Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5
Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5.
Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Robotic rectal dissection begins posteriorly in total mesorectal excision plane (TME) using 30° down-viewing scope. Posterior dissection in a TME plane provides a relatively bloodless plane of dissection and creates an anatomical reference point from which lateral and anterior dissection can proceed.
With an assistant retracting the rectum anteriorly and cephalad, the robotic single fenestrated grasper retracts the posterior aspect of the mesorectum anteriorly and slightly caudally. When performed correctly the surgeon can visualize a “cotton candy”-like areolar tissue between the fascia propria of the rectum and presacral fascia. The hook cautery is used to divide the tissue in a U-shaped fashion. The dissection is taken to the level of Waldeyer’s fascia.
Lateral Dissection and Division of Lateral Stalks
The lateral dissection proceeds initially on the right side where the surgeon has a safer plane of dissection (away from left ureter). A monopolar hook moves from posterior to anterior at a deliberate pace while applying current. If the right and posterior dissection was performed correctly, the only structures that need to be divided on the left side are a layer of peritoneum and a small amount of remaining lateral stalks. The left lateral side is dissected by dividing the peritoneum over the left pararectal sulcus. The left ureter must be visualized during this step. It is important to control all vessels, even the ones that appear to be only mildly oozing. Failure to do so may result in the field becoming bloody and dark. In this video, a vessel, encounterd within the left stalk is coagulated using a bipolar grasper while retracting the mesorectum with the hook. After the vessel is sealed it is divided with hook cautery.
As the dissection advances inferiorly, the right and left lateral peritoneal incisions that are created during lateral dissection at this point are connected in front of the rectum. At this stage in operation, with the switch to a 0° scope and change of the retraction of the rectum from anterior and cephalad to posterior and cephalad, the rectum is pulled straight out of the pelvis. Because the posterior dissection has now released the mesorectum, the rectum can be easily stretched placing under tension the anterior plane of dissection.
Circumferential Dissection of the Rectum
If the rectal cancer is distal within the rectum, the mobilization proceeds to the level of pelvic floor and occasionally performing some dissection within the levator muscle complex. As the surgeon advances towards the pelvic floor, the dissection alternates between the posterior, lateral and interior planes as the tissue tension changes based on dissection performed. One of the signs that the dissection is at the level of pelvic floor is observation of levator ani skeletal muscle fibers that contract upon contact with electrocautery and the tapering of the mesorectum. As it narrows at the level of pelvic floor, the rectum can be carefully grasped with a robotic grasper and retracted to obtain the necessary tension to provide dissection.
Editor Recruited By: Jeffrey B. Matthews, MD
In this video, we demonstrate the set-up, port configuration, and key steps involved in performing a robotic-assisted retroperitoneoscopic partial nephrectomy.
It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot.
The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.
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