Prostate Cancer Smart Surgery Treatment Trifecta

Robotic Prostatectomy After Laparotomy

JOURNAL OF ENDOUROLOGY Volume 24, #10, October 2010
Jonathan S. Brajtbord, B.A., Hugh J. Lavery, M.D., Brian P. Jacob, M.D., Samuel Mccash, M.D., and David B. Samadi, M.D.

Abstract

The laparoscopic management of difficult adhesions can be quite challenging for even the most experienced of laparoscopic surgeons. We describe a case of managing a suspected enterotomy with a laparotomy during a robot-assisted radical prostatectomy and the surgical options after repair. The case was complicated by a Meckel’s diverticulum fused and continuous with a urachal cyst, itself a rare occurrence. After the excision ofthe Meckel’s diverticulum–urachal complex, the laparotomy incision was closed, and the prostatectomy wasperformed robotically. We discuss the controversies regarding continuation of a planned robotic procedure after a midline laparotomy.

Introduction

The intraoperative management of dense abdominal adhesions poses a difficult challenge for laparoscopic surgeons. As adhesions become denser and more complicated, the likelihood of an enterotomy increases.1 Although an enterotomy can be repaired laparoscopically, it is often safer to convert to a laparotomy.2 An enterotomy does not often necessitate abandoning the scheduled procedure. However, once a laparotomy is made, the remainder of the procedure is usually performed in open fashion. Rarely is an attempt made to close the laparotomy and continue the procedure laparoscopically. We believed it necessary to make a laparotomy incision to deal with a suspected enterotomy before beginning a robotassisted radical prostatectomy (RARP). After the general surgical portion of the procedure, three options existed. First, the laparotomy incision could be closed, the surgery terminated, and the RARP rescheduled for a future date. Second, the operation could be converted to an open radical retropubic prostatectomy. Finally, the laparotomy could be closed, the abdomen re-insufflated, and the prostatectomy performed robotically. We decided to perform the last option. We will discuss our reasoning behind this decision as well as the embryology of Meckel’s diverticula (MD) and urachal remnants.