Quor M Leong, MBBS FRCSEd, S H Kim, MD PhD, D N Son, MD, J S Cho, MD, S J Baek, MD, A H Amar, MBBS, J M Kwak, MD PhD. Korea University Anam Hospital, Tan Tock Seng Hospital
IntroductionIntersphincteric resection (ISR) for low rectal cancer has been described as the ultimate sphincter saving procedure. Laparoscopic ISR (LapISR) has been proven to be safe with early post operative benefits. Laparoscopic dissection of the anterior rectum from the prostate/seminal vesicle/vagina, and posterior rectal dissection to the pelvic floor including anococcygeal ligament division is an essential but challenging step in LapISR, even for experienced surgeons. Recently, some colorectal surgeons have begun to perform robot assisted ISR (RoISR) to harness the advantages of the da Vinci robotic system. We present our short term results of a robotic technique of ISR.Methods and materialsData from 29 consecutive patients from a single institution, with very low rectal cancer (<4 cm) from the anal verge who underwent RoISR was prospectively collected between December 2007 to March 2010. Robotic dissection was performed following these steps: 1) ligation of the inferior mesenteric vessels and medial to lateral dissection, 2) mobilization of the sigmoid/descending and splenic flexure colon, 3) rectal dissection with total mesorectal excision down to the pelvic floor including the division of the anococcygeal ligament, which was crucial for the following step. Perineal dissection at the intersphincteric plane and extraction of the specimen transabdominally (for thick mesentery or large tumor) or via the anus. Coloanal anastomosis is performed with a hand sewn technique. Lastly, a loop ileostomy is created.ResultsThere were 23 males and 6 females with a median age of 61.5 years (range, 36-82 years). The median body mass index (BMI) was 23.3 (range, 17.9-32.5). The median distance of the tumor from the anal verge was 3 cm (range, 1-4 cm). The median operative time was 325 minutes (range, 235-435 minutes), with a console time of 130 minutes (range, 110-210 minutes). There were no conversions to open surgery. A protecting ileostomy was performed for all patients. The median blood loss was less than 50 mls (range, less than 50-1000 mls). The median size of the tumor was 3 cm (range, 0-6.9 cm) with a median of 16 lymph nodes (range, 1-44) harvested. The median distal margin was 0.8 cm (range, 0-4 cm) with 1 positive margin. The circumferential margin was negative (>2 mm) for 27 patients. Therefore, complete resection (R0) was achieved in 26 of 29 (90%) patients. The median length of stay was 9 days (range, 5-15 days). Nine patients developed complications, with 3 anastomotic leaks (10%). All leaks were managed conservatively. There were no surgical mortalities. ConclusionRobot-assisted intersphincteric resection for very low rectal cancer is feasible and its short term outcome is acceptable. This is the ultimate sphincter saving procedure for low rectal cancer that combines the benefits of minimally invasive surgery with the advantages of robotic surgery.
Program Number: P488