Madhu Ragupathi, MD, Michael D Yaakovian, MD, Diego I Ramos-Valadez, MD, Eric M Haas, MD FACS FASCRS. Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
Objective/Technique: Robotic-assisted laparoscopic (RALS) low anterior resection (LAR) with total mesorectal excision (TME) for rectal cancer has garnered increasing enthusiasm as a result of favorable preliminary results. The technique affords superior visualization, access, and manipulation of tissues in the deep, confined pelvis while maintaining the benefits of minimally invasive surgery. However, a major limitation involves low division of the rectum and mesorectum using the currently available endoscopic stapling devices.
Methods: To overcome this limitation, we perform RALS ultra-LAR with TME and hand-sewn colo-anal anastomosis for the treatment of rectal cancer. Our technique utilizes division and extraction of the rectum through a transperineal approach, with transanal extraction of the specimen followed by hand-sewn colo-anal anastomosis as a sphincter-sparing procedure. The da Vinci® S Surgical System is utilized for the procedure.
Results: The procedure commences with laparoscopic splenic flexure takedown and high division of the inferior mesenteric vein. The robot is then docked to perform the pelvic portion of the procedure. The essential steps of the procedure include (1) isolation and high ligation of the inferior mesenteric artery in a medial-to-lateral approach with preservation of the left ureter and pelvic splanchnic nerves, (2) development of the avascular presacral plane with preservation of the fascia propria of the mesorectum, and (3) division of the anterior peritoneal reflection, Denonvilliers fascia, and lateral stalks. Robotic dissection is extended to the level of the levator ani and anorectal junction circumferentially. Division of the rectum is then performed under direct visualization in a perineal approach at a level just above the squamocolumnar junction. The specimen is extracted transanally and divided at the proximal extent of the oncologic margin. A primary hand-sewn colo-anal anastomosis is fashioned. A laparoscopic diverting loop ileostomy is then performed.
Conclusions: Robotic-assisted laparoscopic ultra-low anterior resection can be successfully performed with transanal division and extraction of the rectum followed by a restorative hand-sewn colo-anal anastomosis for rectal cancer. This avoids the limitations of endoscopic stapling in the deep pelvis and affords a sphincter-sparing procedure.
Program Number: P170