Robotic total mesorectal excision, a practical solution in an obese female patient

This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids. The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy. The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer. Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”

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Robotic   total   mesorectal   excision,   a   practical   solution   in   an   obese   female   patient

Authors
S Marecik, M Zawadzki, C Corning, J Park, L Prasad
Abstract
This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids.
The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy.
The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer.
Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”
Classification
robotic, contribution
Keywords
Robotic Total Mesorectal Excision, TME, practical solution, obese patient
Media type
Duration
15'06''
Publication
2011-05
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3296.htm

Robotic   total   mesorectal   excision,   a   practical   solution   in   an   obese   female   patient

5. Total mesorectal excision 04'27''
Rectal stump is appropriately retracted and the presacral dissection is begun at the level of the sacral promontory. The autonomic nerves are identified and preserved. A careful dissection is carried out until the level of the retrosacral fascia. Once rectosacral fascia is incised the avascular plane is readily identified and dissected. At this point, the posterolateral dissection becomes easier. This will be continued deep into the pelvis gradually adjusting the tension and retraction on the rectal stump. It is time to discuss the advantages of the new robotic technology in the deep pelvic dissection. We hope that this video will demonstrate the superiority over the open and laparoscopic approach. The responsible factors include the stability of the retraction and the camera platform, unparalleled precision of movements, high resolution imagery, delicate tissue handling and the fact that 5 active instruments are used simultaneously in this challenging operating field. The mid and lower rectal cancer remain the condition difficult to treat. To provide our patients with optimal oncologic outcomes, we are in constant search of the best techniques. We should explore the potential of robotic technology to assist us in this goal. To answer the question why isn’t the entire procedure performed robotically, we have to understand that addressing several quadrants of the abdominal cavity requires change of the robotic cart position. There have been isolated reports of performing the entire procedure with one robotic position; however, the majority of cases in the Western society requires that the position is changed. The most practical approach is to utilize the robot for difficult to access spaces, whereas the more accessible parts of the abdomen can be easily served by the laparoscopic techniques. Additionally the access to the isolated rectum and conduct of the dissection can be standardized while the abdominal colon mobilization is more variable. At this point, we will return our focus to the dissection itself. After posterior mobilization, we turn our attention to the lateral aspects of the upper mesorectum and subsequently the anterior aspect. The rectovaginal septum is dissected. The pelvis is widely open because one of the robotic arms effortlessly retracts the anterior pelvic structures. The dissection is patiently carried out in the circumferential fashion releasing attachments and maintaining the mesorectal envelope intact. The isolation of the rectosigmoid by earlier transection of the bowel mesentery facilitates easier handling of the rectum. Here the levators are exposed. Subsequently, the dissection can be moved towards the rectovaginal septum. The hybrid concept mentioned earlier in this narrative is based on the utilization of the technique best suited for each step of the procedure. That involves using laparoscopic techniques for abdominal colon mobilization, using the open technique through a small horizontal suprapubic incision for bowel transection and isolation of the rectosigmoid, using the robotic technique for total mesorectal excision and finally returning to the open technique for distal bowel control, specimen extraction and creating a secure anastomosis. We believe that in order to make the procedure simple, reliable and efficient, the combination of all available techniques is justified. It also allows for wider adoption among the surgeons. As we all know, purely laparoscopic rectal dissection is very challenging and is performed in very few specialized centers worldwide. In addition, the published results of laparoscopic rectal surgery are not clearly superior to the open techniques. We believe that implementation of the robot for rectal dissection can provide a better quality of dissection than either open or laparoscopic techniques. This in turn should translate into better patient outcomes. In our experience it is possible to perform robotic total mesorectal excision in the obese patients with the BMI higher than 40. At the same time, we can demonstrate the clearly intact mesorectal envelope. This is nearly impossible when using conventional laparoscopic techniques in these patients. With widespread obesity in the Western population developing optimal techniques to meet these intraoperative challenges is critical. We identified that height of the patient is also an important factor to consider. That is why a purely robotic approach with single cart position may not be performed in many patients. Here again, the hybrid technique appears optimal. The deep pelvis is reached during the posterior dissection as in an open technique. The levators are exposed. This allows bilateral access to the most challenging part of the dissection which are the deep lateral mesorectal recesses. The middle rectal vessels are rarely encountered and almost never pose significant bleeding issues. The hook cautery or bipolar grasper cautery is sufficient to control them. Once the India ink mark is identified, the distal target is prepared. In this case, this is just at the anorectal junction. In selected patients, with the tumor encroaching on the sphincter muscle complex, the intersphincteric plane can be developed from the intra-abdominal side. It is necessary to clear the mesorectal tissue from the distal target bowel in order to facilitate the stapler application. The attachments to the pelvic floor are also released to allow for proper alignment of the stapler. It is our observation that implementation of robotic technology for total mesorectal excision will allow a superior dissection not only in obese patients but also in patients with locally advanced rectal tumors. In the future, an appropriate specific technology can be developed to improve the reconstruction process. For now, both a laparoscopic and robotic techniques are not superior to well established open techniques for creation of the anastomosis. Therefore, to accelerate the reconstruction process, we often choose a traditional open technique through the Pfannenstiel incision. It is very rare that a 60mm or a 45mm TA stapler cannot be inserted deep in the pelvis. This allows for a single staple line to be applied precisely at the target point. In some cases, a laparoscopic stapler can be applied, however one of the robotic ports has to be replaced with a 10 or 12mm port. The next step involves undocking of the robotic cart and removal of the laparoscopic ports. The wound retractor remains in place. Subsequently, the proximal bowel is delivered through the wound to confirm that length is sufficient for reconstruction. Next, the mobilized rectum is delivered through the wound. The origin of the superior mesenteric artery is shown here.