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Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes., Methods: From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m 2 , (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection., Results: 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028)., Conclusion: A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database., Methods: The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant., Results: After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery., Conclusions: This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy., Methods: Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates., Results: There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups., Conclusion: In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy., (© 2021. The Author(s).)

Background: Elderly patients are underrepresented in studies demonstrating the advantages of laparoscopy for the management of colorectal diseases. Moreover, few studies have examined the robotic approach in this population. In this retrospective analysis, we compare outcomes for open, laparoscopic, and robotic approaches in elderly patients with nonmetastatic rectal cancer., Methods: The U.S. National Cancer Database was queried for patients aged ≥ 65 with nonmetastatic adenocarcinoma of the rectum who underwent surgical resection from 2010 to 2016. Groups were separated based on approach (open, laparoscopic, robotic). One-to-one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze the primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression., Results: Inclusion criteria and PSM identified 1891 patients per approach (n = 5673). PSM provided adequate discrimination between cohorts (0.6 < AUC < 0.8), and potential confounding covariates did not significantly differ (respective P > 0.05). After PSM, robotic and laparoscopic approaches were associated with decreased odds of 90 day mortality compared to the open approach (P < 0.05). Compared to laparoscopy, a robotic approach was associated with increased odds of ≥ 12 regional lymph nodes examined and negative circumferential resection margin (P < 0.05). No differences were seen in 30 day or 90 day mortality between robotic and laparoscopic approaches. Cox proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open., Conclusion: Our study demonstrates that in elderly patients, minimally invasive surgery for rectal adenocarcinoma was associated with equivalent or improved short- and long-term mortality over open surgery. Compared to laparoscopy, the robotic approach showed no survival disadvantage and greater odds of an appropriate oncological resection. Our study adds evidence to the conclusion that robotic rectal surgery can be safely performed in patients regardless of age., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Purpose: Minimally invasive resection of colon cancer at the splenic flexure can be technically challenging with concerns for a suboptimal oncologic outcome. We aimed to compare open and minimally invasive approaches following curative resection., Methods: The National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma at the splenic flexure who underwent resection from 2010 to 2016. Cohorts were separated into open and minimally invasive approaches, and demographic and clinicopathologic variables were compared. Propensity-score matching (PSM) was utilized to balance potential confounding covariates between cohorts to elucidate the independent association between surgical approach and outcomes. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival. Secondary outcomes were analyzed by way of logistic regression or Mann-Whitney U test., Results: After matching, 842 patients were compared between approaches. Patients who underwent minimally invasive surgery had no significant difference in regional nodes ≥ 12 examined, positive margins, negative circumferential margins, unplanned 30-day readmission, or time from surgery to initiation of chemotherapy when compared to patients who underwent open surgery. Minimally invasive surgery was significantly associated with decreased odds of 30-day mortality, 90-day mortality, and decreased mortality hazard for 5-year overall survival compared to open surgery., Conclusion: The optimal approach for surgical management of splenic flexure colon cancer has not been standardized given its rarity and exclusion from randomized controlled trials. Our retrospective review suggests that minimally invasive resection of splenic flexure colon cancers in carefully selected patients is associated with equivalent oncologic outcomes as well as improved short and long-term survival compared to an open approach., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Emerging data show a rise in colorectal cancer (CRC) incidence in young men and women that is often chemoresistant. One potential risk factor is an alteration in the microbiome. Here, we investigated the role of TGF-β signaling on the intestinal microbiome and the efficacy of chemotherapy for CRC induced by azoxymethane and dextran sodium sulfate in mice. We used two genotypes of TGF-β-signaling-deficient mice (Smad4 +/- and Smad4 +/- Sptbn1 +/- ), which developed CRC with similar phenotypes and had similar alterations in the intestinal microbiome. Using these mice, we evaluated the intestinal microbiome and determined the effect of dysfunctional TGF-β signaling on the response to the chemotherapeutic agent 5-Fluoro-uracil (5FU) after induction of CRC. Using shotgun metagenomic sequencing, we determined gut microbiota composition in mice with CRC and found reduced amounts of beneficial species of Bacteroides and Parabacteroides in the mutants compared to the wild-type (WT) mice. Furthermore, the mutant mice with CRC were resistant to 5FU. Whereas the abundances of E. boltae, B.dorei, Lachnoclostridium sp., and Mordavella sp. were significantly reduced in mice with CRC, these species only recovered to basal amounts after 5FU treatment in WT mice, suggesting that the alterations in the intestinal microbiome resulting from compromised TGF-β signaling impaired the response to 5FU. These findings could have implications for inhibiting the TGF-β pathway in the treatment of CRC or other cancers., (Copyright © 2021. Published by Elsevier B.V.)

Historically, T4 tumors of the colon have been a contraindication to minimally invasive resection. The purpose of this study was to conduct a National Cancer Database analysis to compare the outcomes after curative treatment for T4 colon cancer between robotic, laparoscopic, and open approaches. The US National Cancer Database was queried for patients with T4 adenocarcinoma of the colon who underwent curative resection. Groups were separated based on approach (open, laparoscopic, robotic). One to one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. Inclusion criteria and PSM identified 876 cases per treatment approach (n = 2628). PSM provided adequate discrimination between treatment cohorts (0.6 < AUC < 0.8) and potential confounding covariates did not significantly differ between cohorts (all respective P > 0.05). Patients who underwent a robotic approach had lower odds of conversion to laparotomy compared to the laparoscopic cohort (P < 0.0001). Laparoscopic and robotic approaches were associated with increased odds of > 12 lymph nodes examined, decreased odds of positive margins, and decreased odds of 30-day readmission, 30-day mortality, and 90-day mortality compared to the open approach. Cox-proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. Both laparoscopic and robotic-assisted surgeries achieved improved oncologic outcomes and survival compared to open resection of T4 cancers. A robotic-assisted approach was significantly associated with a lower conversion rate compared to the laparoscopic approach. This case-matched study demonstrates safety of using minimally invasive techniques in T4 cancers., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Background: Crohn's disease has historically been managed medically with sparing use of surgical resection. With the development of strictures or fistulas, surgical management such as an ileocecal resection may become necessary. Minimally invasive options such as laparoscopic and robotic-assisted techniques are alternatives to open surgery. The purpose of this study was to evaluate the safety of minimally invasive surgery for Crohn's disease., Methods: We performed a retrospective review of the National Surgical Quality Improvement Program (NSQIP) database to select 5158 patients with Crohn's disease who underwent ileocecal resection (open, laparoscopic, or robotic-assisted). Preoperative, perioperative, and 30-day postoperative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant., Results: The three treatment groups (open, laparoscopic, and robotic-assisted ileocecal resection) had 30-day postoperative outcomes reported in NSQIP. The average BMI was 25 kg/m 2 and the average age was 41. The rate of anastomotic leaks was significantly higher in the open surgery group compared to the minimally invasive groups (p = 0.001). The open surgery group had a significantly higher reoperation rate (p = 0.0002) and wound infection rate (p < 0.0001). The robotic-assisted group had significantly longer operative times compared to the laparoscopic and open groups (p < 0.0001)., Conclusions: The decision to operate on a patient with Crohn's disease involves selecting an approach based on patient factors, surgeon preference, and availability of equipment. When evaluating the short-term postoperative outcomes in patients that have undergone ileocecal resection for management of Crohn's, minimally invasive techniques have had a lower incidence of wound infections, anastomotic leaks, and re-intervention in carefully selected patients. This retrospective review of a large national database demonstrates the efficacy of minimally invasive techniques in managing Crohn's disease in selected patients.

Background: Robotic-assisted techniques in colorectal surgery have dramatically increased. Comparative data on the management of uncomplicated and complicated diverticulitis using robotics is lacking. The purpose of this study is to examine outcomes of patients who underwent robotic-assisted resection in diverticulitis., Methods: A prospectively maintained database performed by a single surgeon was retrospectively reviewed to identify patients who underwent robotic-assisted surgery (RAS) for diverticulitis from October 2009 to November 2018. Demographic data, preoperative and intraoperative parameters and postoperative outcomes were assessed using χ 2 or Fisher exact test with p values <0.05 considered significant. IRB approval was obtained for this study, #NCR190935., Results: Comparison revealed significant differences in operative times (222 vs. 291 min, p < 0.00001), mean estimated blood loss (130 vs. 304 cc, p = 0.0003) and mean length of stay (3.9 vs. 5.0 days, p = 0.006). Low rates of postoperative complications were observed, with no significant differences noted for conversion to laparoscopy, surgical site infection, leak, intra-abdominal abscess, 30-day unplanned readmission or recurrence., Conclusion: Patients with complicated diverticulitis required longer operative time, had increased estimated blood loss and more often converted to an open procedure; however, overall rates of post-operative complications were low in both groups. RAS shows promise for use in complicated diverticulitis., (© 2021 John Wiley & Sons Ltd.)

Background: This study examined utilization and conversion rates for robotic and laparoscopic approaches to non-metastatic rectal cancer. Secondary aims were to examine short- and long-term outcomes of patients who underwent conversion to laparotomy from each approach., Methods: The National Cancer Database (NCDB) was reviewed for all cases of non-metastatic adenocarcinoma of the rectum or rectosigmoid junction who underwent surgical resection from 2010 to 2016. Utilization rates of robotic, laparoscopic, and open approaches were examined. Patients were split into cohorts by approach. Subgroup analyses were performed by primary tumor site and surgical procedure. Multivariable analysis was performed by multivariable logistic regression for binary outcomes and multivariable general linear models for continuous outcomes. Survival analysis was performed by Kaplan-Meier and multivariable cox-proportional hazards regression., Results: From 2010 to 2016, there was a statistically significant increase in utilization of the robotic and laparoscopic approaches over the study period and a statistically significant decrease in utilization of the open approach. The conversion rates for robotic and laparoscopic cohorts were 7.0% and 15.7%, p < 0.0001. Subgroup analysis revealed statistically lower conversion rates between robotic and laparoscopic approaches for rectosigmoid and rectal tumors and for LAR and APR. Converted cohorts had statistically significant higher odds of short term mortality than the non-converted cohorts (p  < 0.05).Laparoscopic conversion had statistically higher odds of positive margins (p  < 0.0001) and 30-day unplanned readmission (p  < 0.0001) than the laparoscopic non-conversion. Increased adjusted mortality hazard was seen for converted laparoscopy relative to non-converted laparoscopy (p  = 0.0019)., Conclusion: From 2010 to 2016, there was a significant increase in utilization of minimally invasive approaches to surgical management of non-metastatic rectal cancer. A robotic approach demonstrated decreased conversion rates than a laparoscopic approach at the rectosigmoid junction and rectum and for LAR and APR. Improved outcomes were seen in the minimally invasive cohorts compared to those that converted to laparotomy.

Background: Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSeal ® is a valve-less trocar system that overcomes these flaws by utilizing a system of laminar flow and CO 2 recirculation. The purpose of this paper is to examine the effect of the AirSeal ® versus a traditional trocar system in operative time, EBL and post-operative complications. To the best of our knowledge, this is the first analysis of this system in robotic colorectal surgery., Methods: A single surgeon's database was reviewed and all LAR and right hemicolectomy robotic cases from 2014-2015 and 2017-2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS., Results: Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014-2015 and 232 ± 74.6 min in 2017-2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014-2015 and 150 ± 173.9 cc in 2017-2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014-2015 and 2017-2018. Length of stay was reduced in both populations between 2014-2015 and 2017-2018; however, it neither reached statistical significance., Conclusion: In patients undergoing low anterior resections, the AirSeal ® trocar system demonstrated a statistically significant reduction in mean operative time and EBL compared to the traditional trocar system. There was also a trend towards decreased length of stay and post-operative complications with AirSeal ® use in low anterior resections and right hemicolectomies. In patients undergoing distal colorectal procedures, the AirSeal ® trocar system should be considered.

Aim: This study aimed to present our experience with robotic colorectal surgery since its establishment at our institution in 2009. By examining the outcomes of over 500 patients, our experience provides a basis for assessing the introduction of a robotic platform in a colorectal practice. Specific measures investigated include intraoperative data and postoperative outcomes for all operations using the robotic platform. In addition, for our most commonly performed operations we wished to analyse the learning curve to improve operative proficiency. This is the largest single-surgeon robotic database analysed to date., Method: A prospectively maintained database of patients who underwent robotic colorectal surgery by a single surgeon at the George Washington University Hospital was retrospectively reviewed. Demographic data and perioperative outcomes were assessed. Additionally, an operating time learning curve analysis was performed., Results: Inclusion criteria identified 502 patients who underwent robotic colorectal surgery between October 2009 and December 2018. The most common indications for surgery were diverticulitis (22.9%), colon adenocarcinoma (22.1%) and rectal adenocarcinoma (19.5%). The most common operations were anterior/low anterior resection (33.9%), right hemicolectomy/ileocaecectomy (24.9%) and left hemicolectomy/sigmoidectomy (21.9%). The rate of conversion to open surgery was 4.8%. The most common postoperative complications were wound infection (5.0%), anastomotic leakage (4.0%) and abscess formation (2.8%). The operating time learning curve plateaued at 55-65 cases for anterior and low anterior resection and 35-45 cases for left hemicolectomy and sigmoidectomy. A clear learning curve was not seen in right hemicolectomy., Conclusion: Robotic-assisted surgery can be performed in a diverse colorectal practice with low rates of conversion and postoperative complications. Plateau performance was achieved after 65 anterior/low anterior resections and 45 left and sigmoid colectomies., (© 2020 The Association of Coloproctology of Great Britain and Ireland.)

Colorectal cancer remains the third most common cancer effecting adults. Surgical guidelines recommend transanal excision of early rectal neoplasia up to 8 cm from the anal verge. A retrospective review of two novel approaches for transanal robotic local excision with R0 resections of rectal cancers which was, on average, higher than 8 cm. Twenty-one cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) were reviewed. The first 10 cases performed with the da Vinci ® Si robotic platform between 2013 and 2016, and the first 11 cases performed using the Flex ® Medrobotics platform between August 2017 and August 2018. The average distance from the anal verge was 11.1 cm and 9.5 cm for the da Vinci ® Si and Flex ® Colorectal Drive, respectively. The average operative time was 167.6 min for the da Vinci ® Si and 110.1 min for the Flex ® Colorectal Drive; the average EBL was 37.5 cc and 9.1 cc for the da Vinci ® Si and Flex ® Colorectal Drive. In the da Vinci ® series, four cases required intraoperative conversion. In the Flex ® series, one case was aborted due to unfavorable robotic positioning. All margins were histologically negative when surgically complete with no recurrences to date. Transanal robotic surgery may provide a method to address rectal lesions farther from the anal verge than previously described. The Flex ® Colorectal Drive platform may provide superior ability to navigate the nonlinear anatomy of the rectum and distal sigmoid colon.

Introduction: Ulcerative colitis (UC) is a chronic inflammatory intestinal disorder that can be managed surgically with a proctocolectomy. Minimally invasive techniques such as laparoscopic or robotic-assisted surgery are available based on the surgeon's preference and familiarity. To date, there is a paucity of literature evaluating the safety of these techniques in comparison to the open approach in patients with UC., Methods: We surveyed the National Surgical Quality Improvement Program (NSQIP) database to select patients with the diagnosis of UC who underwent either robotic, laparoscopic, or open proctocolectomy between 2012 and 2017. A total of 2129 patients were included in the study. The 30-day postoperative outcomes were compared using multivariable logistic regression models after adjusting for confounding variables. The confounding variables were defined as any preoperative variable that was associated with the type of procedure., Results: The 30-day postoperative outcomes reported in the NSQIP database were reviewed for each of the treatment groups (open, laparoscopic, and robotic). The anastomotic leak rate was significantly higher in the open group ( P = .022). The robotic and laparoscopic groups had significantly fewer occurrences of postoperative ileus ( P = .0006) and wound infections ( P < .0001). There were significantly more strokes, cardiac events, and pulmonary events in the open surgical group. Operative time was significantly shorter in the open group ( P < .0001). Reintervention rates were not significantly different among the groups., Conclusions: Minimally invasive proctocolectomy has significantly fewer postoperative complications compared with open proctocolectomy for UC. There is no significant difference in the postoperative outcomes between robotic-assisted and laparoscopic proctocolectomy.

Background: Data regarding the effect of conversion from minimally invasive surgery (MIS) to laparotomy in rectal cancer is limited. This study examines the impact of conversion from laparoscopic or robotic-assisted techniques to open resection on oncologic outcomes in a large population database., Methods: The National Cancer Database from 2010 to 2016 was reviewed for all cases of invasive adenocarcinoma of the rectum or rectosigmoid junction managed surgically. Patients were divided into 3 cohorts by approach: laparoscopic/robotic (MIS), converted proctectomy (CP), and open proctectomy (OP). Kaplan-Meier estimation was used for unadjusted survival analysis, followed by adjusted multivariable Cox-Proportional Hazards regression. Secondary outcomes were analyzed by multivariable logistic regression., Results: The inclusion criteria identified 57 574 patients cases of adenocarcinoma of the rectum managed surgically. Of these patients, 23 579 (41.0%) underwent MIS, 3591 (6.2%) CP, and 30 404 (52.8%) OP. Five-year overall survival was greater in the MIS (70.4%) versus CP and OP (64.4% and 61.4%). No differences were detected for positive margins, 30-day, or 90-day mortality between CP and OP. MIS and CP approaches were significantly associated with increased odds of 12 or more regional lymph nodes examined and decreased overall mortality hazard compared with OP (all respective significant P < .05)., Discussion: While similar odds of positive margins and short-term mortality is seen in patients whose procedure converts to laparotomy compared with planned laparotomy, both short-term and long-term oncologic benefit is seen in those who undergo a minimally invasive approach. Thus, a minimally invasive approach should be attempted for patients with rectal cancer.

RING-finger E3 ligases are instrumental in the regulation of inflammatory cascades, apoptosis, and cancer. However, their roles are relatively unknown in TGFβ/SMAD signaling. SMAD3 and its adaptors, such as β2SP, are important mediators of TGFβ signaling and regulate gene expression to suppress stem cell-like phenotypes in diverse cancers, including hepatocellular carcinoma (HCC). Here, PJA1, an E3 ligase, promoted ubiquitination and degradation of phosphorylated SMAD3 and impaired a SMAD3/β2SP-dependent tumor-suppressing pathway in multiple HCC cell lines. In mice deficient for SMAD3 ( Smad3 +/- ), PJA1 overexpression promoted the transformation of liver stem cells. Analysis of genes regulated by PJA1 knockdown and TGFβ1 signaling revealed 1,584 co-upregulated genes and 1,280 co-downregulated genes, including many implicated in cancer. The E3 ligase inhibitor RTA405 enhanced SMAD3-regulated gene expression and reduced growth of HCC cells in culture and xenografts of HCC tumors, suggesting that inhibition of PJA1 may be beneficial in treating HCC or preventing HCC development in at-risk patients. Significance: These findings provide a novel mechanism regulating the tumor suppressor function of TGFβ in liver carcinogenesis., (©2020 American Association for Cancer Research.)

Introduction: Laparoscopic abdominoperineal resection (APR) for low rectal cancers is technically demanding. Robotic assistance may be of help and can be hybrid (HAPR) or totally robotic (RAPR). The present study describes outcomes of robotic APR and compares both approaches., Material and Methods: A multicentric retrospective analysis of rectal cancer patients undergoing either HAPR or RAPR was conducted. Patients' demographics, surgeons' experience, oncologic results, and intraoperative and postoperative outcomes were collected., Results: One hundred twenty-five patients were included, 48 in HAPR group and 77 in RAPR group. Demographics and comorbidities were comparable. Operative time was reduced in RAPR group (266.9 ± 107.8 min vs 318.9 ± 75.1 min, P = .001). RAPR patients were discharged home more frequently (91.18% vs 66.67%, P = .001), and experienced fewer parastomal hernias (3.71% vs 9.86%, P = .001)., Conclusion: RAPR is safe and feasible with appropriate oncologic outcomes. Totally robotic approach reduces operative time and may improve functional outcomes., (© 2019 John Wiley & Sons, Ltd.)

Background & Aims: We studied interactions among proteins of the carcinoembryonic antigen-related cell adhesion molecule (CEACAM) family, which interact with microbes, and transforming growth factor beta (TGFB) signaling pathway, which is often altered in colorectal cancer cells. We investigated mechanisms by which CEACAM proteins inhibit TGFB signaling and alter the intestinal microbiome to promote colorectal carcinogenesis., Methods: We collected data on DNA sequences, messenger RNA expression levels, and patient survival times from 456 colorectal adenocarcinoma cases, and a separate set of 594 samples of colorectal adenocarcinomas, in The Cancer Genome Atlas. We performed shotgun metagenomic sequencing analyses of feces from wild-type mice and mice with defects in TGFB signaling (Sptbn1 +/- and Smad4 +/- /Sptbn1 +/- ) to identify changes in microbiota composition before development of colon tumors. CEACAM protein and its mutants were overexpressed in SW480 and HCT116 colorectal cancer cell lines, which were analyzed by immunoblotting and proliferation and colony formation assays., Results: In colorectal adenocarcinomas, high expression levels of genes encoding CEACAM proteins, especially CEACAM5, were associated with reduced survival times of patients. There was an inverse correlation between expression of CEACAM genes and expression of TGFB pathway genes (TGFBR1, TGFBR2, and SMAD3). In colorectal adenocarcinomas, we also found an inverse correlation between expression of genes in the TGFB signaling pathway and genes that regulate stem cell features of cells. We found mutations encoding L640I and A643T in the B3 domain of human CEACAM5 in colorectal adenocarcinomas; structural studies indicated that these mutations would alter the interaction between CEACAM5 and TGFBR1. Overexpression of these mutants in SW480 and HCT116 colorectal cancer cell lines increased their anchorage-independent growth and inhibited TGFB signaling to a greater extent than overexpression of wild-type CEACAM5, indicating that they are gain-of-function mutations. Compared with feces from wild-type mice, feces from mice with defects in TGFB signaling had increased abundance of bacterial species that have been associated with the development of colon tumors, including Clostridium septicum, and decreased amounts of beneficial bacteria, such as Bacteroides vulgatus and Parabacteroides distasonis., Conclusion: We found expression of CEACAMs and genes that regulate stem cell features of cells to be increased in colorectal adenocarcinomas and inversely correlated with expression of TGFB pathway genes. We found colorectal adenocarcinomas to express mutant forms of CEACAM5 that inhibit TGFB signaling and increase proliferation and colony formation. We propose that CEACAM proteins disrupt TGFB signaling, which alters the composition of the intestinal microbiome to promote colorectal carcinogenesis., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The use of transanal total mesorectal excision (taTME) for treatment of rectal cancer is growing, but anatomic constraints prevent access to the proximal rectum with rigid instruments. The articulated instrumentation of current surgical robots is promising in overcoming these limitations, but the bulky size of current platforms inhibits the proximal reach of dissection. Flexible robotic systems could overcome these constraints while maintaining a stable platform for dissection. The goal of this study was to evaluate feasibility of performing taTME using the semi-robotic Flex® System (Medrobotics Corp., Raynham, MA) in human cadavers., Methods: taTME was performed by two surgeons in six fresh human cadaveric specimens using the Flex® System, with or without transabdominal laparoscopic assistance. Both mid- and low-rectal lesions were simulated. Metrics including quality of visualization, maintenance of pneumorectum, maneuverability of instruments, effectiveness of pursestring suture placement, and dissection in an anatomically correct plane were evaluated., Results: The semi-robotic endoluminal platform allowed for excellent visualization, insufflation, and dissection during taTME. Adequate pursestring occlusion of the rectum was achieved in all six cases. In cadavers with simulated mid-rectal lesions (N = 4), dissection and anterior peritoneal entry was achieved in all cases, with abdominal assistance utilized in two of four cases. In cadavers with simulated low-rectal lesions (N = 2), dissection was incomplete and aborted due to difficulty maneuvering instruments in close proximity to the rigid transanal port., Conclusions: Use of the Flex® system for taTME is feasible for mid-rectal dissection. Advantages over the traditional multi-armed robot include longer reach of instruments with the ability to dissect up to 17 cm from the anal verge, as well as tactile feedback. The current design of the flexible platform does not permit safe dissection in the distal rectum, although this constraint may be resolved with future adjustments to the equipment.

Intracorporeal options for sigmoid resection have been recently developed but not extensively evaluated. This study was designed to assess outcomes comparing intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection in an established enhanced recovery pathway. This is a retrospective comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection for benign and malignant disease. Operative technique for the newer intracorporeal innovation is described in detail. Propensity score matching was performed using patient characteristics as predictors in the propensity score model. 169 cases met inclusion criteria. After propensity score matching, 114 cases were available for analysis (intracorporeal 57, extracorporeal 57). Almost 90% were for diverticulitis in each group. There were significantly fewer conversions in the intracorporeal group when compared to the extracorporeal group (5.26% vs. 19.3%, P = 0.029). Operative time was significantly longer in the intracorporeal group (193.33 vs. 159.89 min, P < 0.001). There was no significant difference between groups for time to flatus and bowel movements, hospital length of stay, postoperative 30-day complications, and readmission rates. There were significantly fewer extraction site hernias in the intracorporeal group (0 vs. 6 (10.53%), P = 0.027) likely because there were fewer midline extraction sites (8.77% vs. 38.6%, P < 0.001). When compared to extracorporeal techniques for robotic sigmoid resection in an enhanced recovery pathway, the intracorporeal approach is safe and associated with fewer conversions, fewer extraction site hernias, and longer operating times. As adoption of the intracorporeal approach continues to increase, further analysis of this technique in larger studies may be warranted.

Purpose/background: Using robotic surgery, we report successful resection of deep invasive pelvic endometriosis with a multidisciplinary team of colorectal and gynecologic surgeons., Methods/interventions: Fifteen cases of robotic-assisted endometrial resections for deep invasive endometriosis were performed by a multidisciplinary team between 2013 and 2016., Results/outcomes: The average total operative time of robotic endometrial extirpation was 342 minutes, and the average blood loss was 283 cc. There were no intraoperative complications and no conversion to laparotomy. Postoperative complications, including one superficial wound infection, four patients with pelvic abscesses, a bowel leak, and one rectovaginal fistula, occurred in five of 15 patients, three of which required percutaneous drainage and one required reoperation. All patients who followed up after surgery showed 100% dysmenorrhea resolution at one month (13 of 15 patients)., Conclusion/discussion: Deep infiltrating endometriosis is a complex disease associated with significant morbidity and requires highly trained, multidisciplinary team approach for safe and efficient excision., (© 2019 John Wiley & Sons, Ltd.)

Purpose/background: The surgical approach to adenocarcinoma of the rectum remains a controversial topic. Although current data focus on the noninferiority of minimally invasive surgery (MIS) for rectal cancer compared with laparotomy, conclusions are drawn from smaller sample sizes and may be underpowered. Methods/Interventions: The National Cancer Database (NCDB) from 2010 to 2014 was reviewed for all cases of invasive adenocarcinoma of the rectum (SEER Histology Codes 8140) who underwent surgical resection for malignancy. Groups were separated based on laparotomy or an MIS approach and stratified by NCDB Analytic Stage. Multivariate Cox regression analysis was used to evaluate for survival after diagnosis of adenocarcinoma of the rectum. Results/Outcomes: The inclusion criteria identified 29,199 cases of adenocarcinoma of the rectum managed surgically. After controlling for differences in the cohorts, survival after diagnosis and definitive surgical treatment for adenocarcinoma of the rectum is improved when an MIS approach was used (adjusted hazard ratio [HR] = 0.82, 95% confidence interval [CI] = 0.77-0.88, P < .001). The protective effect of an MIS approach applied to Stages I, II, III, and IV adenocarcinoma of the rectum. The protective effect of a minimally invasive surgical approach applies to Stages I, II, III, and IV adenocarcinoma of the rectum. The rate of negative circumferential margins (86.2% versus 83.5%, P < .001), proximal and distal margins (94.7% versus 92.1%, P < .001), and lymph node yield >12 (73.2% versus 70.1%, P < .001) was higher in the minimally invasive group compared with laparotomy. The intraoperative conversion rate from MIS to laparotomy was 13.9%., Conclusion/discussion: Minimally invasive resection for adenocarcinoma of the rectum shows promising survival benefit compared with open surgery after adjusting for measured confounds.

Background: Robotic surgery has increased in recent years for the treatment of colorectal cancer; however, it is not yet the standard of care. This study aims to compare the 30-day outcomes after robotic colectomy for right-sided colon cancer from our institution with those from a national dataset, the targeted colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database., Methods: Patients undergoing elective, robotic, right colon resection for stage I, II, and III colon cancer were identified within the targeted colectomy ACS-NSQIP database from 2012 to 2014. Patients meeting the same criteria were identified within a prospectively maintained institutional database from 2009 to 2015. Univariate analyses using chi-square tests and Student's t-tests were done where appropriate to compare baseline characteristics and outcomes between the two groups., Results: Patients at our institution had a significantly higher average number of lymph nodes retrieved (24.4 versus 20.1, P = .046). There was no statistically significant difference between the two groups regarding the incidence of wound infections, anastomotic leaks, blood transfusions, unplanned return to the operating room, or prolonged length of hospital stay. There were no 30-day mortalities at our institution and only one in the ACS-NSQIP database., Conclusions: Our institutional experience with robotic right colon resection is equivalent to that of a national sample. This study demonstrates the safety of performing robotic right hemicolectomy for the treatment of colon cancer.

Purpose/background: In 2017, an estimated 39 910 people will receive a new diagnosis of rectal cancer. Current surgical guidelines limit transanal excision of early rectal neoplasia to 8 cm from the anal verge. We report that R0 resection of higher rectal cancers is possible using transanal robotic microsurgery., Methods/interventions: Ten cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) between 2013 and 2016 were reviewed., Results/outcomes: All cases were diagnosed preoperatively with colonoscopy, and the average distance from the anal verge was 11.1 cm. The average operative time was 167 minutes, and the average blood loss was 37.5 cc. Four cases required intraoperative conversion; one conversion required robotic abdominal access to repair a proctotomy. All margins were histologically negative, and 6-month follow-up showed no recurrences., Conclusion/discussion: Transanal robotic surgery may provide the colorectal surgeon a method to address rectal lesions farther from the anal verge., (© 2018 John Wiley & Sons, Ltd.)

Background: Surgical resection with curative intent remains the standard of care for colon cancer. This study aims to compare the 30-day outcomes and oncologic results following open, laparoscopic, and robot-assisted right colon resection for colon cancer using the Targeted Colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database., Materials and Methods: All patients undergoing elective, right colon resection with primary anastomosis were identified within the targeted colectomy ACS-NSQIP database. Only patients with stage I, II, or III colon cancer were included. The association of surgical approach with oncologic results and 30-day morbidity and mortality outcomes was investigated using a variety of statistical tests., Results: A total of 3518 patients met inclusion criteria; 1024 (29.1%) underwent open surgery (OS), 2405 (63.4%) underwent laparoscopic surgery, and 89 (2.5%) underwent robotic surgery. Patients undergoing OS were significantly more likely to have positive resection margins (P < .001). Patients undergoing OS were significantly more likely to experience prolonged intubation (P = .02), deep wound infections (P = .001), wound dehiscence (P = .005), deep venous thrombosis (P = .04), bleeding requiring a blood transfusion (P < .001), a prolonged postoperative ileus (P < .001), and longer length of hospital stay (P < .001), and were more likely to die (P = .02)., Conclusion: The laparoscopic approach to colon resection for colon cancer has lower 30-day morbidity compared to OS. The robotic approach is equivalent to the laparoscopic approach, and its utilization may increase in the future.

Advantages of robotic-assisted colorectal surgery have been reported, but the effect on outcomes between obese and non-obese patients undergoing laparoscopic and robotic-assisted colorectal surgery remains unclear. Patients who underwent elective laparoscopic and robotic colon or rectal resections between 2012 and 2014 were identified in the ACS-NSQIP database. Propensity score matching was performed to determine the effect of obesity on laparoscopic and robotic-assisted 30-day surgical outcomes. 29,172 patients met inclusion criteria; 27,693 (94.9%) underwent laparoscopic colorectal surgery while 1479 (5.1%) underwent robotic-assisted surgery. Mean BMI was 28.4 kg/m 2 and 35% of patients had a BMI ≥30 kg/m 2 . A 10-to-1 propensity matching of laparoscopic to robotic approaches was performed, resulting in 14,770 (90.9%) laparoscopic patients and 1477 (9.1%) robotic-assisted patients available for analysis. Robotic-assisted surgery was associated with lower conversion to laparotomy (2.4 vs 3.4%; p = 0.04) and decreased length-of-stay (4.5±3.2 vs 5.1±4.5 days; p < 0.0001). After adjusting for BMI and surgical approach, obese patients undergoing robotic-assisted surgery had a reduced odds ratio for developing prolonged ileus (p = 0.03). Robotic-assisted colorectal surgery is associated with fewer conversions to laparotomy and shorter length-of-stays compared to laparoscopic surgery. Risk of prolonged ileus is significantly reduced in obese patients undergoing a robotic-assisted approach.

Background: Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death., Objective: This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection., Design: This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database., Settings: The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2)., Patients: A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection., Intervention: Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention., Main Outcome Measures: The incidence of C difficile infection in the 30 days after surgery was measured., Results: The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p < 0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p < 0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period., Limitations: The study was limited because it was a retrospective database review with observational bias., Conclusions: Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

Study Objective: To describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform., Design: A technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study., Setting: There is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1-3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4-6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs., Patient: A 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence., Interventions: Preoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff., Measurements and Main Results: Complete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms., Conclusion: We encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background: Reports demonstrate laparoscopic colorectal surgery in obese patients is associated with higher conversion to laparotomy and complication rates. While several advantages of robotic-assisted surgery have been reported, outcomes in obese patients have not been adequately studied. Therefore, this study compares outcomes of robotic-assisted surgery in non-obese and obese patients., Methods: A retrospective review of 331 consecutive robotic procedures performed at a single institution between 2009 and 2015 was performed. Patients were divided into non-obese (BMI <30 kg/m 2 ) and obese (BMI ≥30 kg/m 2 ) groups, and were clinically matched by gender, age, and procedure performed. Intraoperative and postoperative complications, operative time, estimated blood loss, and length of stay were examined., Results: Following matching, each group included 108 patients comprised of 50 men and 58 women. Mean BMI was 24.6 ± 3.15 and 36.2 ± 5.67 kg/m 2 (p < 0.0001), and the mean age was 59.2 ± 11.28 years for non-obese patients and 57.1 ± 12.44 for obese patients (p = 0.18). Surgeries included low anterior resection, right colectomy, left colectomy, sigmoid colectomy, excision of rectal endometriosis, total proctocolectomy, APR, subtotal colectomy, ileocecectomy, proctectomy, rectopexy, transanal excision of rectal mass, and colostomy site hernia repair. The mean operative time was 272.69 ± 115.43 and 282.42 ± 120.51 min (p = 0.55), estimated blood loss 195.23 ± 230.37 and 289.19 ± 509.27 mL (p = 0.08), conversion to laparotomy 6.48 and 9.26 % (p = 0.45), and length of stay 5.38 ± 4.94 and 4.56 ± 4.04 days (p = 0.18) for the non-obese and obese groups, respectively. Twenty of the non-obese patients had postoperative complications as compared to 27 of the obese patients (p = 0.30). However, the prevalence of wound complications was higher in obese patients (1.9 vs 9.3 %; p = 0.03)., Conclusion: There is no difference in conversion to laparotomy and overall complication rates in non-obese and obese patients undergoing robotic-assisted colorectal surgery. However, obesity is associated with a higher prevalence of wound complications. Robotic-assisted surgery may minimize conversion to laparotomy and complications typically seen in obese patients due to improved visualization, instrumentation, and ergonomics.

Purpose: To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures., Materials and Methods: We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate., Results: Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001)., Conclusion: This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.

Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.

Background: The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery., Materials and Methods: A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis., Results: The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found., Conclusion: Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Background: Until randomized trials mature, large database analyses assist in determining the role of robotics in colorectal surgery. ACS NSQIP database coding now allows differentiation between laparoscopic (LC) and robotic (RC) colorectal procedures. The purpose of this study was to compare LC and RC outcomes by analyzing the ACS NSQIP database., Methods: The ACS NSQIP database was queried to identify patients who had undergone RC and LC during 2013. Demographic characteristics, intraoperative data, and postoperative outcomes were identified. Using propensity score matching, abdominal and pelvic colorectal operative and postoperative outcomes were analyzed., Results: A total of 11,477 cases were identified. In the abdomen, 7790 LC and 299 RC cases were identified, and 2057 LC and 331 RC cases were identified in the pelvis. There were significant differences in operative time, conversion to an open procedure in the pelvis, and hospital length of stay. RC operative times were significantly longer in both abdominal and pelvic cases. Conversion rates in the pelvis were less for RC when compared to LC--10.0 and 13.7%, respectively (p = 0.01). Hospital length of stay was significantly shorter for RC abdominal cases than for LC abdominal cases (4.3 vs. 5.3 days, p < 0.001) and for RC pelvic cases when compared to LC pelvic cases (4.5 vs. 5.3 days, p < 0.001). There were no significant differences in surgical site infection (SSI), organ/space SSI, wound complications, anastomotic leak, sepsis/shock, or need for reoperation within 30 days., Conclusion: As the robotic platform continues to grow in colorectal surgery and as technical upgrades continue to advance, comparison of outcomes requires continuous reevaluation. This study demonstrated that robotic operations have longer operative times, decreased hospital length of stay, and decreased rates of conversion to open in the pelvis. These findings warrant continued evaluation of the role of minimally invasive technical upgrades in colorectal surgery.

By combining laparo-endoscopic single-site surgery (LESS) techniques with the da Vinci robotic platform, single-incision robotic colectomy (SIRC) aims to further minimize incision-related complications and improve cosmetic outcomes from the current standard of care, laparoscopic colectomy. While there is limited literature on SIRC, all available reports suggest SIRC to be a safe and feasible procedure in terms of perioperative outcomes. Future research should focus on further clarification of proposed benefits of SIRC such as cosmetics, ergonomics, incidence of incision-related complications, and long-term oncologic outcomes., (© 2015 Wiley Periodicals, Inc.)

Background: Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC., Methods: We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate., Results: Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml., Conclusions: Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.