Combined robotic and transanal approach for rectal cancer with local extension

The case is a 74-year-old patient with a history of osteoporosis and depressive syndrome, who was diagnosed with a rectal neoplasm 14 cm from the anal verge , following a rectal bleeding. A CT scan was performed showing a large tumor at the level of the rectum with involvement of the posterior uterine wall and mucinous component with possible perforation. Doubtful invasion of the cecal appendix. No distant disease was identified. MRI was classified as a rectal tumor T4bN0 14 cm from the anal verge , with uterine infiltration. After discussing  the case in our oncological committee it was decided to perform the surgery: LAR + hysterectomy + bilateral salpingo oophorectomy by da vinci abdominal approach + TaTME by Cecil approach.

Clinical case

The patient was placed in the Lloyd Davies position and a transanal access platform was placed. We introduced the GelPoint path transanally using 3 trocars (one for the 3D Olympus scope and two work trocars). A total of four 8 mm trocars were placed in the abdomen (umbilical nº 2, left hypochondrium nº 1, right flank nº 3, and right iliac fossa nº 4) 1, 3 and 4 are work ports and port number 2 is for the scope. In addition, a 12 mm trocar is used as an assistant in the right flank. The first step, before beginning with the dissection, is to clamp the colon to be able to insufflate air from the transanal approach and thus avoid the distension of the whole colon.  Once we locate the target anatomy we proceed to release the left parietocolic . We perform it with care to avoid injury to retroperitoneal structures such as the ureter. We now proceed to the exposure of the mesenteric vessels for proper section. At this time we can see the inflammatory reaction in the pelvis in relation to the large tumor. The dissection starts with an incision of the peritoneum in the mesentery.  A cautery is used to open the peritoneum along this line, opening the plane cranially up to the origin of the inferior mesenteric artery. We continue the medial to lateral dissection , taking care not to injure the iliac vessels or the left ureter. The dissection of the inferior mesenteric artery ends and is transected by LigaSure™   from the assistant trocar.  Then we continue the dissection until the i nferior mesenteric vein is identified. After a careful dissection, we also sectioned it with Ligasure™. At this time we release the posterior side of the colon from medial to lateral. We are able to easily change the approach, completing dissection from the left side connecting with the work done from the medial side and ending releasing the descending colon. Once this step is completed, we decided to continue dissection into the pelvis. The first thing to do is the section of the appendix as it is included in the tumor inflammatory reaction. We use the hook and LigaSure™ to section the mesoappendix and a mechanical stapler to section the base of the same. At this point in the surgery we decided to section the colon to continue the dissection of the pelvis. We proceed to the section of the mesocolon with the LigaSure™ and the transection of the colon with the mechanical stapler. Then we decided to perform a dissection on the posterior side of the rectum , and try to communicate with the transanal team. At this time of the surgery the robot is especially useful to be working in a small and narrow field, with little space. Meanwhile the transanal approach was under way . The tumor was identified and a Prolene Ⓡ pursestring was made setting the distal margin. The dissection of the mesorectum began after sectioning the rectal wall.The surgery progressed down-to-up while the abdominal  team performed the robotic surgery. We also performed a pursestring in the distal rectum to later configure the anastomosis. At this moment we can objectify the opening of the peritoneal reflection. The abdominal team is still not visible as we find the infiltration of the tumor at the level of the uterus. We continue the dissection circumferentially  progressing at the posterior side, then right lateral side, and left lateral side. Here we can see again how the tumor invades the uterus from the anterior side of the rectum. Continuing the dissection in the abdominal approach, we finally connected with the transanal team in the same plane. Now both teams work at the same time, thus having a better view of the structures and different planes, thus avoiding inadvertent injuries. Once dissection of the posterior side is completed, it is decided to perform the hysterectomy, bilateral salpingo oophorectomy by da Vinci abdominal approach to perform an en bloc resection with the rectum. We performed the resection by hook and Ligasure™  to ensure hemostasis. While from the transanal approach the cervix is opened to be able to perform an oncologic resection with safety margins. On the anterior side we can already feel the instruments of the abdominal team. Finally we communicate both teams cutting the cervix to perform a block resection of the rectum and other structures affected. From this point both teams work together to complete a circumferential resection of the entire specimen. Simultaneous work by both teams is important because they are working to improve exposure and clarify the planes in the same area. Finally we completed the surgery, removing the specimen. After this, we remove the robot and proceed to create the anastomosis. The specimen is exteriorized through a Pfannenstiel incision in the hypogastrium. We verify the correct vascularization of the proximal colon and that is sufficient to create an anastomosis without tension. We make an end to end colorectal mechanical anastomosis completing the surgery by laparoscopic approach. To facilitate the introduction of the stapler through the rectum we place a tube in it that serves as a guide through the pursestring previously performed on the rectum stump. The anastomosis is reinforced with 3 stitches and the vagina is closed with a barbed suture. Finally a drain is placed and the surgery is over.

Outcome

The surgery took 145 minutes. The postoperative period was correct. The patient started oral intake 8 hours after the surgery and left hospital on the 4th postoperative day. Pathological examination ruled out an Mucinous Adenocarcinoma of the rectum T4bN0 , with invasion of the uterine wall, negative margins and complete mesorectum.