Safety and Feasibility of Robotic Abdomino -perineal Excision of the Rectum.

Vamsi R Velchuru, FRCS, Slawomir J Marecik, MD, Marek Zawadzki, MD, Albalawi Saeed, MD, John J Park, MD, Leela M Prasad, MD. University of Illinois, Chicago, USA, Advocate Lutheran General Hospital, Park Ridge, USA

Introduction – Aim of the study was to establish safety, feasibility and efficacy of robotic Abdomino-perineal resection (APR) for rectal cancer and recurrent anal cancer. Standard APR can be associated with higher rates of radial margin positivity and intra-operative perforations (IOP). This can lead to poor oncological outcomes and increasing local recurrence rates. In spite of the advances with surgical and stapling techniques, low rectal tumor with involvement of the sphincter is a definite indication for Abdomino-perineal resection. Newer techniques such as Extralevator APR have been developed to reduce CRM positivity and IOP’s.
Methods – A retrospective review of a prospectively maintained database of 24 consecutive cases of robotic APR for rectal adenocarcinoma and recurrent anal cancers was performed. Study period was from April 2007 to August 2011. Patient demographics, perioperative outcomes and complications were evaluated. Independent t test was used for continuous variables such as length of stay, age, estimated blood loss, OR time, etc. Pearson Chi square test and Fischer exact test was used for categorical variables such CRM positivity, lymph node status and postoperative complications. All statistical analyses were performed using SPSS for windows, version 19.0 (SPSS Inc., Chicago, IL).
Results – Twenty two patients had a robot assisted APR for rectal adenocarcinoma and two for recurrent anal cancer. Average age was 65.5 years, with fourteen being male. Average BMI was 27.3 (range, 17.6-38.1), with one third being >30. Twenty two patients had pre-operative chemo radiotherapy. In the adenocarcinoma group, 91% (n-20) were locally advanced tumors (T3/T4). Average estimated blood loss was 262 cc (range, 50-650cc), with one patient needing blood transfusion in the post-operative period. The total OR time was 340 min, with total mesorectal excision time of 120 min. One patient was converted to open TME for a bulky tumor and very narrow pelvis. There were no robot associated intra-operative complications. Average hospital stay was 7.8 days (range 3-36 days). Six patients developed perineal wound infections. One patient died due to aspiration pneumonia in the post-operative period. Subset analysis, showed increased OR time and TME time along with higher estimated blood loss in males compared to females. This was not statistically significant. Circumferential resection margin was positive (<1mm) in two patients (9%) in the carcinoma group. Mean lymph node harvest was 12 (range, 1-27).
Conclusions – Robotic APR is safe and feasible with promising short term results. It may be beneficial for the narrow male pelvis however larger randomized studies are needed for definitive conclusion.
 

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