Morbid obesity poses challenges for a surgeon, including increased rates of anaesthetic complications, prolonged operative time, surgical site infections, venous thromboembolism and postoperative renal dysfunction 1, 2. The Hartmann's procedure remains critical in the armamentarium of the emergency surgeon, especially in the management of perforated diverticulitis. Performing a Hartmann's procedure in a morbidly obese patient can be technically demanding, with poor exposure, restricted instrument reach and difficulty in identifying anatomical planes 3. Robotic-assisted surgery offers potential advantages in this circumstance and for improving the chances of a future reversal procedure. The CT scan is reviewed to plan port placement for the robotic platform (Figure 1A); critical to avoid arm collisions during the procedure. The patient was positioned supine with arms tucked on a table motion-enabled theatre bed and a non-slip pressure mat. Bariatric bed extensions are used to prevent pressure-related injuries. If the pathology is deemed close to the pelvic side wall and ureter, ICG can be instilled in ureteric catheters to delineate this structure. Hasson's cut down was performed above the umbilicus. A diagonal four-port robotic configuration was used (Figure 1B), comprising three 8 mm ports and one 12 mm port. An assistant port was positioned 7 cm behind and between the robotic ports. The assistant port is an 8 mm Lexion 3-in-1 port, allowing for high-flow pneumostability, smoke evacuation and humidification. Pneumoperitoneum was established at 12 mmHg throughout the case. The operation commenced with an exploratory laparoscopy to clear free purulent material (Figure 1C) and to assess the feasibility of robotic approach. An important step is exposure of the operative site; in this case the sigmoid colon, and to manoeuvre the small bowel and omentum out of the pelvis. The patient is positioned in Trendelenburg before docking from the patients' left side. The sigmoid colon is mobilised (Figure 1D). The perforation is identified, and the diseased segment of colon is elevated; helping avoid the ureter. A small mesenteric window is created using the vessel sealer and widened proximally and distally (Figure 1E). The rectosigmoid junction is divided using a Sureform stapler with a black reload. Rapid clamping and unclamping's manoeuvre with the stapler is used to allow for compression of oedematous bowel prior to stapling. The proximal colon is divided using a 60 mm green reload (Figure 1F). ICG is used to confirm perfusion to the colonic conduit prior to exteriorisation (Figure 1G). The robot is then undocked, with ports left in situ. A ratcheted laparoscopic grasper is used to secure both the resected specimen and the proximal colonic conduit intended for the stoma. The conduit grasper is secured with an artery clip to the drapes, maintaining orientation. Following trephine creation and insertion of a small Alexis wound protector, the specimen is retrieved. Epiploic appendages of the colonic conduit are excised to allow ease of delivery through the trephine, and the stoma is matured. The 12 mm port sites are closed at the fascial level (Figure 1H). This case was demonstrated on a 61-year-old, 160 kg male with perforated sigmoid diverticulitis (NELA 9.50). This case marked the first after-hours emergency robotic case performed at our regional hospital. The total operative time was 117 min, including 89 min of console time. His stoma was active day one post and was discharged day four post with no representation within 30 days. Robotic surgery in Australia remains largely elective. After-hours use is constrained by workforce availability, and the development of public-sector guidelines to encourage robotic emergency cases is hindered by episode-based cost–benefit rather than longitudinal. Gavin J. Carmichael: conceptualization, writing – original draft, writing – review and editing, visualization. Yung-Hsin Hsueh: reviewing and editing. Daniel Ng Ying Kin: supervision and writing – original draft. Kirk Underwood: conceptualization, writing – review and editing, visualization. Mathew O. Jacob: conceptualization, investigation, writing – original draft, writing – review and editing, supervision. Informed consent has been obtained from the patient for publication of this report, including the clinical images, and this consent has been documented. This process including providing the patient with a Participant Explanatory Statement and using a Clinical Case Study Report Consent Form used to document consent, as per our Institution's policy. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
Carmichael et al. (Sun,) studied this question.