Robotic-assisted Transanal Endoscopic Total Mesorectal Excision (TME) for Low Rectal Cancer in an Obese Male

Amy Fiedler, MD, Liliana Bordeianou, MD, David Berger, MD, Patricia Sylla. Massachusetts General Hospital

INTRODUCTION: This is the case of a 58 year-old obese male patient with BMI of 38, who presented with rectal bleeding, and was found on screening colonoscopy to have a 2 cm rectal adenocarcinoma located 1-1.5 cm above the dentate line, with no evidence of metastases on staging CT scans.

METHODS: Tumor staging with pelvic MRI and endorectal ultrasound both demonstrated a uT2N0 with an intact internal anal sphincter. He was deemed to be a good surgical candidate for hybrid robotic and transanal endoscopic total mesorectal excision (TME) with intersphincteric resection (ISR) and diverting loop ileostomy.

RESULTS: Combined robotic and transanal endoscopic TME was performed in addition to partial ISR to achieve negative resection margins. The majority of the TME was performed using a transanal endoscopic approach while ligation of the inferior mesenteric artery and completion of the rectal and mesorectal mobilization was performed robotically. The splenic flexure was mobilized laparoscopically, and the rectosigmoid was exteriorized and transected transanally followed by handsewn end-end coloanal anastomosis. The patient was discharged home on postoperative day 5, and final pathology confirmed a pT2N0 rectal cancer with negative margins, 25 negative lymph nodes, and a complete TME specimen. The patient underwent ileostomy reversal 3 months later with good defecatory function.

CONCLUSIONS: Transanal endoscopic TME with robotic assistance is a safe approach that can facilitate completion of a minimally invasive sphincter-preserving low anterior resection for very low rectal tumors in obese male patients.