Madhu Ragupathi, MD, Diego I Ramos-Valadez, MD, Steven Miller, MD, Eric M Haas, MD FACS FASCRS. Division of Elective General Surgery, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
Introduction: Robotic-assisted laparoscopic surgery (RALS) has evolved into a safe and feasible approach for the treatment of diseases of the colon and rectum. Complex colorectal disease processes, such as complicated diverticulitis, and re-operative surgical fields are often associated with dense fibrosis and adhesions, loss of tissue planes, and displaced structures of the pelvic anatomy. These cases pose a unique challenge, especially when maintaining a minimally invasive approach. RALS may help overcome many of these challenges through superior visualization, increased range of motion, and fine manipulation of the tissues. We evaluated intraoperative parameters and short-term postoperative outcomes following RALS for the surgical management of complex colorectal procedures.
Methods and Procedures: Between July 2008 and August 2010, 98 robotic-assisted laparoscopic surgical procedures were performed for treatment of colorectal disease at the Texas Medical Center. Thirty-five of these procedures (35.7%) were categorized as complex colorectal procedures, defined as procedures involving reoperative anatomy, complex diverticulitis, or endometriosis. The da Vinci® S Surgical System was utilized by a single colorectal surgeon (E.M.H.) for the procedures, which included 1 abdominoperineal resection (APR), 3 rectopexies (RP), 5 partial excisions, 9 low anterior resections (LAR), and 17 anterior rectosigmoid resections (AR). Demographic data, intraoperative parameters, and postoperative outcomes were assessed.
Results: Thirty-five patients (16 male and 19 female) with a mean age of 47.1±13.6 years (range: 23-81 years), mean BMI of 30.6±7.2 kg/m2 (range: 21.1-49.4 kg/m2), and median ASA of 2 (range: 2-3) underwent RALS for complex colorectal disease. Twenty-six patients (74.3%) had a prior history of abdominal or pelvic surgery. Procedures were performed for 33 cases (94.3%) of complex benign disease (including diverticulitis complicated by abscess, fistula or stricture, inflammatory bowel disease with fistula, endometriosis, and recurrent rectal prolapse) and 2 cases (5.7%) of complex malignant disease (recurrent rectal cancer). The mean docking, surgeon console, and total operative times were 9.0±3.2 min (range: 4-20 min), 112.8±48.1 min (range: 40-210 min), and 251.1±93.8 min (range: 90-540 min), respectively. Lysis of adhesions was required in 26 cases (74.3%). The mean estimated blood loss was 83.9±48.1 ml (range: 20-200 ml). There were no intraoperative complications or conversions to open or multi-port laparoscopic surgery. A diverting loop ileostomy was fashioned for 12 patients (34.3%). Nine complications (25.7%) were encountered during 30-day postoperative follow-up. These included a urinary tract infection (n=1), dehydration (n=1), anastomotic leak (n=1), pericolic abscess (n=1), pelvic fluid collection (n=1), and postoperative ileus (n=4). Four patients (11.4%) required readmission during 30-day follow-up for percutaneous (PCT) drainage (n=2), IV fluid resuscitation (n=1), and surgical management of the anastomotic leak (n=1).
Conclusions: Robotic-assisted laparoscopic colorectal surgery is an enabling technology that can be safely applied to cases including re-operative pelvic anatomy and complex colorectal disease. The robotic platform facilitates exposure, dissection and manipulation of tissue planes in a hostile environment while maintaining a minimally invasive approach.
Program Number: P168