Robotic-Assisted Extralevator Abdominoperineal Resection
Laparoscopic abdominoperineal resection (APR) with total mesorectal excision (TME) for low rectal cancer has been shown to be safe and effective and is associated with advantages over open techniques. However, laparoscopy has some limitations secondary to
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Kang Hong Lee, Mehraneh D. Jafari, and Alessio Pigazzi
Current Applications of Robotic Abdominoperineal Resection The evolution of surgical technique, instrumentation, and superior outcomes of minimally invasive surgery has made laparoscopy the standard of care for colon cancer treatment. The feasibility and the advantages of laparoscopic colectomy in terms of faster recovery, lower postoperative pain, and shorter hospital stay have been demonstrated by large prospective studies [1–5]. Laparoscopic abdominoperineal resection (APR) with total mesorectal excision (TME) for low rectal cancer has been shown to be safe and effective. It is associated with several advantages including lower morbidity, shorter
K.H. Lee, M.D., Ph.D. Department of Surgery, Hanyang University College of Medicine, 17 Haengdang-dong, Seongdong-gu, Seoul 133-792, South Korea e-mail: [email protected] M.D. Jafari, M.D. Department of Surgery, University of California, Irvine School of Medicine, 333 City Blvd., West Suite 850, Orange, CA 92868, USA e-mail: [email protected] A. Pigazzi, M.D., Ph.D. (*) Division of Colorectal Surgery, Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd., West Suite 850, Orange, CA 92868, USA e-mail: [email protected]
duration of hospital stay, reduced cost, and reduced intensive care unit admissions [6]. However, laparoscopy has some limitations secondary to the anatomical structure of pelvis, rigid visualization system, instrument length, and articulation. The da Vinci robot has the potential to overcome some of the limitations of laparoscopy by providing improved threedimensional vision, enhanced ergonomics, articulated instruments, and tremor elimination [7–9]. Early experiences with robotic rectal resection highlight the potential for decreased conversion rates, lower blood loss, and superior mesorectal grade compared to conventional laparoscopy [8–11]. Robotic APR can be performed utilizing a fully robotic technique or a hybrid laparoscopic– robotic technique whereby the robot is docked after mobilizing the sigmoid colon and dividing the vessels with conventional laparoscopic techniques.
Indications Currently the most common indications for APR in the era of minimally invasive surgery are: • Rectal cancer invading the sphincter complex • Rectal cancer in patients who are not candidate for sphincter preservation because of poor functional status or comorbidities • Recurrent rectal cancer • Anal cancer, which recurs after or does not respond to chemoradiotherapy
K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_21, © Springer Science+Business Media New York 2014
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Robotic Positioning and Docking Room setup is standard as for any robotic colorectal procedure keeping in mind the necessary space requirements for the surgeon, the assistant, and the operating room personnel. The patient is positioned in modified lithotomy in Trendelenburg position with a degree of right-sided table tilt enough to keep the small intestine out
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