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Future Frontiers in Colon and Rectal Surgery Single Incision Robotic Colon Resections: Innovations and early Data

Future Frontiers in Colon and Rectal Surgery Single Incision Robotic Colon Resections: Innovations and early Data. Vincent Obias , MD Director Division of Colon and Rectal Surgery Assistant Professor of Surgery George Washington University Medical Faculty Associates.

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Future Frontiers in Colon and Rectal Surgery Single Incision Robotic Colon Resections: Innovations and early Data

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  1. Future Frontiers in Colon and Rectal SurgerySingle Incision Robotic Colon Resections: Innovations and early Data Vincent Obias, MD Director Division of Colon and Rectal Surgery Assistant Professor of Surgery George Washington University Medical Faculty Associates

  2. Case of Double Inguinal Hernia in which both Sacs were removed through a Single Transverse Suprapubic Incision. • Earliest mention of single incision surgery • 1922 • Proc R Soc Med. 1922; 15(Sect Study Dis Child): 29. • 3 inch incision

  3. Types of Single Incision Surgery • Hysterectomy • BTL, oophorectomy • Colectomy • Cholecystectomy • Gastric bypass • Heller • Hepatectomy • Nephrectomy • Lobectomy • Pneumonectomy • Living donor nephrectomy • Appendectomy • Gastrectomy • Splenectomy

  4. Citations in Literature • Single incision Cholecystectomy 279 • Single Incision Colectomy 117 • Robotic colectomy 81 • Single incision Appendectomy 80 • Single incision Hysterectomy 22 • Single incision laparoscopic surgery 1126

  5. 5’s are Free • Are they? • Vascular injury, bowel injury, and hernias • Port site hernias with 5mm trocars, rare, but not unheard of • Nezhat et al. LLQ port site hernia • Plaus et al. Suprapubic port site hernia • Reardon et al. LLQ port site hernia • Matter et al RUQ port site hernia • Toub et al LLQ port site hernia • Moreaux et al. Reported 2 SB eviscerations

  6. Trocar Complications • 50% of trocar related injuries to bowel and vessels occur in initial entry • 30-50% of the bowel injuries and 15-50% of the vascular injuries are not diagnosed at the time of injury VilosGA, VilosAG, Abu-Rafea B, Hollett-Caines J, Nikkhah-Abyaneh Z, Edris F. Three simple steps during closed laparoscopic entry may minimize major injuries. SurgEndosc. 2009; 23:758-764.

  7. Advantages to Single Incision Laparoscopy • Fewer incisions • Less abdominal wall trauma • Better cosmetic result • Less pain • Possibly less narcotic use • Sooner return of bowel function • Decreased LOS

  8. Single-port laparoscopy in colorectal surgery. • Uni-X Single-Port Access Laparoscopic System used • Right colectomy attempted for unresectable polyp • Incision 3.5 cm • BMI=35 • Op time 115 min • LOS 4 days • No complications Remzi et al, Colorectal Dis. 2008 Oct;10(8):823-6. Epub 2008 Aug 5.

  9. Single-incision vs straight laparoscopic segmental colectomy: a case-controlled study. • 29 SILC performed • Operative time longer for SILC vs multi • 134 min vs 104 min, p=0.0002 • 4 converted to multi port, 1 converted to open • Morbidity similar • LOS same • 3.7 (SILC) vs 3.9 days, p=0.445 • SILC feasible and safe, but takes longer Dis Colon Rectum. 2011 Feb;54(2):183-6.

  10. Early Multi Institutional Experience with Single Incision Laparoscopic Colectomy • 39 SILC performed • Conversion rate 12.8% • 7.7% complication rate • Surgeons felt these areas more difficult in SILS • Exposure of critical structures • Ease of instruments • Ease of camera operation • Flexure mobilization • Ergonomics • Instrument conflict Dis Colon Rectum. 2011 Feb;54(2):187-92.

  11. Noncosmetic benefits of single-incision laparoscopic sigmoid colectomy for diverticular disease: A case matched comparison with multiport laparoscopic technique • Case matched for age, gender, BMI, ASA score, previous abdominal surgery, and splenic flexure mobilization • 20 vs 20 • Operative time, conversions, EBL, SSI, and readmission same • LOS 3.7 for SILS vs 5.0 for LAP (p<0.05) • Visual analog pain score significantly less for SILS vs LAP on POD 1 and 2 Vasilakis V, Clark CE, Liasis L, Papaconstantinou HT. J Surg Res. 2012 May 16. [Epub ahead of print]

  12. Single Incision versus Conventional laparoscopic colectomy for colonic neoplasm: A randomized controlled trial • 25 vs 25 • Pt demographics, tumor characteristics, OP time, EBL, complication rate, number of LN, and resection margins were the same • SILS had consistently Decreased Pain Scores in days 1-3 • Median hospital stay less in SILS

  13. Single Incision Laparoscopy for Colorectal Resection: A systemic review and meta-analysis of more than 1000 procedures • 64 studies reviewed with 1026 single incision colectomies attempted • 15 nonrandomized studies compared single incision to conventional lap (1075 total) • No differences noted in conversions, or op time • Decrease incision length • And shorter length of stay (p=0.008) • Maggiori et al. Colorectal Dis. 2012 may 25 Epub

  14. Advantages to Single Incision Laparoscopy • Fewer incisions • Less abdominal wall trauma • Better cosmetic result • Less pain • Possibly less narcotic use • Sooner return of bowel function • Decreased LOS

  15. Disadvantages of Single Incision Laparoscopy • Technically challenging • Instruments crossing each other • Poor positioning with assistant • Poor ergonomics • Single surgeon technique-no assistant except as camera person • Increased operative time- some studies show no change • LOS decrease- varies between studies • Could Robotic surgery offset these technical challenges?

  16. Robotic assisted single incision right colectomy: early experience • 3 patients total • Through 4 cm incision • Used three ports: 12mm and 2-8mm ports • Medial to lateral approach, extracorporeal resection and anastamosis • Op time 152 minutes • 33% conversion rate (air leak) Ostrowitz et al., Int J Med Robot, 2009 Dec 5(4):465-470

  17. DaVinceSingle Incision Set Up

  18. Robotic Single Port Experience • N=11 • Diagnosis: unresectable polyps and colon cancer • Procedures: right hemicolectomies • Conversion to open=0 • Conversion to lap= 3/11 • Post op complications= 3 • Ileus, wound infection, anastamotic bleed

  19. Single Port Straight Lap Experience • N=10 • Diagnosis: unresectable polyps and colon cancer and crohns stricture • Procedures: right hemicolectomies and ileocectomy • Conversion to open=1 due to adhesions • Post op complications= 1 • Post op bleed, readmitted and required percutaneous drainage

  20. Comparison Robot Straight p val N 11 10 Op time 209.4 217.4 0.69 EBL 190.9 222 0.78 Conversions 0 1 LOS 4.8 3.7 0.16 LN harvest 21.5 24.5 0.90 Complications 3 1 0.59

  21. Current Overall Robotic Single Incision Data • 35 cases: 23 right, 12 left • 19 males: 16 females • Ave age=60.5 • Ave op time 177min • Ave EBL 158cc • 3 conversions to open (8.6%) • Post op complications 6 • Median LOS 4

  22. Comparison to Multiport multi single Pval N 48 35 Age 63.5 60.5 0.33 Op time 259.3 177 .001 Ebl 217 158 0.30 Conv 3 (6.3%) 3 (8.6%) 0.69 LOS 5 4 .52 Complications 5 (10%) 6(17%) .51

  23. Robotics Advantage • Ergonomically superior • Assistant positioning taken out of equation- • now between arms of robot and part of procedure • Wristed instruments ideal in single port setting • Triangulation returned back to surgeon by cross arm technique • Stable camera • 3D view

  24. Disadvantages • Increased operative time-this is decreasing • Tactile sensation lost • Cost of the robot and port

  25. Single Incision Robotic Right Colectomy

  26. Single Incision Robotic Total Colectomy Video

  27. Conclusions • Single incision surgery is becoming more common • Proven to be safe • Does take longer • Robotics can help the negatives of single incision surgery • More Studies needed

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