Robotic Abdominoperineal Resection (APR) with Bilateral Gracilis Muscle Flaps

CHAPTER 1

Hi, I am Dr. Todd Francone. I'm chief of colorectal surgery at Newton-Wellesley and a staff surgeon at Mass General Hospital and director of robotic surgery. And I'm here with Dr. Tomczyk, who's our plastic surgeon from Mass General Hospital. And today we're gonna be performing a robotic abdominoperineal resection with bilateral gracilis flap reconstruction of the perineum. The patient is a 52-year-old with metastatic rectal cancer who initially presented with bone, liver, and lung metastases and initially underwent chemotherapy and had some progression of disease and then was placed on a clinical trial and had an amazing response. And he has been under control for the past two years and has recently had some progression of his symptoms and therefore here we are trying to resect his primary tumor as a palliative, if not curative resection since he's been doing so well with his chemotherapy. So the plan for today is to do a combined approach. We typically start these cases out very routinely in regards to docking the robot, performing a transabdominal approach. And once we kind of get our pelvic dissection set up, Dr. Tomczyk will start mobilizing her gracilis flaps and we'll work simultaneously. And by the time she's finished mobilizing her grafts, we are typically constructing our stoma. So for the transabdominal portion of the procedure, the key steps are getting in, taking a look at the peritoneal cavity, getting good exposure, taking a look at the sigmoid colon, see how much redundancy and what we'll need to do to create an end colostomy. We'll identify IMA pedicle, get into a good avascular plane and that's the initiating of the TME or the holy plane for us. For this particular patient, he had a close margin along the anterior wall on a preoperative MRI. So we're expecting this plane to be a little bit obliterated or challenging. Once we get that TME dissection going, we'll get that all the way down to the levator. And we typically try not to do a coning down on these dissections, so we'll try to keep the levator attached to the end of the distal rectal wall. And those are the key portions of the transabdominal resection. Some key things for our perineal dissection is making sure that we identify our landmarks, which is the coccyx bone, the ischial tuberosities, as well as the midway point between the base of the scrotum and the anal verge. And once we get into that dissection, making sure that we don't cone in and then anteriorly just going very slow. It's critical to take your time on this because there's no good plane for these patients whether they've had radiation or not. And so you can very easily injure the urethra when dissecting going too anteriorly. And then tips for the flaps, Dr. Tomczyk. Sure, so like Dr. Francone said, I'm Ellie Tomczyk, I'm one of the plastic surgeons at Mass General and I spend a lot of my time here at Newton-Wellesley. The goal for today was to bring in some healthy tissue into the field as the skin and soft tissue had already been irradiated. So we wanted to get well beyond that. There's lots of things described in the literature that are commonly used using muscles from the abdomen as a really common source for reconstruction for these cases. But we've been doing a lot more with using the gracilis flap, which is a narrow muscle that runs on the medial deep compartment of the thigh. Starting up at the pubis inserting down on the medial tibia, it has a proximal blood supply that's a dominant pedicle supplied from the profunda and it has then multiple segmental, minor pedicles distally on it. It's innervated by the obturator nerve, which sits about one to two centimeters proximal to the pedicle. And thus this flap is super versatile. It can be used as a free flap, you can use it as a motorized free flap in other parts of the body because it's a very narrow kind of wimpy muscle, we routinely will harvest bilateral gracilis flaps. From a functional standpoint, it doesn't make a big difference for our patients. Even construction workers are back working no issue. And you really need the bulk of two muscles to fill the defect in the pelvis. So the goal is really to raise these muscles, rotate them into the pelvis, and reconstruct the pelvic floor, and then hopefully use the soft tissue in the skin to close primarily over the top. Obviously if there is any tension on that, some additional incisions can be made to rotate that in more as a advancement flap. But the goal for me is to get a primary closure of the skin. The gracilis flap can be harvested with a skin paddle, which is not my typical go-to. If I need a skin paddle, it tends to be a little tenuous and it doesn't always do great and it can't be very large. So if I'm really worried, I would probably choose a different flap. The key landmarks are finding the pubic bone, the medial aspect of the proximal tibia. You can draw a plumb line between those two. You can even palpate the tendon of the adductor and typically about two to three fingerbreadths posterior to that is where you make your incision. I will indicate kinda my typical variations of that. I like to put my incision a little more posterior so I come right down onto the muscle. The pedicle itself typically inserts into the flap about six to 12 centimeters from the proximal insertion of the muscle. And so that's where you should be kind of keyed into it. Most cases it's around nine centimeters and obviously the more proximal the pedicle is, the better because that's where your arc of rotation is of that muscle. You wanna dissect down through the deep fascia of the medial compartment of the thigh to identify the muscle, get circumferentially around the muscle and then I make a counter incision distally down by the knee to find the tendinous insertion of that, you really wanna try to get the entire length of the muscle so that you have that tendon to suture to. I typically close my legs in layers. I put in a 15 round drain, and then I close with PDS and Monocryl and I wrap the legs in an ACE wrap. I create a subcutaneous tunnel into the perineum once the specimen is out, taking care to rotate that muscle without any tension or kinking of the pedicle. I like my subcutaneous tunnel to be about three fingerbreadths in width. That way again, you're not putting any tension or any constriction on the muscle or the pedicle. And I inset it with Vicryl and then I close the layers over the top with PDS sutures.

CHAPTER 2

All right, so good morning. So we're about to get started here. Like every patient, we're gonna do our physical exam. This is an advanced - locally advanced rectal cancer with multiple metastatic disease that's been under control under clinical trials. So before we do an abdominoperineal resection, we wanna understand our anatomy in regards to the tumor itself. So we'll do a rectal exam, and his is obviously quite low, which is the reason why we're doing an abdominoperineal resection and it involves mainly the majority of the anterior rectal wall as well as the right rectal wall. So these are important to know when we're doing our perineal dissection. The left side and the posterior aspect feel free and they feel mobile. The anterior wall feels a little fixed and we know he has a close prostate margin, which is why we'll be doing him in the prone position. So we'll flip him after our abdominal procedure is done. You can see here is his tumor. So we'll use CO2 so that gas will dissipate by the time we go minimally invasive. And you can see here, his residual tumor left behind. It's quite low. So here's the top of it at the levator plate and then we'll bring it down. You can see it right at the dentate line. And that's his anus right there. And then I'll show you our port placement. Legs are in a lithotomy position because we're gonna do a bilateral gracilis flap reconstruction. So when we're doing the port placement for a robotic APR, it's typically four ports and an assist. So the first thing we do is feel our anterior superior iliac spines and we'll mark out the rectus muscle. Can see that he is been preoperatively marked for a colostomy here. And we're gonna kind of move it over to the lateral part. And oftentimes we'll try to use this as our - one of these ports as our colostomy site to minimize the ports. So we'll draw a line from the apex of the AS spine to the midclavicular line. That helps us kind of guide our port placements. So this is gonna be our arm four, one handbreadth, we'll bring up to his belly button here. And then we'll try to do about six centimeters apart. And it might be tough to incorporate that. So we'll just bring it out. We'd rather not limit our dissection. So this will be arm four. This will be our camera port. This will be a bipolar, this will be a Cardiere, this is our scissors. And then an assist port out here to help us with our pelvic dissection. So again, like we can try to bring that down here, but then we would be clustered in the pelvis. We'd have some collisions at the bedside. And to be honest with you, in order to do a good pelvic dissection, I wouldn't compromise on your exposure. So just accept the fact that you have an extra port.

CHAPTER 3

All right, so we're gonna just first start out, we already did our ports in kind of a guidance, but whenever I always just take another feel just to make sure I'm kind of getting myself in the correct spot. And so plus sometimes you can't see the spot. So this is where we're gonna get our camera entry. We like to bring our port down here so that our assist port is very nice and has access to the pelvis and this drops it down so there's no collisions. And this typically won't have any problems with the sacral promontory when you bring it down lower. If you bring it down too wide, you'll hit the right pelvic sidewall. So you don't wanna go too lateral and you don't wanna go too inferior or caudle because then you might have trouble with your anterior dissection. So usually two up, two over is very much a standard position for that, like a stapling port if you're doing a low anterior resection. So we keep it that way and then we'll have just some guides there. We'll always redo our ports when we get insufflation and our pneumoperitoneum. So we'll get in with an Optiview technique. I'll make a small incision here, incision. And then use a regular laparoscopic Optiview point. So the key here is to just let the port do the work here. You'll see that we will guide down through, we're not pulling up yet. We'll guide down through the anterior rectus fascia. So you'll see that here. Then you'll see the rectus muscle. And once we see that posterior fascia, then we'll pull up off the abdominal wall. And then once we see that, kind of enter through that posterior fascia, that tip of it, we're gonna slide our hand down so that we're not driving into the back into the RP or any critical structures. And then you can see here we've gained access under direct vision. We're insufflating. And then we'll put our camera back in, slide our port back a little bit, and then just check underneath and make sure we didn't injure anything. And then the first port I'll put in is always my right lower quadrant port. So we'll do small peritoneal. You can see here with the pneumo, we get a little bit more space and I'll do a small TAP block here. My mentor used to say, make a wheel that your mama can see. That way you know where you're putting the injection so that when you go to put your port, you're not lost. And this will be a eight-millimeter robotic port. If we were doing a low anterior resection, this would be a 12-millimeter port for the stapler. Everything goes under guide. We'll take a grasper. So we're just gonna take a quick look at our anatomy. First step is always put the omentum above the transverse colon. And with an APR, we typically won't do any splenic flexure mobilization. We'll take down the lateral attachments to the pelvic brim to the left pelvic brim. But typically we don't need to do too much. So we're just trying to see what kind of colon we got. And he's got a nice redundant colon. All right, can we get some Trendelenburg for me please? Let's go to about 20 degrees. You want the lights down or leave them on? You can leave them on for a little bit. That's good. So just that's to help get the small bowel out of the way. You can see he's got a nice anatomy, and we'll go over that when the robot's docked. All right, here's our pelvis here. So once we have that, we can put our other ports in. Lemme just the handsbreadth apart. It kind of lines up right here. I just think it's gonna be too - struggle, right? Yeah, I mean we could put it right there. Right? To the side, right next to it. I don't know, it's gonna be so - yeah, it's a little tight. Yep. Let's just go out here. All right, so we're just gonna put our assist port in. This is gonna be triangulated between our camera port and our right lower quadrant port. It's gotta be a little bit offset lateral. So when we're dissecting on the pelvis, the assistant's hands don't get crushed every time we move our camera. This also is a nice port placement for a total colectomy 'cause this can be a robotic port. We have access to the top portion of the torso and then the bottom portion of the torso, this would be the assist when we're at the top. The assistant port's the assist when we're on the pelvis. And then we'll switch to our AirSeal insufflation, which is a valveless jet insufflation and allows instrument exchange and needle exchange without loss of pneumo. Put our camera port in robotic. And then can we have a little bit of tilt towards me and you can take out a little bit of Trendelenburg. That's good with the tilt. Let's see if that helps. Is that about 15? 17 maybe? Yeah, good, okay. So we'll bring the robot over the left hip, come in a perpendicular. This creates more room for the surgeon between the legs to either a plastic surgeon doing a flap construction, when we do a transanal portion, another surgeon can work simultaneously doing like a TA TMA. So we'll rotate the boon around towards our pelvis and then bring the arms out a little wide so that she or he will have some room to work down below. Start with the ports on the inside first. Then work outwards. We typically don't target in the pelvis. Drop your hands first, guide it in. You can see the yellow bar, top right screen. Our docking typically takes around two minutes.

CHAPTER 4

All right, let's just get situated here. Just take an initial glance at our anatomy. You can see here common iliacs here. You can see that the ureter, right ureter crossing over the iliac extending down into the pelvis. Won't be able to see the left side just yet. Sometimes you can, we'll have to find that. Here's a sacral promontory. You can see a hint of the left iliac vein. So first thing we're gonna do is just mobilize off the left pelvic brim so we can just get good retraction outta the pelvis. So we'll utilize arm one and arm two. And we always say nice quick movements when we're dissecting this part off, we stay on the inside of the white line, that'll keep you in the right plane and avoid getting into the RP. And then we frequently move our assist port. Really utilize that fourth arm to give us good tension, counter tension, stick to the principles of good operating. You can see there, I'm even on the wrong side of that white plane. So you can see you start to get into that RP. So we just regroup it on this side and you can see when you stay on that side of the white, it leads you into the right plane. See that? Be careful how you're retracting. Make sure - robot always wins, you don't want to have a retraction injury. So if the body's holding something and the robot's holding something, the robot's gonna win. You'll get tearing of structure. So once we get into the - aim for the pelvis, then Dr. Tomczyk can start her dissection. You're here just trying to stay on the inside of that white. You'll have your ureter crossing over here. You don't want to get into your ureter, you don't wanna go past point when you're dissecting and injure structures that you wanna preserve. So again, staying on the side of that white line is gonna get you into the correct plane. Picking that up here, just continuing to dissect off this pelvic brim here. Always moving that left arm, giving myself good tension to facilitate the dissection. These are just additional attachments you can see now our pelvic brim is somewhat clear. We could do a little bit more staying on that white line. Lifting off off the important structures here. Be on the inside. All right, so usually that's pretty good. He's got a nice redundant sigmoid colon so we should be able to bring that out. And he's nice and thin. So this should be mobilized enough for our colostomy creation. So we're gonna come down here, we're gonna start with a mediolateral, get our anatomy down, make sure we identify our ureter. So the first thing we wanna do is try to identify our inferior mesenteric artery arch, which means putting your mesentery on tension. Getting that colon out of the pelvis helps identify this arch here. Let's see if we can get a better view. So just kind of bringing it up and down. In terms of here, might give us that. You can see that here. So that looks like our - where we might wanna start. Just like that. Then you'll let the air seal or the pneumo do some of the dissection. And when we do that, just gentle sweep up. Remember that he's angled so you don't want to dig straight down. You want to angle up like this when you're dissecting. We're just gonna make our window wider, staying close, be careful not to get our hypogastric nerves, which can affect our pelvic erectile and urinary innervation. And what we're looking for here is our ureter. So try to limit our energy until we identify that. You can see here just making my window open so I have good exposure, and that ureter can sneak up on you during that pelvic dissection. So it's good to know where it is. And something might be right here. Let's see. Just sweeping this stuff down. and the ureter will course and you can see it voliculating there. So we will adjust our attention here. Once we see that, we want to take that plane and we wanna sweep it down systematically so we make sure it's down both approximately and then caudally as well. So just releasing those attachments, dropping that down. Friends, helping friends, just get ourselves good tension, counter tension. Always adjusting. Keep a nice dry field. It will help you visualize your anatomy. It looks like we might be on the other side, but we'll again, the goal is to get that ureter down as it heads into the pelvis. So we can just demonstrate that. Again, here's our ureter. It's gonna be in here. Right there. It's gonna head down and then into the pelvic sidewall. So if I were to flip this over, you can see that we almost basically reached that dissection and we'll just connect the two. You can see right here where we were. Staying close here. Try to stay off that sidewall, here connecting your two. Never go past point. Very thin. So be careful what you're dissecting. Structures can always get pulled up. And release this a little bit, but not too much. Okay. See there's our plane there. So now we're gonna start our pelvic dissection. We're gonna flip this over here so it gets out of our way. Patient's in about 18 degrees Trendelenburg on the robotic system. The trick here is to get your give yourself tension right above where you're operating. So you'll see, I'll grab - my goal, it's gonna give me nice tension there. So I'll use this arm here to get myself down. We're gonna stay on the plane up here. His tumor is not up here. We're just gonna hug that. Get that nice areolar plane between the rectal fascia and the presacral fascia. If you stay on the rectal side, you'll see that you'll be able to drop those hypogastric nerves down. And I'll point them out to you in a little bit. See nice areolar plane. If you go down here and your nerve comes up like this, you're gonna transect your nerves. So you wanna here push them down. Get that ureter down. You can see here, just give, always giving myself tension. Sometimes if you have trouble seeing 'cause the tissue gives a little bit, you could always switch to a 30 up camera here. Help yourself get this stuff down. So we'll switch to 30 down. You can see the iliac vein that Sarah's pointing out. Sarah likes me to stay away from structures like that. So again, if we're operating down here, my tension wants to be directly above that. Okay, so again, here's the nice plane here. You can see a hint of the hypogastric nerves right here. Not clearly seen on the left but perhaps in there. But this one right here, you can see it, you can see it come down here and it's gonna come along to that sidewall. So, now we're just gonna slowly dissection down, do a nice TME dissection. We always start posteriorly. We go as far as we can. For him, we're gonna stop at the - probably at the levator plates. I see his nerves are getting pulled in here and perhaps not giving myself enough tension. So I'm gonna drop that stuff down. I believe these nerves go down. You can just see the curve of the pelvis. Here's your sidewall here. You don't have to try to do everything on this side when we do it from the right side, you'll go to the left. We do try to just maintain pressure and we'll work our posterior and right side first. So here... Again. Gentle retraction. No need to go super fast. You're hugging that mesorectum here and you'll see here as we move to the left, it might hit the camera. You're gonna frame shift, move that so you get more room on the left, subtle, pushing this way just to kind of see where the planes are developing. Use your arm one to give yourself that tension, counter tension and then you continue to dissection down, never going past point, frame shift again. And then this retraction is up and then medial and it can help outline where your sidewall is. You'll notice that I didn't take the IMA pedicle. I like to keep it in. It provides good eventual tension for me when I'm doing my dissection. Lemme see here just following. You can see some edema. Patient's gotten chemotherapy as well as chemo radiotherapy for his tumor. So you can see some edema of that. Again, if your camera's off to the side, this gives you a slightly different view. So you can see really along that left side really well. You'll see that I'll sweep up like that, really develop my left side of the plane. And this tumor's not here but it's nice to do a nice avascular dissection. Nice lateral retraction by Sarah. Let's see. Just following this curve here, you can see here we're gonna follow this curve. Here's your peritoneal reflection and then eventually we will go anteriorly first. Then we'll do the left side until we can't do the - posterior any further. So I'm gonna bring my retraction down a little bit. As we come down here, we can see better retraction here. Eventually we're gonna get to that mid sacrum where we'll see Vulgar's fascia, so you can start to see, and we wanna stay high up here and not be led into the sacrum itself. When we start to see the levator then we know we've gotten to that point. We wanna do a cylindrical APR. See, always giving myself tension here. Less important to try to do all that dissection on the left side 'cause we're gonna go there pretty soon. Little less tension. So we're gonna pull up a little bit. Get your camera down there. Sometimes you get a little too close, a lot of edema. Again, just try to keep your field nice and dry. That's the limit to where we can go posteriorly into the right. Whenever we do anterior, we have our assistant hold out our rectum straight out towards the head. Yep. And then we have two arms to work with. Can we suction this out for me and I'll take a camera clean. So again, holding it straight out like this, so a lot of people can struggle with where to start the anterior plane, he's got a deep pelvis. You can kind of see here is where this kind of pouch of Douglas kind of outlines. We want to stay - get into that plane between the fascia and in order to preserve our prosthetic plexus here, nerve plexus. So kind of just outlining here, again a little deep. This tumor's lower. Depending on the location of the tumor, you can always shy away, go a little higher. Patient should be educated about that. And the risk for nerve dysfunction. Once we get this down, we're just gonna go slow. Try to get a good plane here. Clean off my... Just get a little bit up here. You can start to see this plane right there. And I'm operating without tension, right? So when adjust my retraction here, help me see those planes. Really don't wanna see the seminal vesicles, right? You've seen the seminal vesicles, you're slightly too anterior or ventral. And the more you release from the side, the more exposure you'll get. So just going slow, tip of the scissors is always down. We'll do a little bit here, and you say well we haven't done the left side yet. Yeah, typically we'll do this first 'cause sometimes this will help get that left side down. I like using the Cardiere rather than a tip up. You can see it's smaller, more versatile. It's less bulky. And I use the same instruments for every case - right, left, APR. So here you can see just trying to stay - a lot of edema here. Angling it down. All right, I think we're in a good plane here. You can see sometimes that dip a little bit too low. And I think this is our plane here, so we'll get that fat back down. You see seminal vessicle right there. And you can see here we have nice attachments here. So I'm just gonna free this up here like a zipper start down and stroke up and this will release your plane. If you start in the middle, nothing happens, right? So you want to get these nerves and preserve these parasympathetic nerves on the right lateral sidewall. So just following that plane there. See that? Okay we're gonna start left. So Sarah's gonna hold that out to the left here. We're gonna let that smoke evacuate. Get our picture better. Can we get a camera clean, Sarah? Okay, so here we're gonna do sides. So your assistant pulls out to the right shoulder. You can see here we're gonna give ourselves lateral tension here, our ureter should be down. Here's our iliac, ureter should be in here somewhere. So, this can be sometimes a tight space. You'll see that I'll angle my wrists down and our arm one will be angled up. This gives me space to operate and so that I don't collide here. So one hand's always moving and just heading straight down. When I get down to here, you can see this still needs to be done. So I'm gonna pull up and out. It's gonna straighten out my dissection. What you don't wanna do is course in this way that usually means that you're gonna get into that mesorectum, and that there's not enough tension by your assistant. So always coming up and again sweeping upwards. I giving myself more tension down here. So sweeping up like that. You can see here's our point of where we want to meet our anterior dissection. You can see we have a nice avascular plane here. I'm constantly moving this down and I'm flipping my wrist down. That gives me enough room to get this other arm down like this. You can see here we're gonna meet our dissection. Now be careful here, you don't want to peel away some of that mesorectum. So we're gonna rotate our camera just a little bit. Just gonna make sure we get this fat. It stays with your specimen. Really aim for that. So thin. We're gonna give ourselves a little bit more retraction here. Lateral dissection is usually the toughest part, sometimes no clear plane. You wanna make sure you're medial to your parasympathetic nerves but you don't wanna be getting into your mesorectum. So again, just going slow and just at this point we start doing circular. Sarah, pull a little bit more towards the head. Yep, that's gonna even that out for me. Again, seminal vesicle. Sometimes I've lost a plane at this area. I actually think we're doing okay. You can let go Sarah. So once we do that, typically we'll go back posterior, sweep this specimen this way. A little retraction injury there. So I wanna be careful of that. Okay, so we'll go posteriorly again, you can see just a little bit of time and doing some other dissection. We're gonna aim up here. And stay off our sacral promontory. Avoid getting into that presacral bleeding. I start to see the dissection is now going up. A lot of edema. I say I was doing a nice job keeping that suction outta my face. You see the edema sometimes we get down to wall doesn't release that natural fascial plane. See here, and we put this guy will give us a nice retraction like that and then we will just release some of that. And you can see things tend to get a little bit more stuck as we get where that radiation field was. So up and out. Just gently if the plane doesn't look good, just go to a different part of it. Develop it, it'll help develop the rest of your dissection. We really wanna get down to where the the levator starts so we have a space to enter into when we do our perineal dissection. So you're keeping my camera clean, friends helping friends. And then just... Digging a hole here, right? Can I get a camera clean? It's a lot of edema from the radiation. We're gonna do some anterior again, we just work our way around. A little bit of a retraction injury. So Sarah grab here, pull straight out just enough to give us a little bit of tension so that the specimen doesn't fall in our face each time we try to operate. So we can see here. So here anteriorly, we're just gonna... We're gonna need one on each side. Dr. Tomczyk. Are you almost done with one side already? Well I have the muscle out but I have to close. It looks awesome, he's got a nice muscle. But he definitely will need two. It's as expected. I'm gonna go wide. You're gonna go wide? Oh yeah. Oh great, just don't go wide on the skin. Go big or go home. Okay, Well, he's getting two for sure. He needs them. That's what Sarah told me to say. And anteriorly, if you can go as far as you can anteriorly and follow that plane, that's great 'cause that's usually the hardest part to do from below. And here I'm just gonna change my angle so it's more of a head on view, just giving myself the camera. And I would expect this plane to get a little bit tougher as we go along because I'm gonna shy a little bit more anteriorly or ventral 'cause I know his tumor is more anterior. So what I don't wanna do is get into the wrong plane and get into my tumor. He knows that he'll have some loss of sexual function with this dissection. Just trying to see prostate. Lemme see this fat coming up, I'm gonna bring that down. Nice thing about the robotics platform is that you really get your camera in there when you need to. You can start to see prostate right here. Seminal vesicles. Posterior wall of the prostate. Nice plane again. Just hugging that a little closer than normal. We'll take a camera clean. Yep. So again we're gonna give ourselves some retraction here. You can see that seminal vessicle there. We're gonna bring this down. I'll rotate my camera a little bit and then again that zipper to kind of follow that plane. Make sure you stay in the correct plane the whole way and see you drop my wrist here and when you start losing that. Again, just keep working around. I think the hardest part with an APR is just figuring out when to stop. You don't wanna cone in too much. His tumor is very low. It's within the anal canal so we wouldn't compromise our margin if we coned in just a little bit. But still, you really want to make sure that you're doing a good oncologic dissection here maintaining your margin. So here, bring that camera out a little bit. You can even use the zoom as Sarah likes to remind me. Is there a zoom button Sarah? There is a zoom button actually. I didn't know that. It's good, you can let go. We suction down in there. So again, posterior and right side, I hold, left side anterior, your assistant holds. We're gonna come down here, pull our camera away, give us a little anterior dissection. Once you're getting down like where you're doing anterior, you're probably gonna get down to your levator pretty soon. And you can see this plane's much clearer than it was than prior. And that's just from like all the freeing up that you're doing circumferentially, things start to develop a little bit easier. So giving myself good tension, counter tension with that here. And again, some people like to tip up. I think it maybe appreciate the fact that like the IMA is still intact. So you do get some tension provided by that. And that's just a personal preference. A lot of people divide it and then just pull straight outta the pelvis. I think this helps maintain the planes a little bit better. Helps me visualize the anatomy. Keep my orientation. When you just pull that outta the pelvis, sometimes you can pull out too much. You can start to see maybe muscle there. Really, I want to see... See I've adjusted my arm one just slightly just to give myself a little bit more tension. See his presacral fascia being pulled up. You wanna make sure you stay on that mesorectum and do not get into those presacral veins. That can be disastrous. See right there. Stay out. See how those veins were getting pulled up Sarah? Yeah. So we're gonna just take your time. Don't go past point. So again, I don't think we're at the pelvic floor just yet. He's got a nice narrow pelvis here. So we're just continue to work our way around. Let go by accident. Normally I would just operate with a camera like this. But let's - can we clean it? Do you know what stapler you want? Green's fine or blue? Blue's fine. You want a 45 or a 60? -Let's do 60 just to make sure it's all... Blue? Yeah. Sarah, can you get your instrument down here and gimme some lateral retraction. And again, just following that curve off the sidewall. Okay, can you grab this Sarah? Let's go left side first, yep. Again, staying on the inside of this. That zipper really helps open that up. All right, straight out Sarah, yep. So you always wanna make sure hands are nice and comfortable and these are smaller movements here. Sometimes you can just use your wrist. And it's nice to get down here. But the edema is really... You can see this anterior part is a little bit more stuck. So we're gonna shy away here. Let's try the zoom. I did it at two times, let's see if that helps. It looks like we're getting down to that pelvic floor. You can see the muscle. I think we're getting down to that area. I wanna see if I can go a little bit more anterior. I'm gonna take this Sarah. You can see here's pelvic floor there. So this feels like sacrum. The coccyx bones right here. Might go a little bit more and then stop. It's actually his muscles getting pulled up. You can see it. All right. So here we think this is like some pelvic floor muscle here getting pulled up. Trying to get myself so you can see it. He's very stuck down here. Let's see. You told them he got all the radiation right? Yep. So you were through the levator here. It's through the levator. I will take a camera clean. So you can see where we went through the levator, which is actually quite nice. It prevents us from coning in on our dissection. We're actually just gonna make sure this is all the way down to that same area. Such a narrow pelvis, lemme see. I just want to make sure that this dissection lines up nicely. Can you grab Sarah? Yep, just gently out. So you can see here's where the dissection gets pretty stuck. It's nice when you can see on each side where you have to go. Pull over to the left Sarah. Okay, all right. That's probably as far as we're gonna go. Let's put the 12 port in, which we typically would put in in the beginning, 12 ports in order to get it one - we will have a mini lap as well. Yep, so this will be... All right, I'll take a vessel sealer and a camera clean. All right, so this, Sarah, can you suction in there? So the mini lap head will be placed into the pelvis and that's gonna be our guide for when we're doing our perineal dissection. And we'll look for that. So you wanna put it all way down there. Nice dry dissection. All right, so you can see some retraction injuries from where we were going. All right, I'll take the scissor back. So now we're gonna take our IMA pedicle. Gonna get some of our lymph nodes that come with this. So we'll take the IMA pedicle distal to our left colic. Can I have the vessel sealer now? So taking your left colic should be right here. See that? It's probably gonna come in right there. So this is distal to that. Take your tension off the vessel. We'll do double. You wanna make sure that before you did that, your ureter is down. It's gonna be right there. An endoloop? You want an endoloop? Let's just see here. It is not cleared off enough to do an endoloop, so... And if I was gonna reinforce that, I think I would probably put a stitch. And is that just a sigmoidal branch? Yep. Right there that you're taking right now? Correct. And then the IMV. All right, lemme just take a look and see. This looks like a nice, healthy outlet, distal sigmoid, something like that. Gonna do indocyanine green to confirm, or no? Yep, we will. As soon as we... I'm gonna take it first and then check and see. You could probably go a little bit. He's got plenty to bring up. So we're gonna select that portion of the mid sigmoid colon. This will be a straight shot up here using our vessel sealer. So again, we checked our location of our ureter. We're gonna perform ICG soon. Again, making sure that your RP is down. See that? 'Cause if you don't do that and you come across your RP, you can injure your ureter. All right, so here we're just gonna get this fat up to the level of the posterior wall. You can see that there. Getting ready for stapling. Yep, let's give the ICG and I'll take the scissors. So here, just checking to make sure what we bring up is gonna be well perfused, we've got plenty of redundancy. It should reach. He's nice and thin. So it should reach nice to his abdominal wall. And you can see here... Nice transition. Good, let's clean this up here. Not too aggressive with my strokes here. Our pedicle looks nice and dry. All right, we've got that stapler. We're gonna need a 19 French Blake drain too as well. So here we're gonna let the stapler and just angle it up like this. Slide our staple underneath. Let's get it, there we go. All right, let's see where the green is. 60 green load - 60 blue, 60 blue load for the colon. Green loads for the rectum. Straighten that out. I'll take the scissors. Okay Sarah, just take this, make sure it reaches up to that part there. We don't have to do any further dissection, yep. You can see here easily reaches up. Okay, so we're just gonna check our hemostasis. Everything looks okay. Yep, there's our IMA pedicle. You want us to trim the drain? Yep, we're gonna just put the drain in. Do you want it trimmed? No, we'll trim it from below. Trying to think if we want an endoloop around this. It's just not cleared off enough. It looks pretty good though, okay. All right so we're gonna take - we're getting ready to do our colostomy. And then once we once - we will go to the bedside, create our colostomy. Once Dr. Tomczyk's done mobilizing her grafts, then we'll flip into the prone position. So we like to have a drain in the pelvis. So we're gonna do a suture this drain to our sigmoid stump staple line and then take that port out. Do care if it's dyed? Nope. All right, I'll take the Vicryl. So because we completely close the abdomen, we like to place a drain and then go prone. We're gonna tie this to our sigmoid stump, or our sigmoid staple line. And then when we pull the specimen out from below, the drain will get pulled down into the pelvis, so... Good, good bite. Thank you Sarah. Thanks Sarah. So Sarah was holding that for me 'cause my other arm is now removed 'cause that's where the drain site is. So nice big bites here. All right, so important thing here is that this lies - pull a little bit out Sarah. So it'll get pulled down. We'll trim it in the pelvis. I'll take the vessel sealer. Want this to lie a little bit like that. And you want your sigmoid colon to be on this side of it. You ready? Yep, make sure this - this is all just kind of oozing from here. Hold on, everything else looks nice and dry. Hey, just wanna make sure the colostomy sits nice and you're gonna be able to Brooke it. So we have to check our orientations. So she's just gonna grab it like this, okay, make sure it stays on that side of the, and that's our robotic portion. All right. What we like to do for the stoma is just take this and we'll bevel the edge here so that we have a ridge of dermis. Sometimes if it's tough, we'll take a knife just to cut through the skin. Knife's back, we're gonna just bevel it straight across and it gives you a rim of dermis there. We'll take the Kocher back and we will take out some of the fat here. Straight down, core out the fat a little bit. It makes it a little easier. Not too much, 'cause then you'll lose that support around the stoma. Just straight down. Another DeBakeys Straight down like this right here. Don't undermine. Yep, come straight down. Even if you cone in a little bit. Do you have S-retractors instead or no, great. We'll pass that off, all right. So we're just gonna make a nice vertical incision. You don't wanna make it too big, nope. With your, hold this like that with your left hand. Just don't spread too, just give yourself the guidance. We don't wanna make the skin edge wider. So just make it like that. Come this way. A little bit more. Now we're gonna - the skin have a Kelly, large Kelly. So we make a small cruciate incision right through our rectus muscle here, he is gonna put this S-retractor in. Take a tonsil, take another tonsil. It's gonna reveal our posterior fascia. He's gonna grab opposite. And we're gonna make a similar cruciate incision in this fascia as well. Now we've got pneumoperitoneum, so we have to worry less about injuring small bowel underneath. Yep, go down the other way. You wanna make this nice and wide. The anterior rectus fascia is where you really wanna not make too wide because that's gonna give you a hernia. Right, so go ahead. Small cruciate with of the cautery. Just release it. Yep, right there, that's it, same here. Yep, that's good. All right, so... We're just creating our colostomy here. We've made a cruciate incision in the anterior rectus fascia. Little muscle bleeding here. So we wanna make sure we have that under control before we bring out our stoma. Okay, so another Babcock. So here we're just gonna deliver our colostomy here. See the staple line? So just bring that out, hold on. So we wanna maintain our orientation and just slide it out. Goal is not to rip your mesentery as you pull it out, right? Can we have the air off please. You want me to take my instrument back, or...? Yeah, one second. Use this as like a horseshoe so it doesn't get caught. So you don't wanna make, everybody says well just make it bigger, but you don't wanna make it too big 'cause you don't want to get a hernia. See here we get this out and right there you can tear your mesentary. Let's slide this thing along the anterior border and then come this way around. It brings that up. You get caught, it comes up nice. So we Brooke our colostomy. So we want to have it above the skin. Good level. And then once we do that we're going, can we put the air back on? Two things we're gonna check, make sure that the drain doesn't come on the wrong side of the colostomy. And then make sure our mesentery is, what's that? We want, yeah. Make sure nothing's bleeding. So there's a drain. I'll have a grasper. You see here mesentary is not twisted. Looks nice and straight. Nothing's bleeding, looks good. Gas off, let all the gas out. When we go prone, do you wanna split in a top? It depends on what she likes, I usually don't. I just need access to the proximal thighs also. The S-retractors again. I'll take a 0 Vicryl. So normally we do this with a suture passer, but we forgot. So just put a figure of eight and see it. He's so thin. Yep, figure of eight. Pull through, yep, it's okay. Go straight across. All right, after this we'll do the skin. So we're closing the incisions first before we mature our colostomy 'cause of contamination. You were quite expeditious on the robot today. He's nice and thin. Yeah. I think we even went through the levator. Already, that's great. I love it when you get lower with the robot. I just think like the dissection is really clean, Nice and clean and it helps us pop in a little bit. Yeah. He had a really subtle pelvic floor so you kind of didn't like - very quickly we started to cone in a little bit I think. And so that's why we went through the levator. Do you have to take margin by the prostate again, or...? I think the prostate we have a bit to do 'cause it was really kind of stuck and edematous and that's where it was abutting, so I kind of left that. We are pretty low though. Okay, are we gonna take some frozens? Maybe. Okay. We'll see. Here's a needle. Take the Dermabond. We'll take a drain sponge and Tegaderm. Take a sponge please or a lap. All right, so - all right. The goal is not to keep pulling the colon out. We want to be able to Brooke it nicely. We'll take Adsons. First thing we're gonna do is just trim part here. You're gonna take this, I'll take a tonsil. So just re-trimming off the epi-planer. Perfect timing. Hold on. Probing me, yep. We're just thinning this out a little bit so that it Brookes nice. Thanks. Just getting an idea of how this is gonna go. Here's our staple line here. So I'd like to shift this down like that so that this actually the posteriors, the hardest part to Brooke is the back side of the mesenteric side. So just trying to see what we're gonna do. Yep, take off your staple line. So relax. Come across now, follow this ridge. See this ridge right here? Yep. All right, so 3-0 Vicryl. So always grab the serosa so it doesn't bleed. Big bite, yep, good bite. We're gonna make a - Brooke it. So we're gonna take a seromuscular bite right there. Right at the skin level, right here. Go right to your dermis. Yep. Snap. I'll take another one, please. Let's just drive this up first. Yep, all right, so forehand would be this way for you right? Right here. Just the serosa, yep, good. Three o'clock or the six o'clock for him? Yep. So pull through and we're gonna grab the side of that colon. We're gonna try to line this up. So right here. Nice bite. Bring it down a little bit past the six o'clock. Yep, yep. Back. Stitch to me, same thing. Gonna just take a look here. Nice bite, pull that up. Looking for this wall here. Only be at the same level as the other ones. We can trim that, good bite here and relax. And I'm gonna kind of shift it down and get that dermis Snap please. Needle back, I should dunk that in. Another stitch to me. Good bite here. Sometimes these are just placed in the simple. Hold that up and sometimes we can get the wall over here off to the side and bring that down like that. Snap, you don't wanna make a small stoma, you wanna make it nice and big. Have them easily pouch these stomas. So making it flush to the abdominal wall makes it sometimes challenging. Especially if their body habitus changes over time if they lose or gain weight. So making a nice Brooked stoma really helps kind of mitigate any natural changes in their body habits that may occur. So there's no way to Brooke it here. So we're just gonna kick a nice simple bite. Get all that dermis, get a good purchase. Needle back, snap. So he is gonna put some in between these two. They are gonna be Brooked, nice bite. Yep, if you can Brooke it, I Brooke it. Another snap. Another suture, please. Bring it up. Good. Suture please. All right, needle back. Can I have that suture, please? Gonna be gonna tie it and bring it down like this. Bring it down along the skin, yep. We should be probably okay. We can use it multiple times. Let me help you here. I'm gonna tuck this in. One second. Tuck that in, yep. Some of that mesorectal fat in. Yep, come this way. Yep, tie it up. And we just work our way around. You can see we leave the mesocolon on the left for last as we just tuck it around. 'cause as you tie it'll stay nicer. Get that all the way down. That's a little bit of an air knot there. Yep, that's good. So you don't really want that down. You wanna make sure that the mucocutaneous junction's approximated. Can you think the note is that you get a little lumpier when the mesorectum gets kind of tucked in in there and then everybody says you have a hernia. You don't have a hernia. You're basically helping your colostomy stay well perfused. Fill this little hole here. Really try to avoid the skin. We cinch it this way so they get a nice Brooke around. You can see the less Brooked part is the mesocolon part, but you still get a nice Brooke. Really important when it's right next to your belly button. So just put two simples, all yours there. So usually just one here. If it's been two hours, which I think it has, can we just give the family a call? Someone just stepped out to do so. Oh, okay, great, thanks. All right, let's see. Let's cut these, right here, go right there. Just move your, take your needle and take the bite rather than grab, just take a nice bite. Yep. Just go straight across. Good. Yep. Nice, beefy stoma. Just take the bite first. So let go of that. Take the bite, lift it up, lift. Yep. So make sure we got - now lift up your serosa. Yep, now come straight in and just get the dermis. That's fine. Yep, think that's just the way the bite is. Is this the needle driver? Looks like a snap. Let's take a look here. It's pretty good. It's good, let's go for it. Okay, we're getting ready to flip. This looks good.

CHAPTER 5

So we're gonna make our marks for our gracilis flap. It inserts up here on the pubis with a big raphe, and then inserts down here on the tibia. You can feel along the medial compartment of the thigh and feel the tendinous insertion of the adductor. And if you make a mark from there to this, to the medial tibia to the tibial plateau, you can draw a plum line there. I tend to actually feel that adductor tendon. You go a few fingerbreadths below and that's about where your incision should be. This is a really thin patient so you can actually feel his gracilis. I can get it between my fingers here. Traditionally the mark is made at two fingerbreadths below the adductor tendon. I like to drop mine just a little bit more posterior so I come right down on the muscle. So when I can feel the muscle like this, I like to go right on the center of it. We're ultimately gonna make a second incision distally to access the tendon so that we can disinsert it. But I tend to make that a little later. In terms of the pedicle, it's a perforator off of the profunda and it is commonly about nine centimeters from the insertion of the muscle, which is here, but it can be anywhere from six to 12 centimeters. So I always like to mark that in my mind so I know where to be super careful in my dissection and know where that perforator is coming in. That's gonna be the dominant blood supply of our flap. This flap is super versatile. It can be used as a free flap as well and it can be motorized. The nerve is off the obturator nerve and it comes just a few centimeters proximal to the dominant pedicle. And we'll probably see it, but I don't always go searching for it since I'm not going to be cutting it today. The skin over here can be super floppy. So it's really important you hold yourself kind of steady as you're coming down on each side of the incision 'cause you can really easily get into a plane you don't wanna be or get way below the muscle. The muscle sits just under the deep fascia of the medial thigh. And if you notice as I'm Bovie-ing, it's twitching right below me and I bet we're coming right down, hopefully over onto the gracilis. That's my preferred approach is to come right down on the muscle if possible. So here we are right on top of the gracilis or what we presume is the gracilis muscle. It's in the correct position. We will confirm multiple times that yes, this is in fact the gracilis and I'm just opening up over the anterior surface or the medial surface. The pedicle itself runs on the deep plane so I know everything I'm doing right now is totally safe, which is important. Can you put a retractor in this please? I am gonna have you actually come and hold like that. So again, I'm distal to where I think the pedicle is gonna be. So I'm very safe here working my way, just trying to get circumferentially around the muscle. There's just very thin attachments here. Right here you can see one of the minor pedicles, which we will just take care to buzz. Some people will tie those, some people will clip those. Again, this looks more like a minor pedicle coming in here. But what I like to do is actually head down distally and free everything up and then I find my way around the pedicle. The other alternative is he comes up and find the pedicle right away, but I like to be able to see everything. So I find once I get around the muscle, release it from its distal attachments, then I can more safely identify the pedicle under direct visualization. Right below here you have the adductor magnus. So we're just gonna free up everything here. Totally safe, this is just fascial attachments. So right now I'm just using my fingers to kind of feel along the border of the muscle. I'm gonna use this to find the attachment distally. Just gonna move this a little - totally in my way. Thank you. Once I've come circumferentially around the muscle, I'm gonna throw a Penrose around it just to help. So I'm using my fingers, I can feel the muscle right under them. All right, can I have the marker please? So I'm marking my secondary incision I'm gonna make, I like to do this in two incisions because it just is easier to reorient after the fact and not have one very long incision. Some people orient this incision transversely. I just find this is easier access for myself. The key is to remember when the leg is in this position, the muscle slips down pretty posterior. If you mark them in the pre-op area, it's gonna be a completely incorrect mark from when the time you get to the operating room, which is why I always wait and mark these patients on the operating room table once they're already positioned where we want them. Because this medial thigh tends to be pretty floppy in people. It's just getting through the subcutaneous layer. Let me just see what's bleeding here. Can I get a pickup please? Can I get a - no, can I get a snap please? Or a... I'll take another one. So this is probably the saphenous vein, which if you identify it and can save it, great. You don't obviously have to save the saphenous vein. Obviously it's used in cardiac surgery all the time and we sacrifice it all the time. The key is if you do injure it like I just did, to address it. Do we have any ties Bianca? I'm gonna need like a Vicryl tie please. Like a 2-0. I'm gonna come behind your hands, thank you. I'll tell you when you can release. Okay, go ahead, thank you so much. See we don't need anybody else today. We have each other. Problems of being a lefty. Or they're just bad scissors. Well they didn't cover handed either. So I'll need some 3-0 Vicryl ties. Perfect, you can come off. Thank you. Thanks dude. Lisa's gonna need another 3-0. Thank you, thank you. Jenny, is there a Bovie holster in there? So I'm just trying to get into the right plane down along the muscle and then find the tenderness insertion of the muscle and then we're gonna confirm that we are in fact identifying the correct muscle and we're not grabbing something we don't want. So I'm just feeling along with my fingers in this tunnel right along the muscle, making sure I am getting all the way around so that we'll be able to easily pass it into the proximal portion of the incision and ultimately rotate it into position. Oh that's amazing, you're so good. Just gonna open up now this deep fascia as I get right down onto the muscle. Yeah, go ahead and put that there, thanks Bianca. So, I have identified what I presume is the distal portion of the gracilis muscle. It comes down and forms a tendon, which you can see here, but you always wanna triple check anything before you make any irreversible mistakes. So what I do is I found my gracilis in the proximal portion of the incision, the gracilis in the distal portion of the incision. And as I pull, you can see it's moving the same muscle. So we know for sure that this down here on my distal side is the exact same muscle as what's on the proximal side. It feels pretty free all the way around. So now we're gonna make our move to start disinserting the muscle. So we're gonna put our retractor in distally. The goal is to get as much length on this as possible. And also the tendonous portion is really helpful because it takes a stitch really nicely. Whereas oftentimes muscle itself does not hold suture as well. We can see this beautiful, beautiful tendon here. Pretty cool, huh? Down on there - can you get that just a scooch deeper do you think? Like right in this. That's perfect what you're doing. Yes, thank you. So we're gonna disinsert the muscle there and here it comes easily into the proximal portion of the incision. Obviously I have a small section that I didn't cut. Penrose comes off and come out with that. No bleeding down here. Everything looks safe, everything looks happy. So now what we're gonna do is we're gonna turn our attention to the proximal portion and we're gonna start looking for the pedicle up here. Can you put that retractor in? Thank you Bianca. So obviously for us, the more proximal the pedicle, the better because that is our arc of rotation and I'm just trying to kind of peek in here and look for something. I don't see anything convincing yet, but it's gonna be running on the deep aspect of this muscle, which is why I like to disinsert it so I can look directly at it as I'm coming up. So I'm noticing when I peek up here a fat stripe, oftentimes a fat stripe is a telltale sign that there's a pedicle nearby. So we're gonna go and find out. Where are you little guy? I think it's right here. See right there, sure looks like a pedicle. I'd like to see it coming more directly in. Let's keep searching. Here we go. So as we come up this way, see right here. So I'm just slowly working my way up. And I can see... Right here, what appears to be the pedicle coming in. So here we have the magnus. Here's the adductor right here that Bianca is retracting for us. Thank you. So if I feel, I can feel a nice strong pulse coming right from that pedicle, which is always really reassuring. So then what we wanna do is kind of free up around this so that our muscle will take its turn as we would like and I can get as much length as possible so I can rotate it ultimately over here into the perineum. This is obviously where we're kind of gonna be stuck. I try not to completely isolate everything because you can put too much pull on that pedicle. Whereas if I leave a little bit of attachments around the pedicle, I think it's ultimately safer. And you can see here the pedicle's coming in right into that fat stripe that we saw in the muscle, which is what alerted me that we were coming to the pedicle. The other key thing is to look, you can see where I marked where I thought it would be and it's directly within our lines, which is pretty cool. Anatomy's awesome. Can you hold this again please? Can you see it Bianca? Right here. Look at the pulse. Look right there, isn't that cool? Very. Hey there girl. And you can see our muscle is pink. It's happy, it's super well perfused. So we know our pedicle's up there. Everything down here is totally safe to take. And again, it's just gonna allow us to rotate the muscle better into position. And I'm just gonna kind of start gently creating a tunnel for this to go into going towards the perineum, 'cause ultimately it's gonna slide into place back here. So I'm creating a subcutaneous tunnel. I can do that often very bluntly with my fingers in through the subcutaneous fat. And then I utilize my Bovie to help the cause. And then ultimately we'll complete the tunnel from the defect itself. Once Dr. Francone has the specimen out. It looks great. Pretty good arc of rotation there. Pretty happy with that. I don't really think we need to do a ton more 'cause I can't, I'm really tethered by this. And again, I don't wanna free it up and completely detach all of that because I want to not pull too much on the pedicle. The other thing is I'm not gonna go digging for the nerve. I like to leave these innervated so that the muscle maintains as much bulk as possible. So what we're gonna do now is we're gonna check for hemostasis. We're gonna put a drain in this thigh and start closing. And then we're gonna turn our attention to the contralateral thigh. In general, I like to use two muscles for these because the gracilis is a pretty puny muscle. And that's the case on almost everybody, even major athletes, which is also why it's not missed by many people when you take it. But I think you need enough bulk to really recreate that pelvic floor and having two of them really allows for that. I'm glad I saw that saphenous when we did and clamped it and tied it. Let's do a 15 Schnidt and drain. Let's ee if I can show this to you. It's like a dark hole. Can you see my tips, perfect. You're a star. Thanks dude. All righty, got it. I'll take a drain stitch when you have a second and I'll take a heavy scissor to cut the drain a little bit. Thank you so much. It's a 15, there's gonna be one on each thigh. Dr. Tomczyk, are you almost done with one side already? Well I have the muscle out but I have to close. It looks awesome. He's got a nice muscle but he definitely will need two. It's as expected. I'm gonna go wide. You're gonna go wide? Oh yeah. Oh great, just don't go wide on the skin. Go big or go home. Well he's getting two for sure. He needs them. Can I get the PDS? Do you have a 3-0? Just gonna tuck my muscle up into the proximal thigh. We're gonna leave the proximal part of the incision open. Thanks. So that I can use it to create my tunnel. So I like to close a deeper layer here, kind of that deep fascial layer with a PDS. And then I'm gonna use 3-0 Monocryl to close the skin. So it's a three-layer closure. I'm working in small spaces here between these legs. My gosh, I can barely move my arms. Can I get an Adson? Actually I can keep this down here, but can I get an Adson and a Monocryl please? Do you want me to cut this? I like to - I leave it pretty long 'cause I want it long enough that he can bring it up and tuck it in a pocket of his pants. It could probably be cut a little, but I just, you know, I want it long enough that it reaches up to here so I can be tucked into a pant pocket. Can you just pull the drain back a little bit, thanks. So we'll do the classic moist lap and Ioban proximally. I think we've done those before together, just so that we can, 'cause he's gonna get flipped. Yes. And then I'll take it down. Now are you gonna want to dress this? Yeah, we could. Right now, and then have this with the moist lap with the... Yeah, we can glue distally and stuff. Okay. Is that okay? Of course. And we will put the bulb on the drain. It probably won't hold, hold, but it's okay just to keep it a closed system. Do you think an IV Tegaderm... Typically the medium works better. We can get two of them 'cause we need it for the other side too. I am gonna need another one of these please. Thanks friend. Are you okay if I Dermabond it? Oh yeah. He's actually pretty lax. We could even put a staple and just Ioban and no sponge. Like I can bury this, see? Okay. I can do that. Yeah, we can do that. Okay. He's very lax and has the room for the muscle up there so we're okay. Okay. Oftentimes I can't fit it. Thank you. I'll steal that stapler from you when I give you this. I just left that part open, just the proximal part 'cause then I can reach in to finish the tunnel from that side. The rest is all closed. So then I'm gonna do it on this side too. So we're gonna do both sides. The left side has been harvested already so we're gonna find the same anatomy. Here's the tendinous insertion of the adductor. You can feel along that, down along the medial aspect of the thigh. Tibia. So if you drew a plumb line there and did two fingerbreadths below that, that's a common place to put the incision. Again, he's thin, I can feel, I can actually grab his gracilis between my fingers. I like to try to come down a little bit more right on top of the gracilis. I just find that for me it's easier. So I'm gonna make my incision right along there, which is a little more posterior than what is traditionally described. It's probably three or so fingerbreadths. So I'm just confirming again, I can feel really nicely we're right in the right place. So something like this. I like to bring it proximal enough that my tunnel is not super super long. It just makes it easier. And then we will plan that secondary incision in a bit. So again, we're gonna find - I like to mark where I think the pedicle is gonna be. So it's anywhere from six to 12 centimeters, most commonly around nine. So it just gives me landmarks in terms of where I need to be exceptionally alert and exceptionally careful. Thank you. Again, the incision is really floppy so I'm using my fingers to keep myself centered on it so I can get my finger in this plane and very safely open this right up. So here we see what looks like our gracilis muscle in exactly the position we would expect it to be in. You can see right here what appears to be likely a minor pedicle. Actually impressively large. So normally I start distally and I disinsert the muscle, flip it up. I just, because that pedicle is quite large down here, it is very distal. I would find that to be exceptionally unusual if that was the dominant pedicle, especially 'cause typically the pedicles are similar from side to side. But I just wanna make sure that we're totally safe before I take it. So we are gonna look a little bit up here. We're just going to gonna do a little poke and see. Alright, can you hold this? You can probably take, yeah, thanks. That was a big dominant minor pedicle, not dominant, but a large minor pedicle. That's why it's good to find those and tie them off. Making my way down, trying to feel where that teninous insertion is. Can I get that Penrose again please? So again, I like to put a Penrose around it. It just helps when you're confirming this is the muscle. It's very easy to get your finger around but sometimes it kinda help you elevate it. Make sure you're getting all the flim flam around it off. Obviously we're working in a pretty tight space down here, which is why we have all our instruments kind of clipped on. But I think the key is having my own scrub who can help me. So I'm just slowly working my way down through the subcutaneous fat, getting into the deeper plane of the medial leg. And we're gonna come down onto the deep fascia and go through that. And help us identify the distal portion of the gracilis. All right. Muscle looks super happy, nice and pink. Love that, again, we decide how much we really wanna take here. I like leaving some of this extra attachment. The muscle's gonna rotate down. This is our pivot point anyways. We can release a tiny bit more but I'm not gonna do anything too crazy because the risk is if you release it and it's barely hanging on by the pedicle and you pull it in and I'm not looking at the pedicle, you can avulse that pedicle. So this is actually kind of to me, a safety net. These little extra attachments are supporting that pedicle. So again, I'm just trying to feel along here. It's a subcutaneous tunnel right along here, I'm trying to create. I'm just gonna see if I can release it tiny bit more. All right, sorry Bianca. Perfect. You can follow this pedicle all the way back to the profunda, which we're not going to do. So here's our pedicle coming in. And if we look right here, you peek right up in here. This is your nerve, here it is right here. See it? See the little vein that runs with it. But the nerve is right there off the obturator. So it's about one to two centimeters proximal to the pedicle. Again, anatomy's spot on. It's exactly where it should be. So I'm pretty happy with that. We basically got this dissected as much as we can. We've started our tunnel here a little bit and now we're gonna do a little hemostasis and we're gonna put our drain in and close and then wait for the specimen to come out. They're gonna flip the patient and then we will rotate our muscles into place. Heavy scissor please. And a drain stitch please. Can you do what you did last time and do it like there. It was really helpful. I will take a PDS at your leisure. Oh yes, again, just gonna close the deeper layer. Get the fascia back together. Do you have another PDS by chance? I literally need one more stitch. Sorry, thank you. For this? I would like, can I actually get like 2-0 Vicryl and 3-0 PDS? Yeah, 2-0 Vic, like an SH and probably like three or four 3-0 PDSs. Yeah, what you gave me down here was perfect. Can I get another Monocryl, please? I hope people notice how awesome this is that we work at the same time. It's cool. Look what you guys are doing, what we're doing down here. It's just like, that's how you do it. We're changing the world. Nah, I think we should just wait. We'll Dermabond it all at once on this. But we can do the drain dressing I think. And then we'll put our Ioban here on both sides as soon as I'm done with this. You were quite expeditious on the robot today. He's nice and thin. Yeah. I think we even went through the levator. Already, that's great. I love it when you get lower with the robot. I just think like the dissection is really clean. Nice and clean and it helps us pop in a little bit. Yeah. Do you have to take margin by the prostate again on him? I think the prostate, we have a bit to do 'cause it was really kind of stuck and edematous, and that's where it was abutting so... Okay. I kind of left that, we were pretty low though. Okay. Are we gonna take some frozens do you think?

CHAPTER 6

Okay. Okay, go ahead, close it. Purse string. Just purse string out the anus closed. Yep, right around. Just stay close to the anal verge. It's not gonna close right? So backtrack a little bit, come down. Can I get a gauze sponge? Watching your finger with the needle. Needle driver's in there. You have a scissors? All right so the first thing we're gonna do is do our landmarks. So the issue, he has a very narrow pelvis as we saw robotically. So here's his ischial tuberosities right here. Here. Coccyx bone here. And then his perineum, midway. It's gonna be like right here. It's gonna be something like this. Some people make an elliptical incision. I usually just do a circular incision. A sort of oval? Yep, well a circle. So the goals for when we're doing this are to make sure we don't cone down so you head straight back, right? So we don't want to aim down your column, rectum's like a column. You don't want to go down and just kind of track along the sub-q, you wanna go down. Correct, I'm gonna guide you. So just start here with the cut. Follow around. Honestly his skin looks pretty good despite all the radiation he's had. Yeah. Stop the bleeding. You can come down like this. We're going wide here 'cause his tumor's all in his anal canal. So we're just getting to the fat. Go straight down, straight. Not like out like that, straight. The goal is to get into the ischiorectal fat. So you see that external circulator? You gotta be on the outside of that. Release it. Remember not aiming down here. So here or else you'll end up in the prostate. Okay, can we have the lone star? set up a self-retaining retractor here. I'll have you do the posterior. I'll do the anterior dissection just 'cause that seems to be the - we'll just put it opposite of me. Take an Allis clamp. We'll gonna use the Allis clamp to kind of give ourselves some idea. Here you go. Oh, it's right here. We must see, we wanna get in the ischiorectal fascia. See the fat, fat will change this color to a different color, yep. It'll be like more like shiny and globular, yep. Right here. Yep. See the fat is changing. He's so thin. You could always just feel his ischial tuberosity here. Stay out here. Stay out here. Hold on, it's gonna be back like this, right? So we're gonna aim for his coccyx, his coccyx right there. So you have to come through your anococcygeal ligament first, right? So you'll see muscle strands like right there. Like this. Like this. You're aiming for the rectal wall. There you go. You don't want to aim for the rectal wall, you don't want to cone in, right? Same thing here. You're gonna hold this up for me. If I'm imagining this, I'm imagining a cone and I'm gonna go straight down here, stay outside this muscle here and see here's gonna be the transition to ishiorectal fat. And you'll have inferior rectal vessels that will perforate - grab here. You're not touching me with the metal. I don't think you got it. Do you see how this is pulling up here? You wanna release this fat and be in the Ischiorectal fascia fat and go straight down. And don't do the anterior dissection. Usually we'll leave the anterior dissection last. You can see here's this tuberosity. Oh so narrow. And then you come to just inside the tuberoity. Yeah, the anterior part is more of a judgment. There's no good plane anteriorly. Another Allis. So you have to take your time. And what you don't wanna do is - you wanna stay dorsal to the transverse perinei muscles, right? So if this is the anal verge, we have - you can see there's your... So you want those muscle fibers to kind of drop down? Always feeling for the Foley catheter, again, so narrow. Here's his tuberosity right there. To the anterior, lateral. Go straight down right here, wider. These blood vessels are gonna be pesky, huh? They retract very quickly. Touch that, towards this direction, got it. All right. So here you have coccyx bone here, feel for the tip and you aim right to the inside of the tip. Go ahead. It's straight back. Hold on. Straight back. See I'm not even down like this. I wanna stay wide. Usually you're starting to divide the levator muscles, the rectum. He's got a very inverted coccyx bone. So what we do is we take the Allis clamp here, and we pull that towards us and that'll help us divide this muscle here. We should start to see our... You see we vented into the peritoneal cavity there. See that, there's our sponge. Good, so let me take that, you hold this out for me. Another Allis clamp. Just gently retract this over like that. And then we work our way around. You wanna just get the fat down for that levator. Get our dissection evenly across. Here's his tuberosity. Feel it. Get your retraction. Hold that fat out for me. Same thing here. Feel his tuberosity, yep. All right, so that's muscle, right? So at some point we can get our index finger around so we didn't cone down too much. So there's slightly getting our finger in there. You're gonna hold that like that for me. And we're gonna divide that levator. And again we do a little bit of this along that pelvic floor, right? So... Right there? Yep, go ahead. Do you mind if I switch your Bovie? Sure. Hold that for me there. Bovie right here. Move your Bovie a little bit, back it up right there. So, around this way. So you wanna go wide. We wanna be wide on the levator and do not want to cone in on the levator, right? So you can see it right there. Take your time. It's muscle right? Yep. So the finger is behind the levator, It's super levator. It's pulling the levator down to him and he's dividing it under direct vision here until we get to the anterior portion. And then the harder part of the dissection is gonna be the anterior portion 'cause you have to divide the rectourethral muscles, part of that U-sling that supports the rectum and the prostate. So at some point we will try to one, we wanna make sure this is all hemostatic. Here's the lap pad that was left in there, I'll take another. Yep lap out. Lap is out and we're gonna see if we can get this out and just kind of move it out to give us some room. We take it out so that we can see it, still feel like we've got some work to do right here and stay out. The reason to stay to do that is to get as good a TME as possible Well the TME part is done, right? That is the hard part. Dividing the muscle. Use suction. Hold that. Bovie it. Right here. Bovie me first. Up here. That's good. You gotta be careful not to come along the side of the prostate. So we'll show you that anatomy. So here, doesn't give you much room. So here we're just trying to flip that specimen out which will then give us exposure to our anterior wall of the rectum and posterior wall of the prostate. So there's our drain. Scissors. So we're gonna cut that drain. Alright, so here's the more challenging part here. So this is the anterior wall, the upper rectum here you can see the retraction injury that we had. This is the peritoneal reflection and here's the dissection that we did before and now we have to take down these rectourethral muscles. So I'm gonna ask - remember to hold the retractor, can I have a Deaver? The Deaver please, again. And the goal is that these fibers - let me take this. Will, are hard. There's no plane anteriorly. So again, like we don't want to go on the side of the prostate that'll lead us down the path. Your goal is not to to divide your - you don't want to get into the bulbous urethra. So we're trying to find the anterior wall of the rectum, and just take our time here. And see your posterior wall of the prostate. Right there. Yep, can I have a clean lap? Yep. There's really no potential space, huh? There's no plane. And he's very narrow, right? So you gotta just - see how you're going along the side. You're dissecting along the side of prostate. Don't do that 'cause you can get into bleeding. So we're just drying this area up. And this is the margin that we're worried about. So, I'm gonna work on this side first. And you don't wanna get seduced so you don't wanna get into that membranous urethra. So I'm just kind of watching the edge between the prostate, little finger dissection there. It does seem to be a little like areola plane there but not very pronounced. It just needs to be up here, see that? So right there. This is the side of the prostate. We definitely don't wanna be down there. Just carefully taking the time with this. You see, here. All right so we're gonna come like this, and then... Following this natural curve around the vascular. Back. We're aiming to be dorsal to the transverse perinei muscles. Some muscle back there. Good, take those muscles right there. Right here. Yeah, aim that way. Just retract that outta the way for me. These muscles here, muscle fibers here get taken down. Well muscle fibers and sometimes it's just hard to distinguish between muscle fibers and the prostate itself and the wall the rectum. So you just have to take your time. Yep, you can get really off track and you've closed your anus so it's not like you can put your finger in there and feel where you are, right? So you just have to hit it from both sides. Yep. Try not to do too much blunt for that dissection. So we're just taking down the muscle fibers that are between the rectum and the prostate. And again, like no good plane anteriorly, it's one of the hardest part of dissections. You don't want to go looped into going too deep 'cause you'll hit the bulbar urethra. And the membranous urethra you can get into an injury. We're going a little more towards the prostate anteriorly because of that margin. That's muscle fiber, you can see the difference right there, right? So I'm constantly feeling. How does it feel? It feels good. I mean it's stuck anteriorly. Where you thought it would be. Yeah. It's always the area where it can dip down and you can get the urethra right. So we just have to take our time during that. Of course. I'm just looking for the muscle, right? I'm looking for the muscle. We're just trying to see where the... How many of these does it take to sort of get comfortable with the plane? I dunno, I'm still wondering. I'm just feeling for the Foley catheter. Make sure I don't feel it. All right. So here's our specimen here you can see. The TME dissection was nice, and mesorectum intact. See here's his levator muscle which is still stuck to his specimen. And then here's the fat, he was very narrow, so that fat belongs like there. But the levator's actually still stuck to the distal portion of the rectum, which is what we wanted. And then anteriorly we hugged the prostate a little bit. So we're gonna do a frozen section of just this area right here and then we should be done. So can I have a Metz? Yeah. Frozen? Yep frozen, anterior margin. We'll show the anatomy. Just gonna give you another one. Any further anterior margin? Nope, just anterior, same thing. It all goes together? Yep, yep. No, you can pass it off. I'm gonna ink it so don't send it down yet, but you can pass it off. Here's his, yep. This is his transverse perinei muscles. See that? And once you get past that I'll show the camera but... Feels nice and soft. Feel that, yeah. Yeah it doesn't look bad. Okay, so here's our coccyx bone. You can see we went wide here. Levator hugs the ischial tuberosity here and here and so we thought we had a good dissection. Here's the posterior wall of the prostate. You can see it right here and how it starts to dip down. This is the area where you can get into your membranous urethra. And then so the muscles to the rectum from the prostate are all along this area and there are longitudinals. So part of that U-sling that you hear about all here, and that's actually, this area here is one of the most challenging parts 'cause there's no clear plane in addition to the fact that the patient had chemoradiotherapy. So you just have to take your time. You can see that we wanted to get past and say dorsal to the transverse perinei muscles which are right here. But again, if you start to drift anteriorly, it's all about the angle of the hand. You wanna be coming around the rectum in a cylindrical fashion and not aim out this way, 'cause even slightly aiming out this way you can dive down and get that urethra and then all of a sudden you're looking at the Foley catheter. So... All right. So we're nice and hemostatic. We're gonna have Dr. Tomczyk come in while we wait for our frozen just to... Do you mind if I start tunneling while we're waiting for the frozen? Yep. And then I won't inset until we're... Dry. The drain... Do you have a Russian? Oh yeah, here it is. The drain should sit right there, normally, sometimes if they have enough omentum, we'll put it down into the pelvis and fill the pelvis. But he didn't have a whole lot of momentum so we won't do that. The ischiorectal fat here.

CHAPTER 7

All right, so what we're gonna do is we're gonna try to make these tunnels. I've started it and we're gonna, if you put your hand in here, didn't we do this together once before? I think we have. Okay, I thought we did. So that's kind of where we need to go. Yeah. So what you can do is, I've started it here. I know you're not a lefty but if you can put that hand in and then just take your Bovie and start going right on your fingers. Here's your Bovie my friend. Can I have a shorter Bovie tip please. So we're just gonna make this the tunnel to get our muscles passed into the defect. The goal is really to close this deeper space with the muscle 'cause it's healthy non-radiated tissue. And then we'll close the soft tissue on top. So we're just connecting the dots. And then ultimately you want that tunnel to be at least about three fingerbreadths in width because you don't want the muscle kinked. And you can do a lot bluntly as well. And use the Bovie to start and then really use both hands. Put them both in. Yeah, I'm on my finger now. Perfect, it's nice when I've started it. I'm just so quick. You're that good. That good, yeah, I did rotate through plastic. See, that's awesome. Nice. There is a sort of like a fascia, you know the fascia's a little tight there so I think that will have to do with... Yeah, it's tight in it so I can... I'm gonna see if I can stretch it a little but it's pretty tight on him. I can get two fingers nicely. There we go. And you like you said three fingers for you. Yeah I did three fingers. It depends on the flap, how many fingerbreadths. If I was doing a lap flap, I normally do four fingerbreadths 'cause it's a much bigger flap. But because I don't have a skin paddle on this, you know this muscle is small, right? So then the key is when you bring it through, you wanna make sure it's not kinked. So why don't you get an Allis clamp and you're gonna come from here down. I'll let you... All right, so this is the tip. I just wanna look at the orientation of my muscle. So we're gonna rotate it so that it slips in like this. So we're gonna keep it. This is a very natural rotation. Go ahead, sorry. Sometimes if we can't get it through easily with this, you're grabbing the tendinous portion, great. You can always put a stitch on the end of it and that comes in nice and easy but you lose a lot of the muscle, right? The majority of it sits up in here. That's why you need two of them. But it still sits down in and we'll pull it a little bit more and it will suture up into this but you lose a lot of it. Yeah. It's disappointing always. All right so now let's do our tunnel on the other side. If the tunnel is too big, the muscle can slip right back out if the stitches rip. So that's why it's like this fine line between making it big enough that it's not kinked, it's not pressure on the pedicle. Two of my finger... You think that's three of mine. I think, well maybe not quite. I don't think so. I just don't know how to fit half of my finger. No, that's okay. Even if it's three of yours, you're okay. So I still feel the same fascial tightness right over here. So what I'm doing is I'm just gently kind of just stretching it so it accommodates and now I got three fingers in. Nice. So that feels great. So why don't you grab your Allis. And then again we are gonna check our muscle orientation. So this is how it goes. So we're gonna spin it this way so it's a very natural turn. Go ahead, perfect. So these will inset nicely. I typically kind of cross them a little or do something and you'll see how they're gonna fill in that gap. So now they're pulled into place. The key to look at is see how pink the muscle is. Obviously it doesn't look like it's being necrosed at all. That's huge, they're nice and happy. You can see how easily they wanna slip back through here. But you can pull quite a bit. What I think we'll do is we're waiting on that margin. Why don't we close these proximal incisions. So I'm gonna do this for you so you can see, just so it's more comfortable for him to sew for now. That's great. Can we get an Adson please? Can you just do like one or two deepish? There's you know, the deep fascias right here see the edge. So you're gonna put like one or two deep sutures and then you're gonna do a deep dermal with 3-0 Monocryl and then you'll just do that short little runner. That's why I try to close as much as possible before you get, 'cause this is hard to sew in the prone position. Sometimes we don't flip them. But for the men, especially when it's an anterior tumor where you're close on the anterior margin, it's easier to do the resection in prone. And that's Dr. Francone's preference, which I had never done this this way before. So even like creating my tunnels, everything's a little backwards so I just have to flip it in my mind. But it makes this part harder, like super awkward to sew this. And then you'll do one on your side too if you can see it. This has a scissor on it. You know my fancy plastics drivers, I know. Its more efficient. They always get us inadvertently in trouble. We're just closing the proximal incisions just 'cause we're waiting on a frozen right now. I don't wanna inset the muscle then him have to take more. But I like making forward progress. I hate standing around waiting. We've already made our tunnel. I think it's just a little caught in the fat. It's okay. You can fix it with your deep dermal. I'm not worried about it, it'll look good at the end. Bianca, can we get the 3-0 Monocryl, please. This is just straight. So do deep dermal, do like two or three of them and then you'll do a runner 'cause my runner ends right there. Gotcha. Get some dermis with the, I think you're just more in the fatty tissue. There you go. That looks a little better. Yeah, he just has... He's thin. He's super thin dermis and he is like the thigh is really floppy so I'm just trying to keep it so that you're not gonna have a dog ear. Yep. I would do another one right here and then you can just do one here when you start your runner. But I'd put one like splitting this in half. I think that's the trick, we don't teach people that but that's what I teach medical students now is you gotta pull the dermis away. It's so much easier. Do we have a clip or an automatic or whatever is easiest. There's just this like giant vein staring at us, that's totally gonna bleed. You must have gotten into the same vein on this side. 'cause there's all this Bovie over here. They're just picking up the specimen right now. It came back negative. Oh it's negative, phew, you're good. Great, can I get a Vicryl. I need to rotate it to make a little... Oh, you want me to help you? Nevermind Bianca, I gotta wait a sec. I'm needy. Yeah, needy. He wants to be able to see a suture, you know? Sorry, trying to rotate it. This is in the way. We can just finish this one and then we'll do that leg. Because we can get this outta the way by then. You won't keep hitting your hand on it. Because once we get the muscle inset, all this comes out. Did you wanna set that up? Not yet. I wanna inset the muscle and then we'll do it. 'cause it's giving me the exposure for the muscle right now. And then the soft tissue. I need to close. Sorry, I was grabbing this other one outta your way. Can we put the height of the bed back down for a little bit? Sorry about that. So we're gonna just see how the muscles wanna sit. Can I get a Vicryl, please? I dunno what these handles do. We don't think to do anything. Probably nothing, I'm gonna throw some of these in if that's okay. Is it just me? It's on my thing, I know. Get used to the convenience of being a plastic surgeon. We're just self-sufficient. We don't mess around. I know. So I just start tacking them to see how it looks. You can always undo it, right? So I put one stitch on one muscle. There's no tension on it. It looks great, sorry. So I'm just gonna kind of tack it along. So you put both of them down? Yeah. So this is just one actually this is one muscle. So I just looked, I'm like yeah this looks pretty good, if I put this here and then I'm gonna see if I can, I wanna put 'em together. You put together, yeah. Yeah, the thing is you really can't put a ton of stitches in the muscle, right. It just doesn't hold very well, but this is nice. It's just kind of sitting there. Just so that there isn't a bunch of fluid just kind of like. That's right. It's closing that hole and then we close all this on top. Right, right, right. So it's giving us something nice healthy tissue to recreate the sling of the pelvic floor. Obviously it's not really a dynamic sling, but... Are there other alternatives to this for an APR? Absolutely, I think the most common that people use is a VRAM using the rectus abdominis muscle. The nice thing about that is you get a huge skin paddle with that. You can also orient it obliquely. It's called an ORAM an obliquely oriented rectus abdominis. You take it up here. Yep. And you keep it attached to the inferior epigastric. And you tunnel it. Then you tunnel it. Intra-abdominal. Intra-abdominal, okay. Yep, and then pop it out here. I see it definitely is a much, much bulkier flap. You have bigger muscle, you have a great reliable skin paddle. Gotcha. But if you notice, I don't need a skin paddle for this. Yeah, 'cause he's got enough. Because he's got enough skin. But sometimes they have to take a big section of skin. Like for like a anal cancer... Yeah. Or if they have like Paget's or some other thing going on. And in that case you really need, or if they have to take part of the, can I get that other driver back Bianca? And so like if they have to take part of the vagina, you can resurface the vagina with that. That was actually most of what I trained with originally is doing that. There's downsides to everything, right? So the downside to that is we just did this big robotic surgery to avoid a big abdominal incision and then you give a big abdominal incision, it also really hurts. So in that case you would do the intra-abdominal colon parts first then you do your thing. Drop it in the belly. Then we flip. Yep, and the other problem with that is losing the rectus muscle is a big deal, right? That's a big functional deficit. Unilateral. Yeah unilateral. That's even more wonky I would assume. Yeah, I mean they are fine but it is definitely a functional defect. Yeah. Whereas with this, you really don't miss your gracilis. The downside to this is it's a puny flap. You can take a skin paddle with a gracilis muscle but it's super unreliable and it's hard - I've only done it one time or two times because I don't like it. If I really need a skin paddle, I have to do a different surgery. But this is kind of, Dr. Francone prefers this technique because he doesn't like me making a big belly incision. There are some people that actually do robotic harvest of the rectus muscle. So if you do just the muscle, no skin paddle, you can harvest it robotically. Right, you inside the peritoneum. Right. You see the muscle, you can come through it at the top. Ligate the vessel, drop it down. I really wanna do that. Todd said he would do it with me. Are you getting some? We're gonna think of, well I don't know how to use the robot but he does so I can tell him where to go. He can use his hands to do it, you know, we'll see. He will be your robot. He'll be my robot, yeah. He'll have a robot running the robot. Yeah, exactly. But I think together we could do it. Yeah, that's amazing. So we've talked about it, again, you're still have the functional deficit of that muscle loss, but it is a much, much bulkier muscle. Right, right, yeah. You take the side opposite to your colostomy? Yes, exactly. And that's the other thing. So it's commonly used for pelvic exonerations, right? But when you do those, you get an end urostomy too. And so you have two ostomies. In the same side. And you have to stack them. Which people don't like doing. Because again, everything in medicine. Everything in surgery especially has a trade off. Nothing's free. That's right, nothing is free. So just putting some stitches in. I think this looks pretty good. Yeah. Healthy muscle in good position. They get that like a heavy feeling down here. That's really normal, it gets better with time. That heaviness in the, they'll feel like, oh I have to sit, I have to like put pressure 'cause it feels heavy when this kind of, it's gonna balloon out this way. I did one of these with Dr. Francone and the patient had to come back to the OR because of an anastomosis issue or something, and something with the colostomy, and he had to obviously insufflate the belly. Right, 'cause he did a laparoscopic and I was pretty worried 'cause if you insufflate the abdomen, you're relying on this to hold your insufflation. Yeah. And it held, it was only like four days later and it held and I was like, oh god. It was very, very stressful. I know but it was stressful for me. I bet. I like came into the OR specifically to check it. So the key is I put no strain on this muscle, right. It's like barely laying there. Right, right. And I'm just slowly, yeah, I'll take it. Thanks Bianca, just tacking it into place. I'm gonna put a few more here. Just so it's there. You want that... Oh yeah, I do want that one. This one just doesn't cut lefty. Here's this. Can someone sneak under the drapes? You want one more? Feels okay. I think it's okay. So he - let's take all these out. There's tape on him. If we can just sneak under and release it. All right. See the difference because obviously you can't get that closed. Yeah, no. So then it's gonna close primarily. Can we get a 2-0 PDS Loaded righty please.

CHAPTER 8

All right, so you're gonna start, I want like something in this deeper plane here brought in together, okay. Scarpa's? Yep. Get some Scarpa's all the way along, please sir. That's perfect. 2-0s? Yeah. Or 3-0s? No, I want 3-0s too. Okay, how many 2-0s do you have? I only have that one. We'll see we only need like a few of these. Like one layer and then we're gonna do two layers of 3-0. That's about what you had in mind, right? Yeah, that looks perfect. That looks great. She's in finance. Can you do one more down here and maybe one more up here too if you don't mind. Yeah. Can you load a 3-0 PDS righty please. Alright, so now you're gonna do basically like a deep dermal with that. It is looking great. Yeah, I get that lined up. Do you want to do Dermabond? No, just the thighs. Actually we can probably do it from here. We'll clean it up. Just two Dermabonds. One for each thigh. We're not Dermabonding this, the perineum. We still have to close just this proximal thigh over here. I always put dissolvable sutures in this area, even on the skin. And we're gonna put them in like they're skin sutures. Like it's a silk or like it's a nylon or a Prolene because then if they don't want them removed, they don't have to be removed. They will ultimately go away on their own. 'Cause this is a very sensitive area to take sutures out of. But I still use a PDS 'cause it lasts a really long time. It's like six months now, right? It's like a little earlier than that, like four. I had done it with Vicryl in the past and I found the Vicryl just went away too fast. So I do PDS about six weeks, they look perfect and the suture is bothering them. I will take the skin stitch out in clinic. Nice. But if they don't care we just leave it in. What do you think? Think that looks great. Can we get another PDS, a 3-0 please? All right. I'm gonna do part of this and then you're gonna do the rest. Yeah, that's fine. All right, so this stitch one of my attendings see bring things from lots of places. So this is one of my attendings from UMass does this stitch, he calls it the running reverse. The point of the stitch is to get closure of dead space, eversion of skin edges, and to never have to backhand. All it is is a fancy whip stitch. So the first like bit you're going, you're kinda wide and what you can do is if you really need to, you can get really deep. So these are actually really good for amputation sites. 'cause you can get deep and close that dead space at the end of an amp. So this is just a whip stitch. Right. I do these in short segments here so that if you have a problem with one, it's not the whole thing. I don't want one runner here, I do like three runners here. So again, I'm just getting nice, deep wide stitch. We'll do probably one more and then, 'cause we're breaking this up into segments. So deep and wide, that brings in the dead space down like that. And then it helps start the eversion process. And now we're gonna lock it in. So now the second way I'm gonna go, so that's all forehand. I'm gonna continue forehand, but I'm running back this way. But instead of being wide, I'm gonna stay closer to the skin edge like this. And you're really gonna lock, see how it like perfectly, because you can see these skin edges don't look perfect. It's rolled in. They're kind of on different planes. If you do this too tight, you can cause ischemia as with any whip stitch. Right, right, right. So don't do it too, too tight. But just a little bit of... And it looks like a shoelace, which I personally like the way the stitch looks 'cause it looks really fancy. Yeah, yeah. If say I put a stitch here and I didn't think these edges lined up perfectly. You know what you could do? You could just put a second one right here. There's nothing that says you have to jump to the next one yet. It's very versatile. Just 'cause the goal is just to get it to look good. You want the skin edges to look perfect. So you can do that. And then I'm gonna go to here. So I'm saying, so it's far on the way down. Close on the way back, getting those skin edges, and then it's one knot. All right. And that's it. I love it. So you're gonna do the - I think I put a knot in it, that's okay. There it is, you wanna undo it? Yeah, I got it right here. But see how it's like... You keep it loose kind of. Yep, it can swell, exactly. So see how loose that is. And then you can even like pull it out a little bit. But they look okay. So I want you to do the next one. This is, so again, it's great for amp sites, like on the leg or the finger. And it's really good for like if you took off a big skin cancer on someone and you need a little help getting it closed, you can really get stuff together with this. It's crazy. It's a cool stitch, right? Doesn't it look pretty? I like it, yeah. Here you go. Yeah, exactly. Just in case 'cause it's shorter for you now. All right my friend. So I would do it to like here and then we'll do a third one. Actually his looks pretty good. You could do the whole thing. You might not have enough suture though. Yeah, I think we're gonna have... We'll do it in three. Again, that way if there's an issue, they're separated. I don't like doing one long runner. It makes me nervous but I don't like having a thousand knots either. Patients hate that. All right, I would turn it back now. So come this way, yep. Just a tiny bit tighter. These are a little loose. There you go, that's better. Yeah, that's good. You are gonna start using this stitch. You're gonna be like, what was that crazy stitch that crazy plastic surgeon did. Then you tie across, isn't that cool? It looks pretty. It looks great. But it's also super effective at what it needs to do. 'cause it closes dead space. It everts the skin really well, and you're doing a forehand stitch the whole time. 'cause I think naturally a running whip stitch, people don't evert the edges very well. They really, they curl in a lot. They do, yeah. And then that just doesn't heal well. That has to like slough off in order to heal. Yeah, it looks terrible because they're a very depressed scar and so the more eversion you get, really, they look better. I'm sorry, you want me to cut? Oh sorry. It's cool, right. The nice thing is you also notice that there's no tension on this, right? This feels great. This comes together really nicely. And remember this skin is - righty. This skin is radiated. I know, yeah. So I don't always, you know the skin you worry about but say for worst case scenario, this all breaks down. He has healthy muscle underneath. He's gonna granulate, he's gonna heal. That's the whole point of bringing healthy muscle, non-radiated tissue into a wound bed. Right, right, yeah. That's what plastics does. We fill the hole, we solve these kind of problems. You can go right here like that, or...? I'm just gonna do it. Yeah, why not. I'd rather just get it sealed before we flip. The distal incision's already glued like the second one. So, have you taken care of one of these patients? Never. Okay, so nothing, honestly, most of the stuff is per Francone. But the big thing for me is these patients have to follow a sitting protocol. The whole goal is to get, you know, you're kind of like reconditioning the muscle. So today he's on bedrest and then tomorrow he can be up and ambulating but no sitting. So he can stand, he can walk and he can lay down, he can lay on his back. He can lay on his side, I don't care, but no sitting tomorrow. Gotcha. And that's Friday. So then on Saturday he'll start sitting. And it's 15 minutes three times a day and then on Sunday will be 30 minutes three times a day and then it goes up 15 minutes until they reach an hour. Once they're at an hour it's ad lib. So it's four days of that. So it's a five day total thing. Right, no sitting, 15, 30, 45 an hour and then it's whatever. Oftentimes, like they can be discharged before that, but they often get an ileus and they're still here anyways. My drains typically stay in for about a week. Okay. So I already have, he has an appointment already for next Thursday. Gotcha. Just in case, and we can pull 'em out there. Less than 30 than for two days. He's gonna get ACE wraps on his legs. And those stay on, so like as he's walking it will probably slide down and the nurses can just rewrap it and then I just do ABD and mesh panties here. Like a wad of ABD or no? No, just an ABD, no wad.

CHAPTER 9

We just completed the robotic abdominoperineal resection with the bilateral gracilis flaps. And so from the transabdominal perspective, I thought things went as planned. You could see a nice TME plane. From a robotic perspective, we like to really teach short, quick movements and really utilizing that fourth robotic arm to give us good exposure and you really utilize your assistant at the bedside and just kind of circumferentially move around that TME plane to give you good exposure. You can see that as you start to lose the plane a little bit, then just moving on to a different section and then eventually as you move more distally, the planes just continue to open up. Anteriorly, I think we were able to get very distal down and we saw a good plane between the prostate and anterior rectum, which we thought was gonna be a particularly difficult dissection given his MRI, which showed an abutment of the tumor along the prostate. But I thought that particular portion of the dissection went well. We were able to even divide the levator. His pelvic floor came up on us a little bit. He has a very narrow pelvis, you can see. And his coccyx bone and then his levator. So we probably coned in for maybe about a little bit of a centimeter. But we were able to divide the levator and started that dissection, which kind of helps us from below. I thought the colostomy was nice and Brooked and was elevated and that's gonna be the best thing for him as far as from a quality of life perspective. From the perineal dissection, I guess from your graft dissection, everything looked great. Nice bulky muscle. Yeah, I was super happy. The muscles were exactly as I expected. This is a very lean guy. You know, the muscle itself was narrow and lean, which is why I knew right off the bat I needed to do two. And that was confirmed when I dissected the first side. But luckily for me, the pedicles were a little bit more on the proximal side, which really helped. So I could rotate more of the muscle into the field that I needed. You know, it's always a little lackluster. You feel like you have all this muscle but most of that actually sits in the tunnel. It's only the most distal aspect that makes its way into the actual defect that you're closing. But it rotated beautifully. I had plenty of length, I had a lot of redundancy that I could then overlap to create a nice closure of the hole. On the left side, in the distal part, I did get into the saphenous, which runs right along where this muscle is and it's a known thing. I just found the two ends, clamped it and tied it off. I didn't even encounter it on the right side, but it's just good to know that that runs there. Obviously we sacrifice the saphenous vein all the time and it's not a big deal, it's just when you identify it you need to take care of it so you don't have issues down the road. But yeah, I was super happy with how things looked. He had exactly what I expected. He had beautiful anatomy and that makes my job a lot easier. And I think his skin and the soft tissue actually up at the perineum looked great. Which is pretty surprising because he's had a lot of radiation. But I think having some time from his last radiation helped. But things were nice and soft and they came together really nicely, which will help and hopefully he won't have issues healing. Yeah, I think it's important to realize with the perineal dissection, typically we don't leave any levator for Dr. Tomczykk to sew to, 'cause we're going wide because of the margins and the oncologic reason why we're there. The perineal dissection went well. We had good landmarks. Again, he had a very narrow pelvis, which does make it easier to potentially approximate. And the gracilis muscle flaps are good for a narrow pelvis like that. So that worked out. We flipped the patient into the prone position. And this is particularly important for patients who have close margins along the anterior aspect of the rectal wall and the posterior wall of the prostate. 'cause it sits right in front of you. If you're in the lithotomy position, you tend to try to be cramped in between the legs and trying to look up and establish this margin. So that's the real benefit to prone. It's nice to have a plastic surgeon that's agreeable to that, 'cause you can see they temporarily close their wounds. They have to make sure it stays sterile, but it really does from an oncologic perspective, help with these anterior tumors. So overall I thought that part of the procedure went really well. His frozen section was negative, and I think he got a good oncologic procedure as well as a good closure. One of the best things about this approach and using the gracilis flap closure is that we're able to one, the patient will benefit from the minimally-invasive approach. 'Cause you could see he had four or five small incisions in addition to his colostomy. So all these patients get placed on an enhanced recovery protocol and really minimal modification due to the flap reconstruction 'cause they're up and outta bed moving around next day, same day. So, that's different than other bigger, bulkier flaps like the VRAMs that they tend to make big incisions. They take all this muscle and you can see by no means needed that for this patient. So this was the benefit from this approach plus the fact that we operate concurrently really reduces the time. I think the operative time is about four hours. What's the typical recovery? All our minimally-invasive patients go on an enhanced recovery protocol. On the average, they are here between two to three days. Usually with an ostomy, patients are more likely to stay three days. But about 80% of our patients for all minimally-invasive procedures will go home on day two, about 10% will go home on day one. So that's one of the advantages of the approach that we do in regards to one, we reduce operative time by operating at the same time, so we tend to be more efficient. And two, with the gracilis flaps, it's a much, I would say, less morbid flap. It's less bulky as compared to a VRAM, right? So again, those are much larger incisions. So again, this allows patients to really stick to that enhanced recovery protocol.