VM06 - Robotic Sigmoid Colectomy and Bladder Repair for Recurrent Diverticulitis and Colovesical Fistula

Purpose/Background: Robotic surgery offers similar morbidity and mortality rates to the laparoscopic colorectal surgery. The robotic platform has been used successfully increasingly in challenging diverticular disease cases as the da Vinci XI® has allowed the multi-quadrant surgery. Three dimensional, high-definition visualization, increased dexterity, availability of the wristed instruments, and use of simultaneous energy devices (vessel sealer & fenestrated bipolar) provide technical benefit in the management of complicated diverticular disease.

Methods/Interventions: We report a case of a 40-year-old male with past medical history of diverticulitis complicated by colovesical fistula and multiple episodes of diverticulitis. His preoperative workup included reviewing the available imaging which showed the colovesical fistula and colonoscopy. He was taken to the operating room for a robotic sigmoid colon resection with splenic flexure mobilization and colorectal anastomosis, and bladder repair using the da Vinci Xi® platform. Patient was placed in lithotomy position. After pneumoperitoneum was achieved, three 8 mm trocars and a 12 mm trocar were placed in a diagonal fashion. An assistant port was placed in the right upper quadrant. The colonic mobilization was then commenced by incising the right aspect of the rectosigmoid mesentery at the level of the sacral promontory. The retroperitoneal fusion plane was entered and dissection was carried out in this plane laterally. The left ureter was identified and protected. The inferior mesenteric vein was then dissected away from the 4th portion of the duodenum, and divided at the inferior border of the pancreas with the Vessel Sealer. The inferior mesenteric artery was then isolated and divided at its origin with the Vessel Sealer. The lateral attachments of the sigmoid colon and descending colon were divided. The splenic flexure was mobilized. The lesser sac was entered. The distal omental colic attachments were divided to the mid transverse colon. The sigmoid was found to be densely adherent to the bladder dome. Blunt and sharp dissected were used to separate the colon from the bladder. Subsequently, the fistula was identified and repaired at the bladder side using V-lock suture. The upper rectum was mobilized off the sacral promontory in the mesorectal fascia plane. The lateral attachments of the upper rectum were divided. A point was chosen in the upper rectum were it was soft and normal appearing. It was bluntly dissected away from the mesorectum. The upper rectum was then divided with the robotic stapler. Colorectal anastomosis was created using a 29 mm EEA circular stapler. Specimen was removed from 12 mm port site. The donuts were inspected and were intact and the anastomotic air-leak test was normal. A drain was left in the pelvis.

Results/Outcomes: Patient tolerated the procedure well and discharged home on postoperative day 2 after an uneventful recovery and removal of pelvic drain.

Conclusion/Discussion: Robotic sigmoid colon resection with primary anastomosis and bladder repair (using da Vinci Xi®) is safe and feasible for complicated diverticular disease in experienced hands. The endo-wristed movements of the robotic arms help overcome difficult dissection in post-inflammatory adhesions and fibrotic tissue planes which are very common after complicated diverticular disease.