VM65 - Robotic Assisted Management of Acute Small Bowel Obstruction after Pelvic Exenteration

Image or Table (Do Not add text here):

Purpose/Background: The use of the robotic platform in emergency surgery remains controversial and is still being investigated. However, in hospitals with operating room staff trained in robotic-assisted surgery, the robot can be a viable option for emergency procedures. The high-definition visualization, enhanced dexterity of the robotic arms, and surgical precision, combined with minimally invasive techniques, may facilitate the surgeon’s task and potentially improve postoperative outcomes for patients.

Methods/Interventions: We present a video demonstrating the management of an emergent small bowel obstruction using the da Vinci Xi platform in a 63-year-old male with cerebral palsy and T4b, N2b, MSI-proficient rectal adenocarcinoma. He completed total neoadjuvant therapy with FOLFOX chemotherapy and Xeloda chemoradiation, followed by robotic-assisted abdominoperineal resection, radical prostatectomy, and colostomy revision in collaboration with the urology team. His postoperative course was complicated by recurrent small bowel obstructions managed nonoperatively, as well as a urine leak at the vesicourethral anastomosis, which was treated with bilateral percutaneous nephrostomy tubes.
Despite resolution of the SBO, he experienced intermittent obstructions and had slow recovery. He acutely became obstructed again and developed severe abdominal distention. A CT scan performed showed pneumatosis, mural thickening and small bowel distention. Portal venous gas raised concern for bowel ischemia. He was brought emergently to the operating room for abdominal exploration with the da Vinci Xi platform. Patient was placed in a lithotomy position. The port sites were placed higher than his prior incisions. Three 8 mm trocars and a 12 mm trocar were inserted in an oblique fashion with the assistant port in the epigastric region. The abdomen was examined for any signs of ischemia or perforation. There were areas of small bowel that appeared dusky however not frankly ischemic. The distended small bowel was traced into a decompressed loop in the pelvis. This loop was carefully dissected off the pelvic side walls and deep pelvis. The pelvic loop of the small bowel had multiple serosal tears and appeared unhealthy. A side-to-side functional antiperistaltic anastomosis was then created using two 60 mm blue load staplers. ICG was utilized prior to creation of the anastomosis. The specimen was removed from the 12 mm port site. Hemostasis was adequate and the procedure was concluded.

Results/Outcomes: Patient tolerated the procedure well and was transferred to the surgical intensive care unit post operatively for further resuscitation. His NGT was eventually removed and his ostomy was functional.

Conclusion/Discussion: In emergency situations, robotic surgery can be a safe and feasible option for select patients, particularly when performed by experienced robotic surgeons. As a surgeon, it is crucial to have a well-thought-out plan. Proper port placement and atraumatic tissue handling are particularly important in acute settings to ensure optimal outcomes. It is important for operating room team members to be thoroughly trained in the use of the robotic platform to ensure seamless and efficient procedures. The enhanced visualization offered by the robotic camera, along with the precision of the robotic instruments, has the potential to improve patient outcomes.