Beatriz Martin-Perez, MD, Ana Otero-Piñeiro, MD, F Borja De Lacy, MD, Victor Turrado-Rodriguez, MD, Raquel Bravo-Infantes, MD, Antonio M Lacy, MD. Hospital Clinic
INTRODUCTION: Combined transabdominal and transanal approach for rectal cancer (Cecil approach) is establishing as the technical solution for the challenging mid and low rectal cancer, particularly on narrow, male, pelvis. Beyond these indications, locally advanced rectal cancer may also benefit from the transanal approach, as it provides an excellent pelvic visualization as well as adequate distal resection margins resection. Additionally, robotic surgery grants a precise dissection and exceptional access to the pelvic cavity. We present a case with locally advanced rectal cancer invading the uterus approached simultaneously transabdominally with the robotic and transanally.
METHODS: Seventy-four year-old female with osteoporosis and depressive syndrome, was diagnosed with a rectal neoplasm 14 cm from the anal verge due to rectal bleeding. CT scan and MRI showed a large mucinous rectal tumor involving the posterior uterine wall with possible perforation (T4bN0). No distant disease was identified. Patient was proposed for a robotic bilateral salpingo oophorectomy and hysterectomy and a transanal total mesorectal excision (TaTME).
RESULTS: Four 8 mm trocars were placed in the abdomen to dock the Da Vinci Xi robot. The colon was clamped previous to the rectal insufflation. Vascular control was achieved followed by colonic mobilization and transection. Robotic instruments are ideal to work on limited space such as in this pelvis due to a large tumor. Transanal access platform was placed and the tumor was localized, creating a purse string 5 cm below the tumor. The mesorectal dissection was performed on a down-to-up approach, connecting with the transanal team posteriorly. Distal purse-string was performed prior of communicating both fields. Simultaneous dissection continued laterally around the cervix until the anterior wall, completing the en bloc resection. Robot was undocked and the anastomosis was created with laparoscopic assistance. Operative time was 145 minutes. Recovery was uneventful and patient was discharged the 4th postoperative day. Final pathology confirmed a T4bN0 mucinous adenocarcinoma, with negative margins and complete mesorectum.
CONCLUSION: Locally advanced tumors are technically demanding and a combined transabdominal and transanal approach may overcome the difficult aspects of the dissection. Advantages of both the robotic and the transanal procedures are enhanced when combined and may certainly benefit the minimally invasive approach of locally advanced tumors.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87310
Program Number: V133
Presentation Session: Colorectal 2 Session
Presentation Type: Video