Backgrounds and Objectives Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique. Method With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD). Results Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m 2 . 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality. Conclusion Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.

Synovial sarcoma (SS) is a rare and aggressive subtype of soft tissue sarcomas with an estimated incidence of 1.77 per 1 000 000 in the United States. Synovial sarcoma classically arises in younger patient populations from periarticular tissues, but can theoretically arise anywhere in the body. To our knowledge, only 2 other cases of primary rectal SS have been reported in peer-reviewed literature to date. Herein, we report a unique case of metastatic primary rectal SS and associated clinical findings to advance detection, knowledge, and treatment of this rare neoplasm.

We present a video of a 76-year-old woman who was diagnosed with an ascending colon adenocarcinoma, and she was also found to have a large, functioning, right adrenal mass.She was prescribed alpha blockers in preparation for a combined operation, as well as beta blockers pre-operatively.The right colon was mobilized and a right hemicolectomy with primary anastomosis was undertaken.Circumferential dissection was carried out around the highly vascularized mass.The right adrenal gland was excised, and an omental flap was used to buttress the area of resection.The patient tolerated the procedure well and was discharged home on POD 3.

BACKGROUND:Circular staplers perform a critical function for creation of anastomoses in colorectal surgeries. Powered stapling systems allow for reduced force required by surgeons to fire the device and may provide advantages for creating a secure anastomosis. The objective of this study was to evaluate the clinical performance of a novel circular powered stapler in a post-market setting, during left-sided colectomy procedures.MATERIALS AND METHODS:Consecutive subjects underwent left-sided colorectal resections that included anastomosis performed with the ECHELON CIRCULAR™ Powered Stapler (ECP). The primary endpoint was the frequency in which a stapler performance issue was observed. Secondary endpoints included evaluation of ease of use of the device via a surgeon satisfaction questionnaire, and monitoring/recording of procedure-related adverse events (AEs).RESULTS:A total of 168 anastomoses were performed with the ECP. Surgical approaches included robotic-assisted (n = 74, 44.0%), laparoscopic (n = 71, 42.3%), open (n = 20, 11.9%), and hand-assisted minimally invasive (n = 3, 1.8%) procedures. There were 22 occurrences of device performance issues in 20 (11.9%) subjects during surgery. No positive intraoperative leak tests were observed, and only 1 issue was related to a procedure-related AE or surgical complication, which was an instance of incomplete surgical donut necessitating re-anastomosis. Postoperative anastomotic leaks were experienced in 4 (2.4%) subjects. Clavien-Dindo classification of all AEs indicated that 92.0% were Grades I or II. Participating surgeons rated the ECP as easier to use compared to previously used manual circular staplers in 85.7% of procedures.CONCLUSION:The circular powered stapler exhibited few clinically relevant performance issues, an overall favorable safety profile, and ease of use for creation of left-sided colon anastomoses.

A 64-year-old woman with recurrent ovarian cancer isolated to the left pelvic sidewall underwent robotic resection of a tumor adherent to the external iliac vein and encasing the ureter and internal iliac vessels. A narrated video-clip of the case is included.

Liver metastasis from colorectal cancer is the most common metastatic tumor in the liver. Up to one-third of the patients with colon cancer have metastatic disease on initial presentation and 20 per cent of them have synchronous liver-only metastasis.1 The 5and 10-year survival benefits of resecting liver metastasis from colorectal cancer has been well established.2 Most liver and colorectal resections are presently undertaken using the conventional “open” approach and synchronous occurrence often requires two separate operations.3 Recovery from two major operations often delays the administration of adjuvant chemotherapy, which in turn negatively affects the overall survival. A potential solution to this problem is combining both operations, using a minimally invasive approach for colectomy and synchronous metastatic liver lesion(s).4 Our hypothesis in undertaking this study was that minimal invasive combining colon and liver resections can be performed safely with minimal postoperative morbidity and excellent clinical outcomes. We, therefore, designed a prospective registry study to document our initial experience using this approach in our comprehensive digestive health program. The study design and patient data collection were conducted after obtaining an institutional review board approval. All patients who underwent robotic combined colorectal and liver resections were followed prospectively beginning from July 2017. Colon and liver resections were undertaken using the DaVinci System (Intuitive Surgical Inc., Sunnyvale, CA). Demographic data and operative outcomes including age, BMI, operative time, estimated blood loss (EBL), postoperative complications, and length of stay (LOS) were collected and analyzed. For illustrative purposes, data are presented as median (mean ± SD). Data were maintained using a spreadsheet and analyzed with Microsoft Excel Data Analysis Pack (Microsoft Corp., Redmond, WA) and GraphPad (GraphPad Software, San Diego, CA). Cystoscopy with bilateral ureteral stent placement was undertaken before starting; indocyanine green was injected into each ureter for aid in identification throughout operations. A fifth generation Da Vinci Xi (Intuitive Surgical, Sunnyvale, CA) robotic surgical system was used for all operations. Four robotic ports along with two assistant ports were used for all resections. A medial-to-lateral approach was used for both right colectomies and low anterior resections. A high ligation of the vessels (i.e., ileocolic pedicle or inferior mesenteric artery and vein) was performed using the robotic Vessel SealerTM (Intuitive Surgical, Sunnyvale, CA). The white line of Toldt was taken down using a combination of robotic Vessel SealerTM and monopolar cautery. The splenic flexure was mobilized and a total mesorectal excision was performed in all low anterior resections. A green load robotic stapler was used to transect the rectum, and the distal end of the specimen was exteriorized through a 5-cm Pfannenstiel incision. The proximal portion was transected, and the anastomosis was created using Ethicon circular stapler (Ethicon Inc., Bridgewater, NJ). An intracorporeal anastomosis was performed for right colectomies. For robotic abdominoperineal resections (APR), the dissection was carried down to the levator ani complex into the subcutaneous perineal tissue using a combination of robotic Vessel SealerTM and monopolar cautery. The APR was completed with a wide excision from the perineal approach. Once the colorectal operation was completed, the robotic liver resection started with a five-port technique. Preferably, no adjustment was made to trocar position(s) and no trocars were added. Anatomical right or left hemihepatectomy was undertaken using the extrahepatic Glissonean technique (Takasaki’s method). Liver parenchymal transection was undertaken with the robotic Vessel SealerTM and bipolar energy forceps for Address correspondence and reprint requests to Iswanto Sucandy, M.D., Department of Surgery, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL 33613. E-mail: Iswanto_sucandy@yahoo.com.