BRIDGE ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD)

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.