eP700 - A Rural General Surgeon’s Experience of Robotic Sigmoidectomy with Intracorporeal Primary Anastomosis for Acute Diverticulitis

Purpose/Background: In a rural area with no colorectal surgeon available and patients with varying social determinant of health, it has been left to the general surgeons to manage a wide variety and severity of acute diverticulitis cases. Management has differed with approaches including, exploratory laparotomy or laparoscopy with creation of an ostomy or extracorporeal versus intracorporeal primary anastomosis. Most recently however, we have begun to successfully perform robotic sigmoidectomies. Here we present a case of a successful robotic sigmoidectomy with intracorporeal primary anastomosis on an elective case for recurrent diverticulitis, indicating the potential for future cases.Methods/Interventions: The patient is a 55 y/o M with past medical history pertinent for recurrent diverticulitis, hypertension, diet-managed diabetes mellitus and no significant past surgical history. Prior to the procedure the patient underwent a transversus abdominis plane (TAP) block. The patient underwent robotic sigmoidectomy with intracorporeal anastomosis as per the method discussed below. We placed four ports, one 5mm port at Palmers point to enter the abdomen under Opti view – which was later transitioned to a 12mm port and used for air seal, a 12mm port in the right lower quadrant, an 8mm port in the right upper quadrant, and an 8mm port in left upper quadrant. The patient was positioned into Trendelenburg position and the robot was docked. The sigmoid colon was mobilized and divided proximally and distally to remove the diseased section of the bowel and mesentery. The proximal bowel was further mobilized by division of the White line of Toldt to the splenic flexure to ensure re-anastomosis without tension. The end-to-end anastomosis (EEA) anchor was placed within the proximal colon and secured with a purse string suture. A rigid sigmoidoscopy was performed, followed by EEA stapler placement. The stapler was coupled with the anchor, closed, and fired. The anastomosis was oversewn. Leak test was negative. Two complete rings were retrieved from the EEA stapler after firing. The robot was undocked. The right lower quadrant 12mm port incision was extended, through which the resected sigmoid colon was removed. The fascia was closed with PDS and all skin incisions were closed with Monocryl and covered with skin glue.Results/Outcomes: We compared our operative time, length of stay, time to flatus, time to bowel movement, and time to regular diet to the national average, taken from Giordano et al which can be viewed in Table 1. Our operative time was 210 minutes, 47 minutes longer than the national average by colorectal/minimally invasive surgeons trained in this operation. Additionally, our length of stay, time to flatus, time to bowel movement, and time to regular diet were equivalent to national average. Finally, our pain scales were lower with the exception of POD 3, which was equivocal, which may be attributed to the TAP block.Conclusion/

Discussion: Based on our outcomes, we believe that general surgeons in rural areas who have access to a robotic system and are adequately trained on using this system, have the potential to provide standard of care robotic sigmoidectomy with intracorporeal primary anastomosis comparable to national averages for selective patients with uncomplicated acute diverticulitis. While our greatest limitation is our sample size, after this successful case we perceive more cases in the near future, selecting for uncomplicated diverticulitis patients with the hopes of evolving in the distant future to more complex cases, as our population needs demand it.Table 1. MVHS Outcomes Compared to National Average OutcomesThis table compares the outcomes of our case to national averages based on Giordano et al and Al-Saadi et al for operative time, length of stay, time to flatus, time to bowel movement, and time to regular diet, as well as a comparison of our pain scale outcome to Yao et al for national averages on pain scale outcomes.