#186 First Robotic No Incision Colectomy In Europe: New Technique for Optimising Results Petropoulou

This is one of the 2023 KS International Innovation Awards videos selected for inclusion in the Vattikuti Foundation – ORSI Humans on the Cutting Edge of Robotic Surgery Conference, October 6, 7 & 8, 2023 in Ghent, Belgium. Posting does not imply that is has been selected as a Finalist, just that the content will be discussed at the Conference.

From the entry: Dr. Thalia Petropoulou

Abstract: First robotic natural orifice transluminal extraction colectomy (NOTEC) in Europe: New technique for optimizing results

Natural orifice transluminal extraction colectomy, is an advanced, minimally invasive, method used to perform a colectomy. It is technically complicated and difficult, and have some pitfalls including bacteriological concerns and oncological outcomes and it has not yet been widely used. The potential benefits of this procedure includes reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay and better cosmetic and psychological effects Despite these significant advantages, the high level of surgical skill required and the potential pitfalls of this technique have contributed so that the technique has not yet been widely used.

Several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Also, significant time in the operating room is needed. The robotic platform enables us to perform very complex surgical maneuvers and techniques in an extremely precise, accurate minimally invasive manner — To our knowledge, we present the first robotic NOTEC (natural orifice transluminal extraction colectomy) in Europe and we performed some steps in a different way than the previously described for natural orifice extraction colectomies.

The main reason is that, due to the bacteriological concerns raised with the technique in several concensus, we did not want to cut and leave the specimen open in the abdomen, neither in benign or malignant cases. We also wanted to save operative time, so we did not perform the peripasis robotically, but we did it from the anus, after removing the specimen.

Our steps are usually as follow:

• Lateral to medial mobilization and adhesiolysis (of the uterus and side wall peritoneum)

• Complete medial mobilization • Identification of the ureter

• Take IMA/IMV after the origin of left colic artery (In benign conditions, as this was, we do an IMA preserving sigmoid colectomy- we take the IMA after the origin of the left colic artery, so our proximal colon has good blood supply.

• We take the IMV, so we have sufficient length)

• Mobilization of upper rectum in the TME or near TME plane

• We fully mobilize the splenic flexure so we have enough length for the colon to reach the anus and be anastomosed without tension (REFERENCE MINE)

• Staple the distal rectum

• Rectal washout

• Open the rectal stamp

• Remove the mobilized colon from the anus

• While the colon is in the anus, we cut the distal colon, put the anvil in and secure it with a 3.0 vicryl stitch.

• Return the bowel in the abdomen

• Staple the rectal stamp and removal of the staple line throught the assistant port

• Put the head of the GUN (31 mm) through the anus

• Perform an end-to-end colorectal anastomosis

• Leak test

• Washout and closure of port site incisions

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