Category: Robotic Surgery: New Techniques - Malignant

VS18-4 - A Novel Technique of Precise and Surgeon-Controlled Robotic Stapling During Intracorporeal Ileal Conduit Creation

Sun, Sep 23
2:00 PM - 4:00 PM

Introduction & Objective :

Ileal conduit (IC) creation was traditionally performed in an open fashion after robotic-assisted radical cystectomy (RARC). More recently, intracorporeal IC has been performed with bowel segment harvesting and ileal-ileal anastomosis completed robotically via an assistant-controlled endoscopic stapler. Often, this requires a skilled bedside assistant and introduction of the stapler from several different port sites due to its limited articulation. By using the robotic stapler, bowel anastomosis can be performed under complete surgeon control with greater safety and precision. Herein, we describe our initial experience with IC utilizing the robotic stapler and an arm hop technique.

Methods :

The da Vinci Xi system and traditional horizontal port placement is utilized for RARC. A 12 mm robotic port is placed in left lateral-most position. This is used initially as a bedside assistant port during the extirpative portion. After extirpation, the table position is reduced from 25 to 15 degrees Trendelenburg. The #1 robotic arm is transitioned over (arm hop) to the lateral 12 mm robotic port to allow for robotic intracorporeal stapling.  The terminal ileum is identified and a 15 cm segment of ileum is harvested 15 cm from the ileocecal junction using a robotic stapler with a tissue (blue) load. A deep mesenteric defect is created at the distal staple line to allow for mobility of the conduit. A 5 cm discard segment of ileum is stapled off at the proximal staple line to allow for more facile bowel-bowel anastomosis. This obviates the need for a deep mesenteric defect on the proximal end which would threaten blood supply to the conduit.  The ileal-ileal anastomosis is formed anterior to the conduit by placing each stapler limb into the lumen of the proximal and distal ileum and stapling at the anti-mesenteric aspect. Two staple loads, one intussuscepted into the other, are required for appropriate patency. The apex can be stapled or oversewn. 

Results :

We have conducted RARC with IC in over 50 cases and have utilized this technique over the past 10 cases.  Our technique utilizing the robotic stapler affords surgeon-controlled positioning of the stapler in a precise fashion allowing for exact depth and angulation, all from a single port site. It decreases surgeon dependence on a skilled assistant and likely decreases need for additional 12 mm ports given its range of angulation.

Conclusions :

In this video, we describe our novel technique for robotic stapler utilization for IC creation and bowel-bowel anastomosis.  Our technique is feasible and may offer several benefits including decreased need for additional 12 mm port sites and decreased reliance on a skilled surgical assistant. 

Charles F. Polotti

Resident Physician
Division of Urology, Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Charles F. Polotti, MD
PGY-4 Resident
Division of Urology, Rutgers Robert Wood Johnson Medical School
New Brunswick, NJ, United States

Rutveej Patel

Division of Urology, Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Sammy Elsamra

Residency Program Director and Assistant Professor
Division of Urology, Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

I joined the Urologic Cancer Program at Rutgers Cancer Institute of New Jersey in August 2014 and am an assistant professor of surgery in the Division of Urology at Rutgers Robert Wood Johnson Medical School. I received my undergraduate degree in Chemical Biology at the Stevens Institute of Technology (Hoboken, NJ) with high honors and then completed my medical degree at the University of Medicine and Dentistry of New Jersey (now Rutgers)—New Jersey Medical School in Newark, NJ. Excelling in both clinical and research endeavors, I completed my urologic surgical residency at the Alpert Medical School of Brown University (Providence, RI). During my residency, I developed an interest in minimally invasive urology, assisting in hundreds of endoscopic, laparoscopic, and robotic urologic procedures. Also during this time, I co-authored numerous abstracts, more than a dozen manuscripts, and several book chapters pertaining to advancements in and outcomes of minimally invasive urologic surgery.

Following graduation from urologic residency at Brown University, I completed a two-year Endourology Society accredited fellowship at the Smith Institute for Urology. Under the guidance of Dr. Arthur Smith, who is an internationally recognized pioneer in endourology, I conducted more than 200 percutaneous renal surgeries, for stones, strictures, and cancer. I was also co-surgeon for nearly 200 laparoscopic and robotic urologic cases under the tutelage of Dr. Louis Kavoussi, a pioneer of laparoscopic urologic surgery credited with the first laparoscopic nephrectomy. I have extensive experience with nearly all laparoscopic and robotic urologic procedures, but have special interest in laparoscopic and robotic partial nephrectomy, radical prostatectomy, and radical cystectomy with intracorporeal urinary diversion (completely robotic approach to urinary diversion after robotic cystectomy). I also have a special interest in organ-sparing procedures for cancer, including percutaneous resection of upper tract urothelial carcinoma.