Totally robotic low anterior resection (RLAR) with trans-anal specimen extraction and single stapling technique

We present the case of a 76-year-old woman with a low rectal cancer (T3N0 at 7cm) status post-chemoradiation therapy. Using a four-arm DaVinci system, we carry out the dissection in a medial to lateral fashion dividing the inferior mesenteric vessels and mobilizing the splenic flexure. A total mesorectal excision is performed to the level of the pelvic floor. The specimen is delivered through a wound protector covering the anus. The sigmoid colon is divided extracorporeally, an anvil is secured. Using robotic instruments, a purse-string is sutured to the rectal stump and tied around the EEA stapler spike. An end-to-end anastomosis is created under vision. A diverting ileostomy is performed. This novel robotic procedure eliminates the need for an incision for specimen extraction and may facilitate transection of the rectum during RLAR.

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Totally robotic low anterior resection (RLAR) with trans-anal specimen extraction and single stapling technique

Authors

JH Baek, C Pastor, J Garcia-Aguilar, S McKenzie, A Pigazzi

Abstract

We present the case of a 76-year-old woman with a low rectal cancer (T3N0 at 7cm) status post-chemoradiation therapy. Using a four-arm DaVinci system, we carry out the dissection in a medial to lateral fashion dividing the inferior mesenteric vessels and mobilizing the splenic flexure. A total mesorectal excision is performed to the level of the pelvic floor. The specimen is delivered through a wound protector covering the anus. The sigmoid colon is divided extracorporeally, an anvil is secured. Using robotic instruments, a purse-string is sutured to the rectal stump and tied around the EEA stapler spike. An end-to-end anastomosis is created under vision. A diverting ileostomy is performed. This novel robotic procedure eliminates the need for an incision for specimen extraction and may facilitate transection of the rectum during RLAR.

Classification

new techniques, robotic

Keywords

Totally robotic low anterior resection, RLAR, trans-anal specimen extraction, single stapling technique

Media type

Surgical video

Duration

11'00''

Publication

2009-07

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Subtitles

E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2699.htm

Totally robotic low anterior resection (RLAR) with trans-anal specimen extraction and single stapling technique

1. Clinical case presentation 00'08''

This video shows a totally robotic low anterior resection with trans-anal specimen extraction and single stapling technique. This is a 76-year-old woman with a rectal cancer located at 7cm from the anal verge, who underwent neo-adjuvant chemoradiation treatment and now presents for elective low anterior resection 10 weeks after.

2. Robotic system presentation 00'29''

The operation is performed with a totally robotic technique using the 4-arm DaVinci S system. The robot is docked over the left lower extremity to four ports. In addition, one extra port is used for the assistant who sits to the patient’s right. The position of the robotic system will allow us to approach both the splenic flexure and the pelvis without the need to re-dock.

3. Medial to lateral dissection 00'56''

The dissection begins in a medial to lateral fashion in the inferior mesenteric vein.

4. Division of IMV 01'07''

The vein is dissected free and subsequently divided with an endoscopic stapler. The dissection continues in a medial to lateral fashion, separating the left mesocolon from Toldt’s fascia.

5. Dissection and division of IMA 01'49''

Next, the inferior mesenteric artery is identified, dissected and divided between clips. The left ureter is identified prior to dividing the vessel. The medial to lateral dissection continues all the way laterally to the abdominal wall. The last remaining attachments of the descending colon to the abdominal wall are taken down sharply.

6. Splenic flexure mobilization 03'18''

Next, we turn our attention to the gastrocolic ligament, which is divided in order to facilitate a full splenic flexure take down. Once the flexure and the descending colon have been completely mobilized, we turn our attention to the pelvis.

7. Total mesorectal excision 03'39''

The dissection starts at the sacral promontory separating the hypogastric nerves from the mesorectum. The total mesorectal excision starts by following the areolar plane separating the visceral and parietal fascia of the rectum. The dissection continues posteriorly utilizing only monopolar cautery down to the rectococcygeal ligament, which we can see in this view. The lateral attachments are taken down next. Then, the dissection continues anteriorly, opening the peritoneal reflection and separating the rectum from the vagina. It can be noted that this woman had a prior hysterectomy. The two organs are meticulously dissected utilizing the robotic scissors. The low attachments of the rectum to the pelvic floor are divided with cautery. Likewise, anteriorly, the last remaining attachments of the rectum to the vagina are taken down. Here we can appreciate the musculature of the left-sided pelvic floor. Next, the mesocolon is divided just proximally to the origin of the mesenteric artery, all the way to the bowel wall.

8. Transanal specimen extraction 06'48''

In this procedure, we will utilize a trans-anal specimen extraction. To facilitate this, a silk tie is placed just distal to the location of the tumor. Once we confirm that the tumor is located distal to the tie just placed, the rectum is opened sharply, utilizing scissors and monopolar cautery. Prior to transection, the rectum had been irrigated and packed with a lap-pad, which we can see in this view. A laparoscopic wound protector is therefore placed into the pelvis through the anus. The assistant grasps the silk tie, and the specimen is extracted trans-anally. This is a view of the specimen showing a complete mesorectal fascia.

9. Anvil insertion 07'59''

The bowel is divided; an anvil is secured to the proximal colon and pushed back into the pelvis. The edges of the lower rectal stump are identified. The anus is packed with a new lap-pad and the 2/0 PDS is sewn around the edges for a second purse-string in preparation for the end-to-end anastomosis. This part of the procedure has to be done very meticulously to ensure full-thickness bites without grabbing adjacent structures.

10. End-to-end anastomosis 09'58''

Next, the stapler is inserted into the anus, and the spike is extracted; the purse-string is therefore tied around it. This low rectal anastomosis will be protected with a diverting loop ileostomy. The end-to-end anastomosis is performed under robotic vision as shown here. This patient had an uneventful recovery and has had no anastomotic-related complications.