Ashley J. Alden

William N. Doyle Jr, Ashley J. Alden, Jetsen A. Rodriguez-Silva, Jin Kim, Sharan Poonja, Melissa A. Kendall, Kaylee Smith, Carolina Martinez, Allen Chudzinski, Lisa Moudgill, Paul Cavallaro, Jorge E. Marcet, Robert D. Bennett. Journal of Minimally Invasive Surgery 2026;29:22-30. https://doi.org/10.7602/jmis.2026.29.1.22

Introduction: Tailgut cysts, or retrorectal cystic hamartomas, are uncommon developmental lesions found in the theoretical space between the rectum and the sacrum. Frequently asymptomatic and incidentally detected, they occur predominantly in women. Compression of nearby structures may cause perineal and back pain and even obstructed labor. Case Report: We report a case of a 50-year-old man with prior coccygeal fracture who presented with dull perineal pain, worsened by prolonged sitting. MRI revealed a cystic mass, and surgical excision was performed via a posterior perineal approach. Postoperative recovery was uneventful apart from surgery-related increased perineal pain. Pathology demonstrated a retrorectal cystic hamartoma. Discussion: Tailgut cysts are thought to originate from the embryonic tail, which normally regresses by the eighth week of gestation. MRI is the preferred imaging modality, with cysts appearing hypointense on T1 and hyperintense on T2 images. Solid components or irregular cyst walls on imaging may suggest malignancy. Preoperative biopsy carries risks of hemorrhage, infection, and tract seeding. In purely cystic lesions, complete surgical resection without biopsy is preferred. A perineal approach is recommended for small lesions below S3, while abdominal and abdominoperineal approaches are needed for larger lesions and those superior to S3. Routine coccygectomy was previously thought necessary to prevent recurrence but is now understood to be avoidable unless needed for exposure or the cyst is adherent. Malignant transformation occurs in up to 27% of cases, with recurrence up to 16%. Complete excision is essential to prevent recurrence and obtain a definitive diagnosis. Conclusion: Tailgut cysts, the most common retrorectal tumors, are often asymptomatic. MRI is the preferred imaging modality. Complete surgical resection is crucial to prevent malignancy and recurrence. The role of preoperative biopsy is controversial, and routine coccygectomy is no longer recommended.

The advent of a single port robotic platform offers many potential improvements compared with single incision laparoscopy for both patients and surgeons. However, the technology will likely be prohibitively expensive for most hospitals. This is a retrospective review of adult patients who underwent our (rSIS) technique for a colorectal indication from December 2023 to April 2025. The primary aim of this study was to report our unique, single-incision robotic surgery (rSIS) technique utilizing a fascial wound protector device and a multiport robotic surgical system in colorectal surgery. Additionally, we assessed the feasibility and safety of our technique across the full spectrum of colorectal procedures. 50 patients were reviewed. 40% were men and 60% were women with an average age of 53.5 years and median BMI of 27.2 kg/m². Pathologies treated included: Crohn’s (26%), diverticulitis (22%), colon cancer (16%), colostomy status (8%), rectal cancer (4%), deep infiltrating endometriosis (2%), colocutaneous fistula (2%), and other neoplasm (6%). Both right (14%) and left-sided (28%) colectomies as well as total colectomy (4%), rectal resection (4%), small bowel procedures (22%), and ostomy creation/reversal (18%) were all successfully performed. Intracorporeal (50%) and extracorporeal (42%) anastomoses were executed as indicated, regardless of procedure sidedness. There was a 0% conversion to open rate and a single case when additional robotic ports were needed. 30-day all-severity morbidity was 20% with 30-day major morbidity of 6%. Our rSIS technique utilizing a multiport robotic system is safe and feasible across a wide spectrum of colorectal procedures.

Background/Objectives: Nonoperative management (NOM) of patients with locally advanced rectal cancer (LARC) who achieve a complete clinical response (cCR) to total neoadjuvant therapy (TNT) has been shown to be oncologically safe and is an attractive treatment option for patients. However, identifying responders to TNT that may benefit from nonoperative management is clinically challenging. Circulating tumor DNA (ctDNA) testing has shown promise in detecting minimal residual disease but has not yet been studied extensively within this clinical context. Methods: This is a single-institution retrospective case series study of LARC patients treated with TNT from 2019 to 2023 who underwent ctDNA testing as an adjunct to standard clinical response assessments. Results: A total of 28 patients had ctDNA testing as part of their response assessments after TNT. In total, 9 patients had positive ctDNA, and 19 patients had negative ctDNA during surveillance. Baseline characteristics of these two groups were not different. In this study, 6/9 (67%) patients who had positive ctDNA required surgery for residual rectal cancer, whereas only 4/19 (21%) patients who had negative ctDNA required surgery (p = 0.035). Conclusions: ctDNA testing has the potential to detect MRD in LARC patients treated with TNT.

Background Over a century ago, Virchow proposed that cancer represents a chronically inflamed, poorly healing wound. Normal wound healing is represented by a transitory phase of inflammation, followed by a pro-resolution phase, with prostaglandin (PGE2/PGD2)-induced ‘lipid class switching’ producing inflammation-quenching lipoxins (LXA4, LXB4). Objective We explored if lipid dysregulation in colorectal cancers (CRCs) is driven by a failure to resolve inflammation. Design We performed liquid chromatography and tandem mass spectrometry (LC–MS/MS) untargeted analysis of 40 human CRC and normal paired samples and targeted, quantitative analysis of 81 human CRC and normal paired samples. We integrated analysis of lipidomics, quantitative reverse transcription-PCR, large scale gene expression, and spatial transcriptomics with public scRNASEQ data to characterize pattern, expression and cellular localisation of genes that produce and modify lipid mediators. Results Targeted, quantitative LC–MS/MS demonstrated a marked imbalance of pro-inflammatory mediators, with a dearth of resolving lipid mediators. In tumours, we observed prominent over-expression of arachidonic acid derivatives, the genes encoding their synthetic enzymes and receptors, but poor expression of genes producing pro-resolving synthetic enzymes and resultant lipoxins (LXA4, LXB4) and associated receptors. These results indicate that CRC is the product of defective lipid class switching likely related to inadequate or ineffective levels of PGE2/PGD2. Conclusion We show that the lipidomic profile of CRC tumours exhibits a distinct pro-inflammatory bias with a deficiency of endogenous resolving mediators secondary to defective lipid class switching. These observations pave the way for ‘resolution medicine’, a novel therapeutic approach for inducing or providing resolvins to mitigate the chronic inflammation driving cancer growth and progression.

The modified Graham patch repair is a well-established technique for management of perforating foregut injuries, often learned by surgeons during general surgery training. There is, however, little to no data regarding the utilization of this technique for perforation of the distal midgut or in the re-operative field. We present two cases of midgut anastomotic complications successfully managed with modified graham patch repair at our institution. The first case is a 79-year-old female who underwent an emergent right hemicolectomy at an outside institution for management of an iatrogenic perforation during endoscopic polypectomy. Over the course of two years she underwent numerous abdominal operations, due to various complications, ultimately resulting in multiple resections and end ileostomy creation. She then had her ileostomy reversed by laparoscopic single incision (SILS) technique at our institution. This was also complicated by anastomotic leak. Intraoperatively, adequate mobilization of the anastomosis for resection was deemed not safe due to dense fibrosis and adhesions in the re-operative field; therefore, she underwent a SILS modified Graham patch repair of an ileocolic anastomotic defect with diverting loop ileostomy. Post-operatively, she had no radiographic evidence of leak from the repaired anastomosis, which facilitated successful loop ileostomy reversal five months later. Our second case is a 64-year-old male referred to our institution for management of his stage IV colon cancer. He underwent an open right hemicolectomy and hepatic metastectomy, which was complicated by anastomotic leak. The small defect was repaired via a SILS modified Graham patch technique. Five months postoperatively, he had neither radiographic nor endoscopic evidence of a leak; therefore, he successfully underwent ileostomy reversal without complication. We encourage further investigation and reporting of the role of the modified graham patch repair in management of midgut anastomotic complications, particularly when resection and re-anastomosis is unsafe due to a hostile re-operative field.

Diverticulitis is a prevalent gastrointestinal disease that often warrants surgical intervention. However, the optimal approach between traditional laparoscopy (LC) and robotic-assisted laparoscopy (RAC) for diverticulitis remains unclear. Our research compares these techniques in patients diagnosed with left-sided diverticulitis treated at a single, tertiary referral center from 2019 to 2022. Among the 134 patients, 86 underwent laparoscopic and 48 robotic-assisted surgeries. The surgeries included in this analysis are left colectomy, sigmoid colectomy, low anterior resection, and Hartmann’s procedure. Primary outcomes were major morbidity and 30-day mortality. Secondary outcomes were operative time, conversion to open, length of stay, unplanned return to the operating room, 30-day readmission rate, and overall morbidity. While demographics and comorbidities were similar for both groups, the robotic-assisted group displayed a statistically significant longer operative time (198.0 ± 84.4 LC vs. 264.8 ± 78.5 min RAC, p < 0.001). When investigated further, there was a significant difference in operative time for uncomplicated diverticulitis cases favoring the LC approach (169.17 ± 58.1 LC vs. 244.82 ± 58.79 min RAC, p < 0.001). This significant difference, however, was not present in complicated diverticulitis cases. Other factors, such as overall and major morbidity, rate of conversion to open approach, ostomy creation, estimated blood loss, time to return of bowel function, length of stay, and 30-day readmission rate, did not significantly differ between the groups. There was no 30-day mortality in either group. Favorable patient outcomes, lack of significant difference in operative time compared with traditional laparoscopy, and absence of differences in morbidities or efficacy, raises an interesting question in the world of minimally invasive surgery: is the robotic-assisted approach emerging as the advantageous approach for complicated diverticulitis cases? We encourage additional, multi-center analysis of specifically complicated diverticulitis managed with both surgical approaches to investigate if these findings are replicated outside of our institution.