Single stage robotic total mesorectal excision-a stepwise approach.

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The totally robotic procedure was traditionally described as a two-stage technique or a three-stage technique. The number of stages corresponds to the number of movements of the robotic cart. In this video article, we develop a stepwise approach video of robotic total mesorectal excision (TME) for mid rectal cancer (the surgery was performed by SHK) using a da Vinci® Si HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) at Korea University Anam Hospital, Seoul. After the induction of general anesthesia, the patient is placed in a modified lithotomy position. Six ports are used, including one 12-mm camera port, four 8-mm robotic working ports, and one 5-mm port for the assistant. The patient is tilted to the right side and placed in the Trendelenburg position. The small-bowel loops retracted out from the pelvic cavity to the right upper quadrant (RUQ) to expose the inferior mesenteric artery (IMA). The surgery is divided into three phases: (I) abdominal phase: vascular ligation, and sigmoid colon to splenic flexure mobilization; (II) pelvic dissection phase; and (III) rectal reconstruction phase. Mesorectal clearing was done at the level of rectal transection line (1-2 cm from distal tumor margin), then the rectum was transected with robotic stapler. Once this step is finished, the robotic arms are undocked and the cart is moved away from the patient. The remaining steps are performed in a conventional laparoscopic method. Robotic TME was performed in a 56-year-old man with an endoscopically define rectal mass. The lesion was moderately differentiated adenocarcinoma, 8 cm from the anal verge (AV). The rectal mass was managed with single stage robotic TME. The operative time was 160 minutes and the patient was discharge on post operative day 10. Final pathology revealed moderately differentiated adenocarcinoma. Single stage robotic TME was efficient and feasible technique for mid rectal cancer resection.