Society: SSAT

Cytoreductive surgery for peritoneal metastases can result in long-term survival in patients with gastrointestinal and gynecologic malignancies. CRS is traditionally performed via laparotomy but the morbidity of such operations remains a major limiting factor.
In this video we present the operative technique for achieving a complete cytoreduction (CC0) using the robotic DaVinci Xi platform. Omentectomy is performed first. The small bowel and its mesentery is inspected and any suspicious nodules resected. Select peritonectomies are performed of all surfaces involved by tumor.
In conclusion, CC0 can be achieved via robotic-CRS without compromising oncologic outcomes.

We previously defined Twisted Pouch Syndrome (TPS) as a triad of symptoms including 1) erratic bowel habits with urgency/frequency, 2) abdominal/pelvic/rectal pain, often severe (suggestive of ischemia) and requiring opioids, and 3) obstructive symptoms including small bowel obstruction and/or obstructive defecation (Holubar, Gastroenterology, 160(3), S22-S23, 2021). In this video, we present 1) a video clip demonstrating TPS during open surgery, 2) intra-operative video of diagnostic laparoscopy for TPS, and 3) a novel radiographic method for detecting TPS using CT-scan 3D segmentation of staple-line morphology.

Treatment of rectovaginal fistulas (RVFs) is challenging and oftentimes requires multiple procedures. Current treatments range from simple local procedures to complex perineal and abdominal operations. Gracilis flap repair is recommended for recurrent and complex RVFs. The gracilis muscle has a very proximal pedicle, which makes it convenient for perineal transposition. The gracilis muscle provides healthy well-vascularized tissue that can be placed over the repaired internal anorectal opening and this will separate the internal opening from the repaired vagina. This video describes the technique of gracilis muscle interposition for recurrent RVFs.

Classic steps of ESD are marking, injection, circular incision followed by submucosal dissection. However, multiple modification had been made to make it much easier. For example, Pocket creation method in which a short tunnel is created below the lesion. Here we present Bridge technique in ESD in which we start with the oral (ceacal side of the lesion) followed by anal side (forward) and then communicating both together forming a bridge. This bridge will help a lot in performing counter traction that helps in easier & more precise dissection with limiting the use of traction devices especially in the colorectal lesions.

Large rectal polyps can present a challenge as to the feasibility of excision and the best approach when circumferential and spanning a long distance in the rectum. A 71-year-old-man had been living with a carpeting villous adenoma for many years developed worsening mucus drainage affecting his quality of life. Given there was no evidence of malignancy based on work up, excision was recommended to avoid radical resection or proctectomy. This case highlights the combined use of both open and minimally invasive transanal approach to excision of a large rectal polyp.

Large pedunculated polyps are usually managed either by endoloop application or clips & EMR. However, in huge pedunculated polyps with large heads piecemeal resection was the only resort or surgery for the fear of expected significant bleeding. Here we present a series of huge pedunculated polyps head 6cm & stalk 3 cm. In the first patient multiple clips were applied to the base to minimize the bleeding followed by dissection the stalk with the knife & getting out the lesion enbloc. Another large twin polyp was noted almost occluding the hepatic flexure resected with ESD to the base of the pedicle.Thinking outside the box to avoid invasive procedure as surgery or suboptimal solutions as pEMR

A 36 years old woman underwent rectal resection with colpotomy for endometriosis. The patient presented an anastomotic leak and colpotomy breakdown, and a laparoscopic lavage of pelvic fecal peritonitis with a protective ileostomy was performed. Patient developed a rectovaginal fistula. We performed a pull-through procedure with delayed anastomosis associated with the repair of the vaginal defect and ileostomy closure. The coloanal anastomosis was performed 8 days after the pull-through procedure. A new rectovaginal fistula recurrence was observed, and a new redo pull-through was performed. Further resection of the colonic stump with a coloanal anastomosis after 18 days was uneventful.

We present a 62-year-old male with a ten-year history of a complex fistula-in-ano leading to chronic purulent drainage. MRI showed a high blind tract extending from the perianal skin to the levator muscles and examination under anesthesia failed to reveal any communication with the anal canal or rectum. With limited options, we opted to perform a wide excision of the chronic tract and cavity. The defect was filled with healthy muscle harvested from the right thigh and skin was closed primarily.

This video regards a controllable bendable endoscopic grasper now available for use in conjunction with a double channel therapeutic upper endoscope that facilitates ESD. This presentation considers use of this system in the rectum/sigmoid. For ESD, the grasper system can be used for the latter 50- 65% of the case. This system permits active retraction of the cut edge which improves exposure. The device design and limitations are explained and the numerous technique modifications necessary to accommodate this tool are presented. Video from ex vivo bovine colon ESD cases is included. Multiple ways in which the device can be used to provide traction and potential pitfalls are discussed.

Yanni Hedjar

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