Robotic Total Mesorectal Excision and Sphincter-Saving Operation

Abstract

The concept of total mesorectal excision (TME), which is the standard technique in rectal cancer operations, was established by Heald and Ryall in 1978. Overall local recurrence rates vary widely from 3% to 33% in conventional surgery, whereas TME has consistently achieved LR rates below or equal to 10%. Otherwise, neoadjuvant chemoradiotherapy and technical advances with stapling devices facilitate sphincter-saving operation (SSO) in lower rectal cancer (LRC) patients with competent oncological and functional outcomes. The SSO consists of anterior resection and low anterior resection (LAR) including ultra-LAR with intersphincteric resection (ISR), according to the level of dissection and anastomosis. With the advent of laparoscopic rectal cancer surgery, robot-assisted SSO appears to be a promising technique with its minimal invasiveness and clear visualization into the deep pelvic cavity. Robot-assisted TME and SSO have become recognized as being safe and feasible in comparison with open and laparoscopic approaches. The robot approach possesses many advantages over the latter two approaches, including its magnified view, dexterity supported by wristed instruments and stable traction, and ergonomic excellence. Robot-assisted TME could therefore enable deeper dissection and lower anastomosis in the pelvic region than is possible with a laparoscopy or open approach, with slightly better functional recovery. Several comparative studies reported robot-assisted ISR showing an equivalent oncological outcome with a little improved immediate postoperative outcome compared with open ISR. However, further studies including randomized controlled trials are needed to complement and establish the evidence for the oncological superiority of robot-assisted SSO compensating its financial burden.