AIS ACADEMY

About the Pre-Test - Introduction

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About the Pre-Test

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Div_right: The Pre-Test is the perfect way to assess your knowledge of surgery for the following course and shelf exams. You'll find critical questions that address the clerkship's core competencies. All questions have been reviewed by Khirus faculty and other students. There are 10 questions on this exam and you will have 30 minutes to complete it.

Once you have completed the pre-test, click the right arrow at the upper right-hand corner of your screen to advance to the next learning content. Please do not hit the back button as you are permitted one attempt on this test.  

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CME Infromation - CME Information Details (1/3)

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CME Information Details (1/3)

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Course Title	Xi Robotic Right Colon Resection with Intracorporeal Anastomosis
CME Author	Dr. Craig Johnson
CME Open Date	10/01/2018
Expiration Date	10/01/2021
Course Credit	Maximum of 3 AMA PRA Category 1 Credit(s)
Developed and funded by	KHIRUS

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CME Information - CME Information Details (2/3)

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CME Information Details (2/3)

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Format:	Online CME
Department/Specialty	Medicine
Division/Sub-Specialty:	Department of Colorectal Surgery
Area(s) of Interest:	Quality Improvement, Patient Care, Medical Knowledge, Education
Target Audience:	Physician, Fellow, Resident, PA, Colorectal surgeons
Course Director	Dr. Craig Johnson M.D.
CME Course Associates	Carol Gonzalez Abos, M.D.

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CME Information - CME Information Details (3/3)

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CME Information Details (3/3)

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The following individuals took part in the planning of this course offering:  

Course Planners	Craig Johnson, MD, FACS, FASCRS, Carol González Abos, M.D.
Course Reviewers	Ron Surowitz, D.O. CME Committee Chairman (Jupiter Medical Center)  Vincent Turiano,M.D. Sujal Shah, M.D.

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CME Information - Disclosures

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Disclosures

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Div_left: Jupiter Medical Center requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Jupiter Medical Center encourages authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Editor/Content Provider 

Craig Johnson, MD, FACS, FASCRS. 

CME Reviewers-Jupiter Medical Center

Ron Surowitz DO,CME Committee Chairman
Vincent Turiano, MD 
Sujal Shah, MD

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CME Information - Accreditation Statement - For Physicians

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Accreditation Statement - For Physicians

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Accreditation

Jupiter Medical Center is accredited by the Florida Medical Association (FMA) and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians and nurses.

Jupiter Medical Center designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This enduring material received no commercial support.

Course Description: 

The purpose of this course is to train colorectal surgeons in Xi robotic right colon resection

The target audience is  general surgeons, fellows, general surgery resident, coloproctologists.
The goal of this activity is to provide clinical updates and to enhance the level of patient care for clinicians who work with patients who undergo a bariatric surgery.

This course is intended for colorectal surgeons experienced in colorectal surgery  who want to train in robotic surgery.

8  Modules

Credit:  3 CME

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CME Information - Target Audience & Goal Statement

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Target Audience & Goal Statement

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Div_right: The target audience is colorectal surgeons (or general surgeons/surgical oncologists with a dedicated colorectal practice) experienced in laparoscopic and/or robotic colectomy.

The goal of this activity is to provide clinical updates and to enhance the level of patient care for clinicians who work with patients who have had colorectal surgery.

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CME Information - Course Objective

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Course Objective

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This course is intended for colorectal surgeons experienced in laparoscopic and/or robotic colorectal surgery. 

1.  Understand the indications for robotic right colon resection

2.  Understand the operative set-up in Xi robotic right colon resection

3.  Understand the operative steps in Xi robotic right colon resection

4.  Understand the value and technique for robotic intracorporeal anastomosis

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Operative Set Up - Patient Positioning

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Patient Positioning

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• Supine

• Arms tucked

• No need for bean bag or thoracic fixation.  No extreme table positions are necessary

• Foley catheter is optional.  If no foley is used, have the patient empty their bladder prior to surgery

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Operative Set Up - OR Set Up: Instrument table

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Operative Set Up - Patient Set Up

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Patient Set Up

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• TAP block

• Placement of trans esophageal monitor

• The Robot is brought in on the patients right side

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Unit 2 Summary - Unit 2 Summary

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Unit 2 Summary

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• No special patient fixation is required for robotic right colon resection

• Regional anesthesia is ideally done in the OR, however, appropriate in the pre operative holding area as well.  Either TAP block (preferable), single shot spinal or epidural

• With ERAS, urine output is not used to monitor the patients fluid status intraoperatively, urinary catheterization is not mandatory

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Port Placement - Port placement and docking Xi robotic right colon resection

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Port placement and docking Xi robotic right colon resection

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• The Xi robot offers multi quadrant access ideal for colorectal surgery. This function requires the ports to be placed in a linear fashion.  

• Non-linear port placement is acceptable with the understanding that the multi quadrant access may be limited.

• Two port placements are recommended in Xi right colon resection.  
• Standard port placement 
• Suprapubic port placement.  
• The choice of port placements is surgeon dependent.

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Port Placement - Standard port placement

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Port Placement - Suprapubic port placement

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Suprapubic port placement

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The suprapubic port placement offers several advantages:  

• All incisions are in the lower abdomen 

• Taking full advantage of a TAP block 

• A superior view of the transverse colon vasculature 

• Ability to do extended right colon resection and sub total colectomy 

• Utility of a pfannenstiel extraction site and affords a cosmetic appearance

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Unit 3 Summery - Unit 3 Summery

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Unit 3 Summery

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• A linear port placement is required for multi quadrant access with the Xi robot, however, non-linear port placement can be utilized in specific situations

• Targeting is not a mandatory step in docking unless planning to use the integrated table motion.  In this case, targeting is a prerequisite for pairing between the robot and table

• Placing the instruments is aided by off screen indicator technology

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Procedural Steps - Step by step (I)

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Step by step (I)

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1. Position the patient 5 degrees left side down. Slight head up a few degrees.  Exposure of the duodenum and ileocolic vessel before docking

2. Medial to lateral approach is the preferred method

3. Isolation and division of the ileocolic vessel

4. Mobilization of the right colon mesentery from the retroperitoneal attachments

5. Isolation and division of the transverse colon mesentery

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Procedural Steps - Step by step (II)

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Step by step (II)

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6. Division of the Omental attachments, takedown of the hepatic flexure and lateral peritoneal reflection

7. Mobilization of the cecum and small bowel mesentery

8. Assess blood flow

9. Division of the small bowel and transverse colon

10. Intracorporeal anastomosis

11. Specimen extraction

12. Closure

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Unit 4 Summary - Unit 4 Summary

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Unit 4 Summary

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• Medial to lateral approach is ideal in robotic right colon resection.  This approach lends itself to efficiency and reproducibility

• The operating room staff performs at a high level when uniform procedural steps are utilized.  Decreasing communication errors, improving patient safety and maximizing efficiency.

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Rationale for Intracorporeal anastomosis - Rationale (I)

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Rationale (I)

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• Minimizes the potential of creating a volvulus of at the anastomosis when doing an extracorporeal anastomosis

• Allows one to avoid a midline incision or upper abdominal lateral incision, decreasing post operative pain and significantly reducing incisional hernia rates

• Requires less dissection around the transverse colon (gastrocolic ligament) decreasing the degree of contiguous tissue trauma

• Avoids mesenteric stretch and mesenteric bleeding that can occur in ECA which may increase potential for ileus

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Rationale for Intracorporeal anastomosis - Rational (II)

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Rational (II)

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• The type of anastomosis (iso or anti) does not show any significant clinical difference.  Preference is surgeon related, however, iso peristaltic anastomosis is preferred.

• Closure of the common enterotomy is most commonly done by suture closure.  A two layer, running absorbable suture, technique is the preferred method.  A 3-0, 180 day, 15 cm in length with a CV23 needle V-lock is my preferred suture.

• The common enterotomy may be closed with the stapler as well

• The mesenteric defect is left open

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Unit 5 Summary - Summary

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Summary

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• Intracorporeal anastomosis allows the surgeon to choose the most preferable extraction site.  Preferably a pfannenstiel incision as this incision is associated with less pain and a significantly reduced hernia rate

• There is less contiguous tissue damage in the ICA technique resulting in less ileus, length of stay and decreased leak rates

• Robotic ICA is performed routinely in right colon resection compared to laparoscopic right colon resection in which is rarely done

• Iso-peristaltic anastomosis is the preferred ICA technique

• The mesenteric defect is not closed

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Specimen retrieval and closure - Specimen retieval

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Specimen retieval

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• A Pfannenstiel incision extraction site is preferred.

  

• A wound protector is routinely used and is preferred over a specimen bag

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Specimen retrieval and closure - Abdomen closure

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Abdomen closure

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• The 12mm stapler port site should be closed either by suture passer or a fascial closure system

• 8mm port closure is not necessary

• The extraction incision is closed in layers.  2-0 vicryl for the peritoneum, a running or interrupted absorbable suture for the fascia

• Skin closure by a subcuticular absorbable suture with a biologic glue is ideal

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Unit 6 Summary - Summary

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Summary

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• ICA allows the surgeon to choose the most ideal extraction site

• A Pfannenstiel extraction incision is superior to a mid line or lateral incision due to decreased hernia rates and decreased post operative pain

• Closure of the Pfannenstiel incision is done in two layers, peritoneum and fascia

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Conclusions - Conclusions (I)

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Conclusions (I)

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• When considering all patients requiring right colon resection, reported laparoscopic rates are 53% at the highest.  Effective laparoscopic rates, when considering conversion rates, are 35%

• Robotic right colon resection enables effective MIS rates as high as and greater than 95%

• Intracorporeal anastomosis enables significantly improved outcomes in MIS surgery in relation to pain, hernia rates and leak rates

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Conclusions - Conclusions (II)

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Conclusions (II)

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• ICA rates in laparoscopic surgery are less than 3%

• ICA rates in robotic right colon resection are greater than 90%

• Advances in technology (robotic surgery) allow for high rates of MIS, ICA and potential future technologies

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Conclusions - Conclusions (III)

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Conclusions (III)

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• Conversion rates in laparoscopic surgery have been reported at 16.6%.  Robotic right colon resection conversion rates are 3%.

• Early studies comparing robotic right colon resection compared to laparoscopic right colon resection have not shown a significant difference, however, these studies did not compare the total cohort of all patients undergoing right colon resection.  In my own experience only 87% of all patients underwent laparoscopic right colon resection while 99.6% of patients had robotic surgery. 
•  Results showed a 1.8 day decreased length of stay and a 73% reduction in post operative pain without a significant difference in complications

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Port Placement: Video - Standard port placement

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Standard port placement

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Port Placement: Video - Suprapubic port placement

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Suprapubic port placement

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Port Placement: Video - Image Comparison

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Syllabus - Syllabus

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Syllabus

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Course Title	Xi    robotic    right    colon    resection    with    intracorporeal anastomosis
CME Author	Craig Johnson  M.D, FACS, FASCRS
CME Open Date	10/01/2018
Expiration Date	10/01/2021
Course Credit	Maximum of 3 AMA PRA Category 1 Credit(s)
Developed and funded by	KHIRUS
Format:	Online CME
Department/Specialty	Medicine
Division/Sub-Specialty:	Department of Robotic Surgery
Area(s) of Interest:	Quality Improvement, Patient Care, Medical Knowledge, Education
Target Audience:	Physician, Fellow, Resident, PA
Course Director	Dr. Craig Johnson, M.D
CME Course Associates	Dr. González, M.D
Course Planners	Dr. Craig Johnson, M.D
Course Reviewer	Ron Surowitz M.D.

The purpose of this course is to train colorectal surgeons in Xi    robotic    right    colon    resection

The goal of this activity is to provide clinical updates and to enhance the level of patient care for clinicians who work with patients who undergo a bariatric surgery. 

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Patient Preparation - Patient Preparation

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Patient Preparation

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• System wide ERAS program

• Nutritional assessment. Immunomodulator nutritional supplement for 5 days prior to surgery.  Carbohydrate loading the 24 hours prior to surgery

• Mechanical and antibiotic bowel prep is preferred.  Antibiotic bowel prep, with or without mechanical prep show significant decrease in SSI.  Mechanical bowel prep allows for easier handling of the colon in MIS surgery.

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Patient Preparation - Enhance Recovery After Surgery

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Enhance Recovery After Surgery

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Patient Preparation - Summary

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Summary

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• System wide ERAS is advantageous

• Use technology to increase the MIS rate in right colon resection

• Mechanical and antibiotic bowel prep is preferred in MIS right colon resection with ICA

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Scientific Data - Right Colon Resection Data

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Right Colon Resection Data

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