisted method for total proctocolectomy with IPAA. If these patients have had a previous laparoscopic or robotic total
abdominal colectomy, the same trocar sites are used. Due to previous surgery, there
is often a significant amount of adhesions encountered that must be lysed in order
to mobilize enough terminal ileum to create the pouch. The patient is then placed
in Trendelenburg position with the left side air-planed up. The small bowel is
delivered outside of the pelvis. The da Vinci robot is docked to the left of the
patient. (If the patient’s initial total abdominal colectomy was done as part of a
three-stage procedure, with the intent of performing a completion proctectomy in
the future, then the inferior mesenteric vascular bundle is purposely left in tact in
order to maintain the planes of the pelvis.) The inferior mesenteric vascular bundle
is identified and dissected, ensuring to also identify the ureter and iliac vessels.
Dissection begins posterior to the rectum in the TME plane. This allows the surgeon to elevate the inferior mesenteric vascular bundle enough to divide it with the
robotic vessel sealer. Continued pelvic dissection is now done posteriorly down to
the tip of the coccyx. The lateral stalks are then divided, and the dissection finishes
by taking down the anterior peritoneal reflection. A digital rectal exam is done
to ensure the rectum has been mobilized 1–2 cm proximal to the dentate line.
The rectum is divided with the robotic stapler. The specimen is removed and the
robot is undocked. Formation of the J pouch and ileoanal anastomosis then proceeds identically as previously described.
Crohn’s Disease
Unlike ulcerative colitis, Crohn’s disease is a transmural inflammatory process that
may affect any portion of the gastrointestinal tract. The incidence is highest in
Scandinavian countries, followed by Scotland, England, and North America. Similar
to ulcerative colitis there is a bimodal age distribution with peak incidence occurring between 20 and 30 years and 60–80 years. It is more common in the Jewish
population and in urban areas [6].
The cause of Crohn’s disease is still unknown, but is thought to be due to a
combination of factors including a genetic susceptibility, triggering infectious
12 Robotic Surgery for the Treatment of Inflammatory Bowel Disease
165
agents, defective mucosal barriers, and an inappropriate host response [17]. There
has been much research to determine which specific agents are responsible for the
development of Crohn’s disease. There has also been some data to implicate previous antibiotic use and use of oral contraceptives as risk factors for the development
of Crohn’s disease [18, 19].
These patients usually present with nonspecific symptoms including abdominal
pain, diarrhea, and weight loss. Unlike UC where the rectum is nearly always
involved, only half of patient’s with Crohn’s disease will have rectal involvement.
The most common place for Crohn’s to occur is the terminal ileum. Anal disease
including anal fissures, abscesses, and fistulas plague almost 50 % of patients with
Crohn’s colitis and 30 % of patients with Crohn’s ileitis [6].
Diagnosis is made by a combination of clinical history, endoscopic evaluation,
and radiographic imaging. On endoscopy, the mucosa may have a characteristic cobblestone appearance. On gross inspection, the bowel may be surrounded by creeping
fat of the mesentery. Because of the transmural nature of this disease, it is not uncommon to see strictures form in the small and large intestine. Histology will reveal
edema, lymphoid aggregation, and fibrosis. In 50 % of surgical specimens, noncaseating granulomas will be seen—a pathognomonic feature of Crohn’s disease [6].
Medical therapy for Crohn’s disease is similar to ulcerative colitis and
includes aminosalicylates, corticosteroids, thiopurines, methotrexate, and antitumor necrosis factor agents. A top-down system has in part replaced the traditional step up approach, where treatment begins with the more potent
immunomodulatory and biologic medications [20]. Aminosalicylates are the
most common medication prescribed for mild to moderate disease. Steroids are
generally used for acute flares. TNF-α inhibitors play a pivotal role in the treatment of fistulizing Crohn’s disease, where a once exclusively surgical problem is
now treated with infliximab in select cases. This shift in management occurred
after results from the ACCENT II trial showed that closure of fistulas was possible with the use of this medication [21].
Despite the many advances in medical treatment for Crohn’s disease, up to 60 %
of patients will eventually need surgery within 10 years of their diagnosis [22], and
in those patients with ileocecal disease, up to 83 % of patients will require resection
at 10 years after diagnosis [23]. Indications for surgery include disease refractory to
medical management, intestinal obstruction, fistulas, intra-abdominal abscesses,
massive bleeding, fulminant colitis, cancer, and severe malnutrition. Unlike ulcerative colitis, surgery is not curative for Crohn’s disease and many patients will have
recurrences after surgical resection, requiring multiple abdominal operations.
Therefore, a major tenant in the surgical treatment of Crohn’s disease is preservation of as much bowel as possible in order to prevent the development of short
bowel syndrome.
The most common surgical procedures performed for Crohn’s disease are ileocecal
resection, strictureplasty, and segmental colon and small bowel resections. In cases of
fulminant colitis, toxic megacolon or disease involving the entire colon and rectum,
total proctocolectomy with end ileostomy is indicated. For those wishing to avoid an
ostomy in the nonemergent setting, total abdominal colectomy with ileorectal
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M. DeLeon and C. Rezac
anastomosis may be performed; however, it should be noted that up to 50 % of patients
may have a recurrence of disease within ten years requiring completion proctectomy
and end ileostomy. In addition, patients who undergo rectal sparing surgery are more
likely to require maintenance medical therapy [24].
There is less data for use of the robot in Crohn’s disease, because unlike total
proctocolectomy with ileal pouch anal anastomosis (the gold standard for surgical
treatment in UC), a low pelvic dissection is not routinely necessary in surgery for
Crohn’s disease, where the goal is symptomatic control rather than cure. In addition, unlike ulcerative colitis where many procedures are done on an elective basis,
a large percentage of patients who require surgical intervention for Crohn’s disease are already hospitalized. These patients are therefore operated on in a more
urgent setting for problems secondary to their Crohn’s disease, like bowel obstruction, perforation, and sepsis. In the urgent/emergent setting, use of the robot is less
convenient. For those undergoing elective surgery however, the da Vinci single
port system is an attractive option especially for this young population where cosmesis is heavily prioritized. A study done by Juo et al. reported on 59 consecutive
da Vinci assisted single port colectomies and found that this method was both safe
and feasible [25].
An additional advantage the robot has is its excellent articulation, making intracorporeal suturing much easier. This is most useful in obese patients, or patients
with a thickened mesentery, where exteriorizing the specimen for extracorporeal
anastomosis would be difficult. There have been successful reports of intracorporeal
suturing for the Heineke–Mikulicz strictureplasty in Crohn’s patients using the
robotic platform [26]. Lujan et al. have also shown success with intracorporeal anastomosis during robotic right hemicolectomy [27]. Though no studies have definitively shown a difference in outcomes between intracorporeal and extracorporeal
anastomosis, intracorporeal anastomosis does appear to be more feasible with the da
Vinci robotic system when it is necessary.
Surgical Technique
Robotic-Assisted Single Incision Colectomy
As stated earlier Juo et al. have successfully reported use of the da Vinci single
port system for colectomies. The patient is placed in the dorsal lithotomy position.
A single 4 cm vertical incision is made lateral to the umbilicus and the GelPOINT
Advanced Access Platform; Applied Medical Inc. Rancho Santa Margarita, CA,
USA is inserted. Four trocars are used—a 12 mm trocar for the 30° scope, two
8.5 mm robotic trocars, and a 5 mm laparoscopic trocar. The robot is docked on
the side of resection—for right hemicolectomies it is docked to the right of the
patient with the base positioned perpendicular to the bed. A “cross armed” technique, which involves crossing of the robotic arms under the fascia, is used to
12 Robotic Surgery for the Treatment of Inflammatory Bowel Disease
167
avoid arm collision. The rest of the procedure is performed similar to laparoscopic
colectomies [25].
Robotic-Assisted Strictureplasty
The technique reported by Tou et al. involves insertion of the robotic camera in an
umbilical port, one robotic arm placed suprapubically and another robotic arm
placed in the left upper quadrant. A 10 mm port is placed in the left lower quadrant
to allow passage of laparoscopic instruments. A laparoscopic bulldog clamp is use
to clamp the proximal small bowel. A longitudinal incision is made over the stricture, and two stay sutures are placed. A two-layer anastomosis is created robotically
with a running inner layer and an interrupted outer layer [26].
The da Vinci robotic system has repeatedly been shown to be safe and feasible
in colorectal surgery and is especially beneficial in the narrow pelvis. It may
allow more cases for inflammatory bowel disease, specifically ulcerative colitis,
to be done minimally invasively. This is of significant importance in this patient
population where infertility has a profound impact on young childbearing
women. Given these benefits, the da Vinci robotic system should be strongly
considered for use in the surgical treatment of inflammatory bowel disease.
References
1. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically
assisted and open colectomy for colon cancer. N Engl J Med. 2004;350(20):2050–9.
2. Halabi WJ, Kang CY, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, et al. Robotic-assisted
colorectal surgery in the United States: a nationwide analysis of trends and outcomes. World
J Surg. 2013;37(12):2782–90.
3. Weber PA, Merola S, Wasielewski A, Ballantyne GH. Telerobotic-assisted laparoscopic right
and sigmoid colectomies for benign disease. Dis Colon Rectum. 2002;45(12):1689–94; discussion 1695–6.
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10. Pedersen ME, Rahr HB, Fenger C, Qvist N. Adenocarcinoma arising from the rectal stump
eleven years after excision of an ileal J-pouch in a patient with ulcerative colitis: report of a
case. Dis Colon Rectum. 2008;51(7):1146–8.