Robotic intersphincteric resection and coloanal anastomosis: technical detail

Introduction Minimally invasive surgery for colorectal diseases has dramatically changed since the introduction of laparoscopic surgery. The frontline for minimally invasive surgery has further progressed since the advent of robotic surgery, with developments more pronounced for rectal cancers especially considering the perceived technological advantages of robotic surgery over the laparoscopic method. The intersphincteric resection for low rectal cancers pro-vides a challenge for open approach and also for laparoscopic method. This paper discusses the method used for a robotic intersphincteric resection and coloanal anastomosis. Methodology Here, we report a detailed operative technique for performing a robotic intersphincteric resection and coloanal anastomosis. Discussion Surgical intersphincteric resection is a realistic option for surgical treatment of low rectal cancers. Introduction The low rectal tumours (<5 cm from anal verge), including those that were close to anal sphincter complex, have been traditionally surgically treated by an abdominoperineal resection, with resultant permanent end colostomy and with perineum closed off. In 1994, Schiessel described an alternative approach of intersphincteric resections (ISRs) for these low rectal tumours1, with acceptable short-term to medium-term results from oncological and functional perspectives. Subsequently, studies have reported the safety, efficacy and satisfactory outcomes of this ISR approach2–5. Since the advent of minimally invasive surgery, there has been increasing use of laparoscopic surgery for treatment of rectal cancers. For low rectal cancers, there have been proponents for undertaking ISR laparoscopically, with evidence showing that it is safe, feasible and with acceptable outcomes6–8, and that outcomes were comparable with open approach9. Since the first robot-assisted colectomy was reported a decade ago10, robotic surgical systems have been utilised for undertaking colorectal resections10–15. There has been particular interest on robotic total mesorectal excision (TME) for rectal cancer surgery16–20. However, there has been only very limited evidence on robotic ISR for low rectal cancers, including the technical aspects of undertaking a robotic ISR. We describe technical aspects of our operative approach to performing a robotic ISR and coloanal anastomosis. Methodology The authors have referenced some of their own studies in this methodology. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies. Operative techniques for robotic high-tie ligation with ISR and coloanal anastomosis There are generally two approaches for undertaking a robotic rectal cancer surgery. The first one is a hybrid technique, with a combination of laparoscopic surgery for the abdominal part and robotic approach for pelvic operation21,22. The second is a totally robotic approach, which has three sub-variations in technique depending on the number of times the robotic patient cart needs to be re-docked. The three-stage technique12 and twostage technique14 were initially developed to aid the ease of dissection for various operative stages – colonic mobilisation, vascular pedicle ligation and pelvic dissection. However, since mid-2007, we have developed a single-stage totally robotic surgery without the need to re-dock the patient cart18. We use the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). Patient position and port placement Once general anaesthesia is induced, patient is positioned over beanbags to use as anti-sliding restrainers and placed in the Lloyd-Davies position. Prior to the start of the operation, we use standard preoperative measures of antibiotics prophylaxis, urethral catheterisation, anti-embolic compression stockings and pneumatic calf pumps. We use six ports as standard for our robotic procedures: 12-mm optical port, four 8-mm robotic working ports * Corresponding author Email: [email protected]; [email protected] Colorectal Surgical Division, Department of Surgery, Korea University Anam Hospital, Anam-dong 5-Ga, Seongbuk-gu, Seoul 136-705, Korea