Robotic Abdominoperineal Resection Research Articles

Robotic abdominoperineal resection for T4b rectal cancer using the daVinci SP platform.

The aim of the present report wasto describe a novel technique of robotic abdominoperineal resection (APR) for the treatment of T4b low rectal cancer using the da Vinci® Single-Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA). A 3-cm transverse incision was made in the left lower quadrant of the abdomen, in the area designated for permanent colostomy. A Uniport® (Dalim Medical, Seoul, Korea) was introduced and a 25mm multichannel SP trocar was inserted into the Uniport. A 5-mm laparoscopic assistant port was introduced on the upper midline. A video showing each step of the technique is attached. Two consecutive female patients (70 and 74 years old) underwent SP robotic APR with partial resection of the vagina 8 weeks after preoperative chemoradiotherapy. In both cases, rectal cancer was located 1cm above the anal verge and invaded the vagina (initial stage and ymrT stage T4b). Operative time was 150 and 180 min, respectively. Estimated blood loss was 10 and 25 ml, respectively. No postoperative complications occurred. The length of postoperative hospital stay was 5 days in both cases. The final pathological stage was ypT4bN0 and ypT3N0 respectively. In this first experience, SP robotic APR appears to be a safe and feasible procedure for locally advanced low rectal cancer. In addition, the invasiveness of the procedure is reduced by means of the SP system, which only requires a single incision in the area designated for colostomy. Prospective studies on a larger number of patients are necessary to confirm the outcomes of this technique compared to other minimally invasive approaches.

Postoperative Complications in Patients Undergoing Nonabdominal Wall Flap Reconstruction after Laparoscopic or Robotic Abdominoperineal Resection

INTRODUCTION: Abdominoperineal resection (APR) is the treatment of choice for patients with rectal cancer. Typically, reconstruction after APR is done with a rectus abdominus myocutaneous (RAM) flap. Given the increased management with laparoscopic APRs, abdominally based flap reconstruction is inappropriate because of its invasiveness and significant abdominal wall morbidity. Therefore, a nonabdominal wall based free flap alternative, such as an anterior lateral thigh flap, gluteal flap, or gracilis flap, may be a superior approach looking forward. The aim of this study is to evaluate postoperative short- and long-term complication rates in patients undergoing nonabdominal wall flap reconstruction after laparoscopic or robotic APR. METHODS: We conducted a review of the literature to include adults with rectal cancer and looked at short-term complications such as increased healing time, seroma, hematoma, surgical site infection, dehiscence rates, reoperation rates, as well as long term complications such as perineal hernia rates. RESULTS: Our study included 64 articles and 306 flaps. The overall wound complication rate was 15.0%. In the short-term, 23 patients experienced hematomas, 16 patients experienced surgical site infection, 3 patients dehisced, and 4 required reoperations. The ALT flap offered the lowest rate of complications at 9.3%. CONCLUSION: In conclusion, the wound complication rate of 15.2% was comparable with literature findings of 14.3% in patients with RAM flap reconstruction. Nonabdominal wall-based flap reconstruction is effective after APR. Owing to its low complication rate, the ALT flap may serve as a superior treatment option for laparoscopic or robotic APR in patients with rectal cancer.

Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study

Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection. This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared. We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8days vs. 11days, p < 0.01). The positive resection margin rates were comparable between the two groups. Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.

Abdominoperineal Resection for Rectal Cancer: Open, Laparoscopic or Robotic Approach.

The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative and early postoperative aspects, in choosing the suitable technique performed by surgical teams with experience in both open and minimally invasive surgery (MIS). Methods: This is a retrospective study, conducted between 2008-2020. Two hundred thirty-three patients with APR performed for low rectal or anal cancer were included. The cohort was divided into two groups, depending on the surgical approach used: Minimally Invasive Surgery (laparoscopic and robotic procedures) and Open Surgery (OS). The perioperative characteristics were analyzed in order to identify the optimal approach and a possible selection criteria. Results: We identified a high percentage of patients with a history of abdominal surgery in the open group (p = .0002). Intraoperative blood loss was significantly higher in the open group (p= .02), with an increased number of simultaneous resections (p = .041). The early postoperative outcome was marked by significantly lower morbidity in the MIS group (p = .005), with mortality recorded only in the open group (3 cases), in patients that associated severe comorbidities. The hystopathological results identified a significant number of patients with stage T2 in the MIS group (p= .037). Conclusions: Minimally invasive surgery provides a major advantage to APR, by avoiding an additional incision, the specimen being extracted through the perineal wound. The success of MIS APR seems to be assured by a good preoperative selection of the patients, alongside with experienced surgical teams in both open and minimally invasive rectal resections. The lack of conversion identified in robotic APR confirm the technical superiority over laparoscopic approach.

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity.

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series.

Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery. Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis, while achieving clear margins. To determine the feasibility of robotic assisted bladder sparing pelvic exenteration. We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles (SV). The da Vinci S robotic system was used. Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient's legs for pelvic phase. All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams. Case 1: 67-year-old with low rectal tumour 3cm from anal verge involving the prostate. He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy. Case 2: 66-year-old with low rectal tumour 3cm from anal verge involving prostate and bilateral SV. He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy. Case 3: 57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum, prostate and bilateral SV. He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy. Bladder neck margin revealed cauterized tumour cells, and he underwent total cystectomy and ileal conduit creation. Histology revealed no residual tumour. All patients are currently disease free. Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.

Robotic Colorectal Surgery using Senhance® Robotic Platform: Single Center Experience with First 13 Cases

[full article, abstract in English; abstract in Lithuanian]&#x0D; Until recently, robotic surgery has been associated only with da Vinci robotic system. A novel Senhance® robotic system (TransEnterix Surgical Inc., Morrisville, NC, USA) has been introduced almost 5 years ago. Published reports on experience in colorectal surgery using this robotic platform is very limited. We present a prospective analysis of first 13 robotic colorectal surgeries in Klaipėda University Hospital, Klaipėda, Lithuania. 13 patients underwent various colorectal resections: 10 for colorectal cancer and 3 for colonic polyps. 7 were men and 6 women, age range 32–77 years, on an average 56 years. Among 10 patients with colorectal cancer, 3 had stage I, 3 stage II, 3 stage III and 1 stage IV colorectal cancer. 2 patients were operated for unremovable ascending colon adenomas and 1 underwent prophylactic subtotal colectomy with ileorectal anastomisis for familial adenomatous polyposis. Complication occurred in 1 case (7.7%). This patient underwent robotic abdominoperineal resection for low rectal cancer, developed postoperative bleeding from perineal wound on day 7 and had to be taken to operative room for oversuturing the bleeding vessel. Operative time was on an average 3 hours 50 minutes, ranging from 2 hours and 55 minutes to 6 hours and 10 minutes. In-hospital stay ranged from 5 to 16 days, on an average 7 days.&#x0D; Conclusion. Our experience with different types of robotic colorectal resections allows us to state that Senhance® robotic system is feasible and safe for colorectal surgery, and wider implementation of this system in our specialty worldwide is simply a question of time.

Combined Gluteus and Pudendal Thigh Flap Reconstruction of Vaginal Defects following Robotic Abdominoperineal Resection.

Summary:Low-lying rectal cancers are being treated more frequently with robotic-assisted abdominoperineal resection, obviating the need for laparotomy and the ability to raise vertical rectus abdominis musculocutaneous flaps. For female patients, posterior vaginectomy often accompanies the resection. Combined pudendal thigh flaps as an extension of bilateral gluteus advancement flaps allow for posterior vaginal resurfacing with thin pliable fasciocutaneous flaps, which rest on the gluteal flap soft-tissue bulk that obliterates the pelvic dead space. For patients with advanced cancers who have had neoadjuvant chemoradiation, the pudendal skin paddle can be planned more laterally to bring in healthier medial thigh skin. The donor incisions lie within the gluteal cleft and crease and groin creases recapitulating normal perineal anatomy and aesthetics.

Robotic vs. laparoscopic vs. open abdominoperineal resection for low rectal cancer: Short-term outcomes of a single-center prospective randomized controlled trial.

3603 Background: Currently, robotic surgery for rectal cancer using da Vinci System is common. However, there is almost no clinical trial reported. This randomized controlled trial aims to compare the safety and efficacy of robotic, laparoscopic and open abdominoperineal resection (APR) for low rectal cancer. Methods: From September 2013 to August 2016, patients aged from 18 to 75 years, with low rectal cancer within 5 cm from anal verge, clinical T1 to T3, no distant metastases, were randomly assigned to receive either robotic procedures (RAP), laparoscopic procedures (LAP) or open surgery (OS) for APR in 1:1:1 ratio. The primary endpoint was postoperative complication rate. This study is registered with ClinicalTrials.gov (NCT01985698). Results: Totally 406 patients were randomly assigned. Actually, 135 finished RAP, 131 finished LAP, and 137 finished OS (including 4 convert from LAP to OS). RAP had significantly lower postoperative complication rate (11.1%) than both LAP (21.4%, P = 0.023) and OS (27.7%, P = 0.001). Also, RAP reduced intraoperative hemorrhage (median [interquartile range], 100 [90-110] ml) than LAP (130 [100-150] ml, P &lt; 0.001) and OS (150 [120-260] ml, P &lt; 0.001). And RAP promoted postoperative recovery, with shorter days to first flatus (1.0 [1.0-2.0] day) than LAP (2.0 [2.0-3.0] day, P &lt; 0.001) and OS (3.0 [2.0-4.0] day, P &lt; 0.001), shorter days to first automatic urination (2.0 [2.0-3.0] day) than LAP (3.0 [2.0-4.0] day, P &lt; 0.001) and OS (3.0 [2.0-4.0] day, P &lt; 0.001), and shorter days to discharge (5.0 [5.0-6.0] days) than LAP (6.0 [5.0-7.0] days, P &lt; 0.001) and OS (6.0 [5.0-7.0] day, P = 0.005). There was no significant difference in open conversion rate, resection margin involvement (including circumferential resection margin), number of lymph node harvested and pathological tumor stage. Conclusions: Robotic APR was safer, and reproduce equivalent surgical quality of conventional laparoscopic and open surgery. Also, it provided less injury and faster functional recovery. Clinical trial information: NCT01985698.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. This study was a review of a prospective database of patients over a 5-year period. Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. All patients received a robot-assisted extralevator abdominoperineal resection. Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. This was a single-institution study with no comparative open or laparoscopic group. Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Perioperative outcomes for robotic total mesorectal excision after preoperative chemoradiation for rectal cancer.

732 Background: Laparoscopic total mesorectal excision (TME) after preoperative chemoradiation therapy (P-CRT) for mid to low rectal cancer was shown to be safe and feasible by a recent randomized trial (COREAN trial). However, the safety and short-term efficacy for robotic assisted laparoscopic TME has not been demonstrated. This study is a review of the perioperative outcomes of robotic TME after P-CRT for mid to low rectal cancer at our institution. Methods: All patients that underwent robotic TME after P-CRT for rectal cancer were retrospectively reviewed in our prospectively maintained, IRB-approved surgical oncology database. All relevant demographic, clinical, operative, pathology and perioperative data were analyzed. These were compared to the COREAN trial results. Results: From 2010 to 2014, 42 patients underwent robotic TME for rectal cancer after P-CRT. Mean patient age was 60+/-13. Robotic low anterior resections (R-LAR) were performed in 69% and 31% had a robotic abdominoperineal resection (R-APR). A majority were obese patients as 74% had a BMI ≥ 25, and 50% had an ASA ≥ 3. Conversion to open rate was 9.5% (n = 4) but 3 of these were within the first 8 cases. Median estimated blood loss was 105 ml (50-400 ml). The 30-day major complication rate (Clavien III-IV) was 11.9% (n = 5) and 90-day rate was 14.2% (n = 6). One patient (2.4%) had an anastomotic leak. There were no mortalities within 90-days from operation. Median length of stay was 7 days (6-12 days). Pathological complete response was 19% while 24% had no response. The average number of lymph nodes harvested was 14.2+/-9.5. The circumferential resection margin was negative in 95.2% (n = 40) of patients. Conclusions: As compared to laparoscopic TME patients in the COREAN trial, the robotic patients in our series were more obese and had a higher ASA classification. Our conversion rate was slightly higher, but this was related to the learning curve. All other short-term outcomes were similar. It appears that robotic TME is safe and feasible after P-CRT even among a more obese and higher risk population than previously reported in large series.

452 Concurrent Robotic Abdominoperineal Resection and Prostatectomy in a Patient With Synchronous Primary Adenocarcinomas

452 Concurrent Robotic Abdominoperineal Resection and Prostatectomy in a Patient With Synchronous Primary Adenocarcinomas

Robotic Abdominoperineal Resection for Lower Rectal Cancers: How We Do It?

Abstract Introduction: Robotic approach has been increasingly applied to the surgical resection of distal rectal cancer. All reports from the advocators on the use of robotic assistance in rectal s...

Robotic rectal cancer surgery: technique of abdomino-perineal resection.

Rectal cancer surgery using a minimally invasive technique has been regarded as a challenging procedure. Since the introduction of the robotic surgical system into the operating theater, totally robotic rectal surgery has been attempted with several techniques. Abdomino-perineal resection might be a more reliable indication for totally robotic surgery than low anterior resection. Because the range of dissection is confined to the pelvic cavity and mobilization of the sigmoid colon, problems during totally robotic surgery can be minimized. With our technique, totally robotic surgery can be performed successfully. Technical advantages of the current robotic system can be reflected in patient benefits after totally robotic abdomino-perineal resection.