IPEG 2020 TOP ABSTRACT: Robotic Colostomy Takedown in a Pediatric Patient

This video demonstrates a robotic colostomy takedown in a pediatric patient. Our patient is a 14-year-old female who underwent a laparotomy for complicated appendicitis. A rectal injury occurred and a Hartmann's procedure was performed. She's had an end colostomy for 3 years. To avoid a subsequent laparotomy, a robotic colostomy takedown was performed. We began by taking down the end colostomy and placing a mini gel platform. 48 millimeter robotic ports were then inserted. Initial inspection of the pelvis revealed extensive adhesions to the uterus, the cecum, and to the left lateral pelvic side wall. Adhesiolysis was then performed with electrocautery and sharp dissection. A long Hartmann's stump had been brought up to the anterior abdominal wall. Further investigation revealed a nest of twisted colon tethered together with many inner loop adhesions. The Hartmann stump was taken down with electrocautery. By releasing this, this allowed us to investigate the remaining distal diverted bowel. It was difficult to tell exactly where the original iatrogenic injury had occurred because of the multiple interloop adhesions. By freeing these limbs of bowel, this enabled us to straighten out the distal, rectum, and colon to allow for endoscopic evaluation of the lumen. A flexible endoscope was then inserted transanally to evaluate the distal diverted bowel. The scope passed relatively easily, although there was some extra luminal compression by adhesions. For the most part, the mucosa of the distal bowel was healthy and pink. The scope was advanced more proximately, and we did enter an area where there was either diversion colitis or was in fact the area of the prior injury to the bowel. Given these findings, we decided to perform a segmental resection of the sigmoid colon to ensure that we had two viable and unobstructed limbs of bowel to create the anastomosis. We elevated the sigmoid stump and used electrocautery to create a window to identify the sigmoid vessels. We switched over to the vessel sealing device to help seal and transect the mesentery all the way up to the bowel wall. We then turned our attention to the sigmoid pedicle, which was also sealed and transected. We turned our attention to the transection of the remnant sigmoid colon. A single firing with the green load stapler was utilized. We decided to create an isoperistaltic anastomosis between the sigmoid and the rectum. Here is a primer on how this is created. The sigmoid and rectum are placed side by side. Several tacking sutures are used to prepare for the anastomosis. Two full thickness erotomies are created using the hot shears as shown above. A linear stapler is then inserted through the erotomies. This is typically a green load. The stapler is then fired to create the anastomosis. A common channel results using a 20 monofilament barbed suture. We closed the common channel in a running fashion. Let's see how this played out in our patient. First, we set up the anastomosis using tacking sutures comprised of 3 of viral. Three separate interrupted sutures were utilized to tack the two limbs side by side. As demonstrated here, the wristed instruments allow us to suture more facilely, especially since the anastomosis is located in the upper pelvis. We then turn our attention to creating the enterotomies in the sigmoid and the rectum to prepare for the stapling. These full thickness defects are created with the hot shears. Once the apertures are made wide enough, the two arms of the stapler can easily be passed down the lumen of the bowel in a traumatic fashion. The common channel is then created by closing and firing the stapler. Upon the removal of the stapler, we can see the anastomosis created in the common channel that remains. To assess the vascular supply of the remaining anastomosis, we use indocyanin green and the firefly mode on the robot. Normal uptake is noted. We then turn our attention to closing this common channel with the 20 barbed monofilament suture in a running fashion. The suture is run from left to right and then right to left again to essentially create a double layer closure of the defect. Sutures, needles, and instruments were then removed. The specimen was removed through the former colostomy aperture. The patient's postoperative course was uneventful, with flatus passed on postoperative day 2 and discharged home on postoperative day 3. Full bowel function had returned by postoperative day 4. Preoperative and postoperative photographs are demonstrated here. Thank you for your attention.