V-01 Step by Step Demonstration of Robotic TME Surgery: Learning resource for surgical trainees
Alberto Ignacio Herrando, Laura Melina Fernandez, Pedro Filipe Vieira, Hugo Vicente Domingos, José Filipe Cunha, Richard Heald, Amjad Parvaiz
Champalimaud Foundation. Colorectal Surgery Unit. Lisbon, Portugal Background: Minimal invasive approach has become a gold standard for colorectal cancer with better short-term outcomes.
The introduction of Robotic platforms have allowed colorectal surgeons to overcome some of the technical difficulties faced during total mesorectal resections. We describe a stepwise approach for robotic TME surgery to facilitate learning experience for young surgeons.
Methods: This video illustrates the most relevant surgical steps to perform robotic TME using the DaVinci Xi system platform. We present a 69-year-old man with a rectal tumor T3 N0 M0 CRM (-) EMVI (-) 6cm from anal verge.
Results: The procedure has been didactically divided into 9 steps:
1. Ports placement and robot docking.
2. Positioning and exposure.
3. Vascular dissection and ligation.
4. Colon mobilization.
5. Splenic Flexure mobilization with three dimensional traction step.
6. Mesorectal excision: dissection started from a posterior approach, to continue with the lateral ones and to end with the anterior one.
7. Rectal section and colorectal anastomosis.
8. Drainage and diverting ileostomy.
9. Closure.
Conclusions: Standardization of operative surgery remains the key for both learning and improvement. Robotic platform provides an excellent tool to achieve this. We believe that combination of standardized approach and precise anatomical dissections can lead to better oncological outcomes.
Keywords: Robotic, total mesorectal excision
V-02 Robotic approach in locally advance colorectal cancer
Komal Yousaf, Mahmood Al Dhaheri, Ali Toffaha, Mohammed Abunada, Amjad Parvaiz
Hamad Medical Corporation, Doha, Katar
Locally advance rectal cancers used to be managed by an open approach. In recent years, minimally invasive surgery in the form of laparoscopy has increasingly become popular to manage such advance tumors however, there are some limitations due to straight non-angulating instruments, especially in males and obese patients.
More recently with the advancement of robotic approach, managing locally advance rectal tumor has become more feasible due to improved visualisation and presence of angulating instruments.
Keywords: Robotic surgery, Locally advance rectal tumors
V-03 Laparoscopic Hartmann’s Procedure, Post-Stent Perforation: A Video Vignette
Muhammad Fahd Shah, Irfan Ul Islam Nasir, Fatima Sarfaraz, Shehzad Faiz, Sajjad Ahmad
Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan
Background: Iatrogenic colon perforation (ICP) can occur as a complication of both diagnostic and therapeutic colonoscopies, with incidences estimated at 0.8% and 3%
respectively.With advances in surgical techniques, minimally invasive approach can be safely used to treat iatrogenic colonic perforations with low morbidity and mortality.In this video we demonstrate a standardized approach to minimally invasive Hartman’s procedure for colonic stent perforations.
A 52 years old female having liver cirrhosis and congenital unilateral renal agenesis was diagnosed with well differentiated adenocarcinoma of the rectum which was annular stenosing and at 10 cm from anal verge. Predicted stage on MRI being T3N0 with negative CRM. Patient was discussed in Multidisciplinary Team meeting. Patient underwent colonoscopy for stent placement which led to perforation, on urgent CT scan, stent was visualized to have perforated proximal tumor margin. The video demonstrates Laparoscopic Hartmann’s procedure post stent perforation, that involves intraoperative ligation and division of inferior mesenteric vessels with rectal mobilisation. Postoperatively patient was discharged home after 4 days with stoma being fully functional and patient mobilized. Completely healed wounds on 2 weeks follow up and histopathology of surgical specimen reported as pT3No
Keywords: Stent perforation
V-04 Laparoscopic Extended right hemicolectomy, post Whipple’s procedure: A video vignette
Muhammad Fahd Shah, Irfan Ul Islam Nasir, Fatima Sarfaraz, Shehzad Faiz, Sajjad Ahmad
Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan
Background: Minimally invasive surgery has revolutionized the surgical aspect of cancer treatment with better short term and comparable oncological outcomes. Surgical approach to splenic flexure tumors has always been a challenge. In this
V-06 Endoscopic management of anastomotic stricture with acute large bowel obstruction
Muharrem Oner, Maher Abbas Al Zahra Hospital Dubai
Background: To describe the endoscopic management of large bowel obstruction secondary to a benign anastomotic stricture.
Various etiologies can lead to large bowel obstruction including benign conditions and malignancy. Patients who present with large bowel obstruction pause significant challenge to the surgeon. Emergency surgery carries significant morbidity and frequently leads to stoma.
Methods: A 63-year-old woman presented with acute large bowel obstruction secondary to a chronic anastomotic stricture following left hemicolectomy for recurrent diverticulitis.
Endoscopic decompression of acute large bowel obstruction by balloon dilation and subsequent needle knife stricturoplasty.
Results: Immediate resolution of the large bowel obstruction following the first dilation, subsequent bowel preparation with repeat dilation, and definitive needle knife stricturoplasty was carried out. The patient did well long-term without the need for surgical intervention.
Conclusions: Endoscopic management of anastomotic stricture presenting as acute large bowel obstruction is feasible and provides a treatment option with minimal morbidity and avoidance of stoma.
Keywords: Endoscopic management of intestinal obstruction.
Large bowel stricture
V-07 Myomectomy for Hirschsprung’s disease in adolescents
Muharrem Oner, Maher Abbas Al Zahra Hospital Dubai, UAE
Background: To describe the surgical management of adolescents who present with ultrashort segment Hirschsprung’s disease. 1 in 5,000 newborns have Hirschsprung’s disease.
Typically, this condition is diagnosed in infancy and managed by pediatric surgeons. Ultrashort segment disease can present in adolescence (<1% of all cases)
Methods: 3 males (age 13 to 16 years) presented with severe constipation since early childhood. Symptoms were progressively getting worse with a frequency of bowel movements between 1 and 4 weeks despite comprehensive medical therapy.Myomectomy was carried out in the posterior anal canal removing a strip of about 1 x 4 cm of rectal wal Results: Patients were discharged on the second postoperative day without any complications. They remained well at last follow-up with resolution of the constipation with bowel movements every 2 to 3 days with the intake of fiber supplementation and occasional use of laxatives.
video we want to show a step-by-step approach to extended right hemicolectomy performed for a patient who had Whipple’s procedure five years ago.
A 39-year-old male patient underwent open Whipple’s procedure for periampullary moderately differentiated carcinoma with mucinous features in 2016, was diagnosed with splenic flexure tumor in May 2021. The case was discussed in multi-disciplinary team meeting, and it was recommended to proceed with colonic resection.
The video demonstrates identification of challenges encountered during laparoscopic surgery and how to overcome them. Video starts with adhenolysis and identification of previous anastomosis. It shows complete mobilization of sigmoid, descending, transverse and ascending colon, along with identification and preservation of ureters and gonadal vessels. Inferior mesenteric artery is preserved. left colic artery is clipped at its base. Division of inferior mesenteric vein, ileocolic and middle colic vessels.
Patient had an uneventful recovery and was discharged home on 5th post-operative day. On follow up all his wounds were healed, and histology showed T3N0 all margins clear.
Keywords: Post Whipple’s, Extended right hemicolectomy
V-05 Laparoscopic Ace Procedure for chronic constipation refractory to medical therapy
Muharrem Oner, Maher Abbas Al Zahra Hospital Dubai, UAE
Background: To describe antegrade continent enema known as the ACE or Malone procedure which is a surgical option for some patients with severe constipation or fecalincontinence.
Constipation is a common complaint for people of all ages.
Severity of constipation varies from person to person; most people experience short periods of constipation during their lives,while others have constipation as a chronic long-term condition that can significantly affect their quality of life.
There are a number of factors that can contribute to developing constipation including diets low in fibre,changes in lifestyle,side effects of certain medications and low fluid intake. People can successfully treat constipation by making changes to their diet and lifestyle or medication, However, surgery may be required to manage constipation for some.Methods: Laparoscopic Ace Procedure was performed. Appendix is used as continent stoma at the umbilicus. Access to the bowel was done through a catheter.Results: Patient discharged on post-operative day 1 without complications. Daily warm water irrigation [500-1000 ml] was started post-operative day 5. Catheter remained in place for 3 weeks.Intermittent daily catheterization afterwards.
Conclusions: ACE procedure good option for adults with severe constipation refractory to medication. Laparoscopic is approach preferable.The procedure is well tolerated by patients with good long-term control of symptoms.
Keywords: ace procedure. Constipation
divided into traditional anastomosis group and angular closure anastomosis group. The difference of anastomotic leakage between the two groups was analyzed by statistical method.
Results: 72 patients with middle and low rectal cancer were analyzed, including 35 cases of traditional anastomosis group and 37 cases of angular closure anastomosis group. 7 cases of anastomotic leakage occurred in traditional anastomosis group, including 1 case of class A anastomotic leakage, 5 cases of class B and 1 case of class C. Only 1 case of anastomotic leakage occurred in angle closure anastomosis group, which was grade C anastomotic leakage. There was significant difference in anastomotic leakage between two group (P=0.014).
Conclusions: Angle closure anastomosis is a novel anastomosis technique of rectal surgery, which can significantly reduce the probability of postoperative anastomotic leakage in middle and low rectal cancer.
Keywords: angle closure anastomosis; anastomotic leakage
V-10 Minimal İnvaziv Rektum Kanseri Ameliyatında Endo Retraktör’ün Ekspozisyonda Kullanımı
Afag Aghayeva1, İnci Şahin2, Bilgi Baca1
1Mehmet Ali Aydınlar Üniversitesi Tıp Fakültesi, Genel Cerrahi Ana Bilim Dalı, İstanbul, Türkiye
2Acıbadem Altunizade Hastanesi, Genel Cerrahi Ana Bilim Dalı, İstanbul, Türkiye
Giriş: Minimal invaziv cerrahinin en zor kısmı ameliyat alanının ekspozisyonudur. Ameliyat alanına giren ince bağırsaklar nedeniyle net görüş sağlamak için hastaya maksimum Trendelenburg pozisyonu verilmesi gerekmektedir.
Bu pozisyon intrakranial ve intratorasik basınç artışı nedeniyle hastada hemodinamik bozukluklara neden olabilir. Özellikle robotik cerrahide pozisyon değişikliği yapılamadığı için ince barsakların ameliyat alanına girmesi nedeniyle cerrahi zorluklar yaşanabilir. Bu nedenle ince barsakları ekarte etmek için selüloz sünger ürünü (Endoractor, Schnell Medical Corp., CH) kullanıma sunulmuştur.
Bu videonun amacı, robotik total mezorektal eksizyon (TME) ameliyatı sırasında ameliyat alanının görünümüne Endoractor’un katkısını göstermektir.
Metod: Bu hastada robotik TME için dört robotik trokar ve bir adet asistan trokarı kullanılmıştır. Hastaya minimal Trendelenburg pozisyonu verilerek Endoractor ile ince barsaklar ekarte edilerek ameliyat gerçekleştirilmiştir.
Bulgular: Ameliyat süresi 260 dakika ve kanama miktarı yaklaşık 20 mL olarak ölçüldü. Hasta postoperatif 3. günde sorunsuz taburcu edilmiştir.
Sonuç: Bu videoda ince bağırsakların ameliyat alanından uzaklaştırılarak daha az Trendelenburg pozisyonunda ve daha rahat yapılabildiği gözlenmiştir. Bu ve benzeri ürünler minimal invaziv cerrahide daha iyi bir ekspozisyon için katkı sağlayabilirler.
Anahtar Kelimeler: robotik, rektum Conclusions: Posterior strip myomectomy significantly
improves the symptoms of adolescent patients who present with ultrashort segment Hirschsprung’s disease. The procedure is safe with long-term efficacy.
Keywords: Myomectomy, Hirschsprung’s disease in adolescents
V-08 Anal abscess drainage. The basics 101
Muharrem Oner, Maher Abbas Al Zahra Hospital Dubai, UAE
Background: The primary goal of incision and drainage is to control the sepsis and obtain relief from the pain.
This operation is deemed as a simple surgical procedure and in training centers is often assigned to the most junior member of the surgical team..However it is important to note that proper drainage can determine the future outcome for the patient.
Methods: Determining the site of the incision is key.The area of most fluctuance needs to be accessed for proper drainage.
Staying lateral to the sphincter muscle is critical to avoid damage while at the same time avoiding too lateral of an incision to shorten any potential fistula tract.Culture the pus as there is an increasing incidence of resistant bacterial organisms.
Dealing with the anal fistula in this setting is controversial.If a fistula is readily identified, a consideration should be made for the placement of a draining seton.Fistulotomy is rarely advisable in this setting.No repacking is advisable as it is often very painful for the patient.Conclusions: Anal abscess is one of the most common colorectal emergencies.Incision and drainage can yield significant relief of the pain and control of the sepsis.Observing the basic fundamentals would hopefully lead to a successful outcome with minimum morbidity.
Keywords: Anal Abscess, how to drain anal abscess