ESCP's 13th Meeting kicked off with the symposium: Tips, Tricks and Error Traps chaired by Beatriz Martin-Perez from Spain and Des Winter from Ireland. The session featured three world-renowned speakers - Steven Wexner from USA, speaking on benign disease; Bill Heald from UK, focussing on primary rectal cancer; and Michael Solomon from Australia, looking at recurrent rectal cancer.
Diverticulitis and ileoanal pouch
Steven Wexner took to the stage first and discussed diverticulitis and ileoanal pouch. One of the first tips he underlined was bowel preparation, highlighting that undertaking a procedure on a poorly-prepped bowel can mean it is difficult to see and manipulate. He also referenced modified lithotomy position and suggested it was a good plan to have endoscopy available in the room.
Another tip, particularly in relation to diverticulitis was timing. Wexner said that where possible it is advantageous to get the patient out of the acute episode so the surgery is elective. This will enhance chances of success and is more likely to be minimally invasive.
In a similar vein, he said that it is key to anticipate what might happen. Being aware of this helps you take steps to avoid issues or to be more ready to address them. That could be by involving an urologist at a beginning rather than afterwards.
He talked about specialist situations. When dealing with a phlegmon, for instance, Wexner advised always to work around it and away from it before addressing it.
Additionally, he pointed to the fact that evidence shows that the more stapler firings there are, the instances of leaks increase. He therefore suggested trying to achieve a single successful firing by assessing visually where you think you are manually, when introducing the stapler.
In relation to Ileoanal pouch, Wexner discussed Intra operative considerations including, minimally invasive surgery, pouch lengthening maneuvers, anastomosis – hand sewn vs stapled and also diversion.
Primary rectal cancer
Bill Heald then talked about primary rectal cancer. He focused on the Denonvilliers’ fascia and also Waldeyer’s fascia.
Heald referenced that there can sometimes seem to be too many choices in relation to Denonvilliers’. The U cut is the open surgeon’s choice. Whereas as a minimally invasive surgeon you can focus on the top edge of Denonvilliers’ to help protect the nerve. Whilst with a robot you can get between the layers of the Denonvilliers’ septum
Heald also warned against thinking about spaces. Saying it is important to think about layers - spaces are created by surgeons themselves.
He underlined that the mesorectal envelope lies within a hammock of Waldeyer’s fascia continuous with the pelvic side wall fascia. Saying that all dangers are effectively outside of this area - focusing on the inner most layer is always safest.
Recurrent rectal cancer and pelvic exenteration
Michael Solomon’s tips focused on recurrent rectal cancer and pelvic exenteration.
He started by raising the conundrum of exenteration – from a pessimistic versus optimistic view point. The former coming down to the question, ‘is it worth it?’ and the latter, focusing on survival, improving quality of life and cost.
His tips advocated a team approach and collaboration. He also suggested, if it abuts ‘it’ resect ‘it’ as well as a sarcoma approach RRC and considering survival and quality of life.
While his tricks included taking a simple approach to the pubic bone and to set up for sacrectomy via lithotomy.
He also referenced the six c’s - the tips refined by visiting international fellow. Firstly, having a coherent plan; then ensuring control (proximal and distal); circumnavigating any issues; having clear exposure; constantly reassessing the situation; and finally to be cool!
He stressed the need for a whole-team approach and collaboration across the whole care programme. He also extolled the fact that overseas fellows bring fresh minds and views.
One of the errors he talked about was the assertion that patients can’t walk without a sciatic nerve / Lumbosacral trunk. He underlined this is possible. He also said that despite some views to the contrary prone doesn’t necessarily give better access than lithotomy.
