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Contributors: Jimmy Lin and Craig Rezac
This procedure is a da Vinci Xi Robot assisted low anterior resection with diverting loop ileostomy performed on a 64 year old male patient who on work-up of hematochezia and change in bowel habits was found to have a locally advanced rectal adenocarcinoma approximately 5-6cm from the anal verge. The patient was found to have a single subcentimeter metastatic liver lesion, which was treated with radiofrequency ablation. He was treated with neoadjuvant chemoradiation prior to undergoing surgery.
DOI: http://dx.doi.org/10.17797/vk8yonl7gj
Editor Recruited By: Vincent Obias, MD, MS
da Vinci Xi robot assisted low anterior resection with diverting loop ileostomy
Rectal adenocarcinoma after neoadjuvant chemoradiation
Patients with history of prior abdominal surgeries and with significant adhesions; Patients requiring emergency surgery; Patients who cannot tolerate insufflation or prolonged operative times
Preoperative subcutaneous heparin and oral Entereg 12mg The patient is laid supine in modified lithotomy position with both arms tucked. Cystoscopy with placement of bilateral ureteral stents by urology. Flexible sigmoidoscopy is performed to confirm the location of the tumor, which had previously been tattooed. In this patient, it is reduced to an ulcer, which is approximately 6cm from the anal verge.
Colonoscopy to determine tumor distance from anal verge and to rule out synchronous lesions. CT chest/abdomen/pelvis to look for metastatic disease. Preoperative medical and cardiac risk stratification.
A supraumbilical incision is made for the camera port, the abdomen is entered with the open Hasson technique. A robotic trocar is inserted and insufflation is induced to 15mmHg. Another trocar is placed in the right lower quadrant. and this site will be used for the loop ileostomy. Two additional trocars are placed in line with the umbilicus at the midclavicular line and at the left lateral abdomen. Two 5mm assist ports are placed in the suprapubic midline and the right upper quadrant. The da Vinci robot is then docked.
The advantages of robotic-assisted low anterior resection are a minimally invasive approach with 3D high-definition visuals, camera stability, and the dexterity of wristed instruments in the narrow pelvic dissection. Disadvantages include longer operation and anesthesia time.
Risk of ureteral injury, difficulty with controlling significant bleeding
Risk of ureteral injury, difficulty with controlling significant bleeding
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Review da Vinci Robot Assisted Low Anterior Resection with Diverting Loop Ileostomy.