Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures.

Funder: CMR SurgicalOBJECTIVE: To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots. METHODS: Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device's safety in performing cholecystectomy or small bowel enterotomy. RESULTS: Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons' preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications. CONCLUSIONS: This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility

Robotic total mesorectal excision for rectal cancer

Robotic TME is an evolution of the classic laparoscopic technique with an aim to overcome the limitations of the non-articulating laparoscopic instruments within the narrow confines of the pelvis. The purpose of this chapter is to share our experience and the experience of others in this constantly evolving field of robotic TME. In the context of pelvic dissection, there are several properties that make the robotic system more advantageous to use as compared to laparoscopic or open techniques. The platform provides very stable optics with the surgeon in control of the camera, allowing for constant adjustments. This, together with simultaneous control of three working, articulating wrist instruments, gives the surgeon the ability to completely control the operating field. This is often essential when working with obese patients, bulky tumors, or within the narrow pelvic confines. Despite many factors that allow for easier completion of this task, it still remains an advanced procedure and is associated with a steep learning curve. Many studies have documented use of the robotic total mesorectal excision technique to be associated with decreased conversion rates, improved mesorectal envelope completeness, and improved genitourinary function. Still, there have been no randomized controlled trials proving unequivocally the superiority of this technique over the other approaches. At the present time, robotic technology should not be treated as a replacement for other techniques, but rather as an available, and powerful tool in a surgeon’s armamentarium. Because of the very high cost of this technology, the most practical option is to select the population of patients that may be best served through use of these surgical techniques

Robotic Combined Anterior & Posterior Repair of a Rectal Prolapse, Rectocele, and Sigmoidocele with a Mesh

RP is often seen in patients over the age of fifty, particularly women. These patients frequently suffer from other concomitant pathologies like rectocele, sigmoidocele, cystocele, or even enterocele. Rectopexy with a mesh has been an established treatment for rectal prolapse. The utilization of the robotic system allows for a successful repair within a confined pelvic space, especially for precise suture placement when working with the mesh. A 77-year-old female presented with ODS symptoms found to be caused by a progressive rectal prolapse. Her pre-operative ODS score was 9/20. Pelvic floor evaluation revealed concomitant rectocele and sigmoidocele. The patient was offered a robotic-assisted rectopexy with mesh placement to address the three concomitant pathologies. During the procedure, a posterior mesorectal mobilization with autonomic nerve preservation was performed to address the posterior leading edge of the prolapse. Subsequently, the vagina was separated from the anterior portion of the rectum and dissected down to the levator ani muscle and the perineal body. This allowed for the affixation of a polypropylene mesh to the anterior portion of the rectum. Anterior suspension of the mobilized rectum with the mesh addressed all three pathologies. No recurrence or complications occurred at two-year follow-up. The patient’s ODS score decreased to 1/20

Robotowa operacja naprawcza wypadania odbytnicy ze współistniejącymi rectocele i sigmoidocele z użyciem siatki

Wypadanie odbytnicy (WO) jest schorzeniem występującym najczęściej u pacjentów w wieku powyżej 50 lat, szczególnie u kobiet. Z WO zazwyczaj współistnieją inne patologie, takie jak: uwypuklenie odbytnicy (rectocele), wpuklenie esicy (sigmoidocele), uwpuklenie pęcherza moczowego (cystocele), a nawet przepuklina zawierająca pętle jelita cienkiego (enterocele). Rektopeksja z użyciem siatki jest metodą o powszechnie uznawanej skuteczności w leczeniu wypadania odbytnicy. Zastosowanie robota chirurgicznego ułatwia preparowanie tkanek w obrębie miednicy mniejszej i jest szczególnie pomocne podczas zakładania szwów mocujących siatkę. W niniejszym artykule przedstawiono przypadek 77-letniej kobiety, u której stwierdzono objawy zespołu zaburzeń defekacji (ang. obstructed defecation syndrome; ODS), którego przyczyną było wypadanie odbytnicy. W trakcie postępowania przedoperacyjnego objawy pacjentki w skali ODS Score oceniono na 9/20. Podczas dalszej diagnostyki, poza wypadaniem odbytnicy, stwierdzono współistniejące rectocele i sigmoidocele. Pacjentka została zakwalifikowana do robotowej rektopeksji z użyciem siatki. W pierwszym etapie operacji wykonano uwolnienie tylnej części mezorektum z zaoszczędzeniem nerwów układu autonomicznego. Następnie wypreparowano przegrodę odbytniczo-pochwową, oddzielając pochwę od przedniej części odbytnicy do poziomu mięśni dźwigaczy odbytu (mięśni dna miednicy) i rozworu moczowo-płciowego, co umożliwiło przymocowanie siatki polipropylenowej do przedniej ściany odbytnicy. Podwieszenie przedniej ściany odbytnicy przy użyciu siatki rozwiązało problem trzech współistniejących patologii. U pacjentki w trakcie dwuletniej obserwacji nie odnotowano nawrotu ani istotnych powikłań pooperacyjnych, a wynik ODS Score uległ obniżeniu do 1/20

Current status of robotic surgery for rectal cancer: A bird′s eye view

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors′ own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included

Protocol-based intravenous fluid hydration for newly created ileostomies decreases readmissions secondary to dehydration

Background: Newly created ileostomies often result in patient readmission due to dehydration secondary to high ostomy output. Implementation of a mandatory home intravenous hydration protocol can avoid this. We aim to evaluate the impact of mandatory home intravenous hydration for patients with newly created ileostomies. Materials and methods: All patients at a single, tertiary care center who underwent ileostomy creation during a period of sporadic home intravenous hydration (February 2011-December 2013) and mandatory protocol hydration (March 2016-December 2018) were reviewed for incidence of dehydration, readmissions, and emergency department visits. Results: 241 patients were evaluated. 119 were in the sporadic group and 122 were in the protocol group. Operative approach differed among both groups, with hydration protocol patients undergoing 15% less open procedures and 4.9% more hand-assisted laparoscopic procedures (P = .0017). Prior to protocol implementation, 23.5% of patients were sent home with intravenous hydration. Length of hospital stay after index ileostomy creation was shorter for protocol patients by 3.3 days (P \u3c .0001). 15.1% of sporadic patients experienced dehydration as compared to 7.4% of protocol patients (P = .0283). Following protocol implementation, the number of patients readmitted due to dehydration increased from 13 to 14 (P = .01). Discussion: Standardized, mandatory at-home intravenous hydration following ileostomy creation leads to a significant reduction in postoperative incidence of dehydration and dehydration-associated readmissions. This protocol should be followed for all patients with newly created ileostomies, so long as adequate home health nursing support and active surveillance are available

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer

Purpose: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. Methods: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. Results: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. Conclusions: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used

Disparities in screening for colorectal cancer based on limited language proficiency

Background:This study analyzes the association between limited language proficiency and screening for colorectal cancer. Methods:This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups. Results:Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P \u3c .001), less physician recommendation for a colonoscopy (87 vs 60%, P \u3c .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P \u3c .001), and fewer fecal occult blood samples overall (P \u3c .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P \u3c .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with Spanish language and other language variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates. Discussion:Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup