Robotic End Colostomy Reversal

A colostomy is a surgical procedure frequently performed as a life-saving intervention in patients with complex abdominal trauma, inflammatory bowel diseases, or oncological conditions.¹ An end colostomy, typically created temporarily to divert fecal matter and allow healing of the distal bowel segment, represents a critical surgical strategy in managing severe intestinal injuries or pathologies.^2,3 The reversal of an end colostomy is a significant reconstructive procedure that aims to restore gastrointestinal tract continuity and improve patient quality of life.^4,5

The case presented in the video illustrates a complex clinical scenario involving a young male patient who sustained multiple traumatic injuries in a motorcycle collision. Following initial emergency management that included an exploratory laparotomy with sigmoid transection and subsequent end colostomy, the patient now undergoes robotic-assisted colostomy reversal. This approach represents an advanced surgical technique that uses minimally-invasive technology to address challenging postoperative reconstructive needs. Robotic-assisted surgery offers several advantages in colostomy reversal, such as better dissection precision and improved surgical field visualization. By reducing tissue manipulation and providing more ergonomic surgical techniques, this approach can potentially lead to shorter recovery times and minimized risk of surgical complications. These benefits make robotic-assisted surgery an attractive option for surgeons performing colostomy reversal procedures.^6–9

End colostomy reversal is indicated in patients who have recovered from initial traumatic injuries and shown adequate healing of associated surgical sites. After stabilizing from initial postoperative complications, patients must show sufficient physiological recovery to safely undergo reconstructive surgery. However, robotic end colostomy reversal may be complicated by postoperative adhesions and potential surgical conversion, with additional considerations including the procedure's significant economic burden.

The surgical procedure presented in this video was initiated with a careful exploration of the abdominal cavity. The main challenge was navigating through dense peritoneal adhesions, particularly around the omentum and liver region. At the beginning the adhesions were addressed through laparoscopic techniques, ensuring precision and minimizing disruption to surrounding tissues. The remaining adhesions were planned to be managed robotically.

An unexpected intraoperative finding was a sizable midline hernia with multiple tissue defects. Although this was not addressed during the current intervention due to a lack of prior patient consent, it represented an important incidental observation that may require future surgical consideration.

The abdominal cavity was carefully explored, and adhesions were released before strategically positioning the robotic ports to optimize surgical access and visualization. The port placement was carefully planned to navigate the complex anatomy resulting from previous surgeries and dense scar tissue. This approach enabled maximum operational flexibility throughout the procedure.

Following the initial robotic port placement, the surgical team proceeded with colostomy dissection. This phase was characterized by a systematic approach to identifying and carefully separating adherent tissue planes. Key challenges during this phase included managing potential vascular structures, minimizing tissue trauma, and creating sufficient working space for subsequent surgical maneuvers. Vessel-sealing devices were employed to separate adhesions and maintain hemostasis.

The final stages of the robotic end colostomy reversal procedure focused on tissue preparation, anastomosis, and careful closure of surgical sites. The anastomosis technique involved precise colon end preparation and a carefully executed two-layer closure. Non-absorbable sutures were utilized to create a robust, multilayered anastomosis, paying particular attention to creating secure tissue apposition with minimal tension. The posterior layer was carefully sutured, followed by a complementary anterior layer closure, ensuring comprehensive tissue alignment. Particular care was taken to address potential bleeding points and ensure hemostasis.

Recognizing the patient's predisposition to developing significant scarring, the surgical team opted for a careful, multilayered closure technique. The robotic platform continued to provide significant advantages during these final procedural steps, allowing for enhanced precision in suture placement, minimal tissue manipulation, and superior visualization of the surgical field.

A paralytic ileus was expected to be experienced by the patient due to the extensive manipulation of intra-abdominal contents during the adhesiolysis. It was anticipated that the patient would spend a few days in the hospital. Pain control was carefully managed, and fluid and food were introduced as quickly as possible. Despite the operational difficulties caused by adhesions, a successful recovery was expected to be achieved. The procedure was performed without significant complications.

This video is a step-by-step demonstration of advanced robotic-assisted colostomy reversal techniques, offering key insights into minimally-invasive surgery. In this complex case, the robotic approach was crucial due to the patient's challenging surgical history, including dense adhesions and previous traumatic surgeries. The robotic platform enabled exceptional accuracy, allowing surgeons to navigate difficult scar tissue with minimal trauma, enhanced visualization, and more controlled tissue manipulation. This video shows how cutting-edge technology improves surgical outcomes, reduces recovery time, and solves complex challenges. It is a valuable resource for medical professionals, especially surgeons and trainees, looking to deepen their understanding of advanced colorectal surgical interventions.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.