Robotic abdominoperineal resection with sacrectomy in obese male patients

This video presents a robotic abdominoperineal resection with sacrectomy in an obese male patient. The patient has a BMI of 37 and a locally advanced rectal cancer invading the sacrum. After preoperative chemoradiation therapy, he developed a localized abscess within the mesorectum. He subsequently underwent a combined procedure, which included robotic total mesorectal excision followed by the perineal dissection that involved sacrectomy at the S3/S4 level. The specimen was removed through the perineum. The purpose of this video is to demonstrate the potential role of robotic technology in surgical treatment of advanced rectal cancer. The potential role of this technology is also noticed when treating obese individuals.

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Robotic abdominoperineal resection with sacrectomy in obese male patients

Authors

S Marecik, A deSouza, C Corning, J Park, L Prasad

Abstract

This video presents a robotic abdominoperineal resection with sacrectomy in an obese male patient.
The patient has a BMI of 37 and a locally advanced rectal cancer invading the sacrum. After preoperative chemoradiation therapy, he developed a localized abscess within the mesorectum.
He subsequently underwent a combined procedure, which included robotic total mesorectal excision followed by the perineal dissection that involved sacrectomy at the S3/S4 level. The specimen was removed through the perineum.
The purpose of this video is to demonstrate the potential role of robotic technology in surgical treatment of advanced rectal cancer. The potential role of this technology is also noticed when treating obese individuals.

Classification

robotic, contribution

Keywords

Robotic, abdominoperineal resection, sacrectomy, obese patient

Media type

Surgical video

Duration

06'29''

Publication

2011-06

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E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3297.htm

Robotic abdominoperineal resection with sacrectomy in obese male patients

1. Clinical case presentation 00'12''

This video presents a robotic abdominoperineal resection with sacrectomy in an obese male patient. The patient has a BMI of 37 and a locally perforated rectal cancer with invasion of the sacrum at a S4-S5 level. Preoperative imaging also revealed invasion of the left levators. The patient was treated with chemoradiation, which resulted in necrosis of the tumor and formation of the contained abscess within the mesorectum. The first step of the procedure is performed with the robot placed between the patient’s legs.

2. Dissection on sacral promontory 01'09''

In order to obtain adequate exposure, the sigmoid is released. This allows retraction of the rectosigmoid so the dissection may be started at the level of the sacral promontory. The plane underneath the superior hemorrhoidal artery is entered. The course of the artery is marked towards the inferior mesenteric artery root. Robotic technology allows for steady retraction and precise dissection. We always try to identify and preserve the autonomic nerves.

3. Sigmoid mobilization 01'52''

After the remaining sigmoid is mobilized, the two planes of dissection meet at the level of the pelvic brim. The left ureter is identified.

4. IMA dissection 02'07''

The root of the inferior mesenteric artery is carefully prepared, isolated and controlled with the energy device below the take off of the left colic branch.

5. Mesorectal dissection 02'20''

Attention is brought back to the mesorectum, where dissection in the presacral plane is continued with gradual extension toward the right and left pelvic sidewalls. We believe that the deeper the dissection is carried into the narrow pelvis, the more pronounced are the benefits of robotic surgery. Here, the mesorectum is separated from the left pelvic sidewall. Subsequently, the dissection is moved to the anterior aspect of the mesorectum. Denonvilliers’ fascia is identified. For the time being, the mesorectum is released posteriorly. However, the dissection is stopped at the level of the left levators. This is the area of concern as seen on preoperative imaging studies. This area will be approached en bloc with sacrectomy. The right pelvic sidewall and anterior aspect of the mesorectum are not involved so dissection can be carried out distally. Gradual circumferential release of the mesorectum is often necessary in the long, narrow pelvis. During anterior dissection, special attention is given to keep Denonvilliers’ fascia intact in an effort to preserve sexual function. In traditional open surgery, the anterior aspect of the dissection is frequently challenging because of poor exposure. With robotic assistance, this difficult part can be easily accomplished. If the dissection is performed posterior to Denonvilliers’ fascia, it is frequently bloodless. Anterior mobilization is stopped at the level of the lower prostate. The final step includes partial exposure of the right levators.

6. Completion of TME and colostomy 04'45''

Once TME is completed, the proximal mesentery is transected, the omental pedicle flap and the colostomy are created.

7. Sacrum excision 04'56''

The patient is then placed in the prone position. The circumferential perianal incision is extended over the lower sacrum. The levators and distal sacrum are exposed. The sacral ligaments are divided, the segments of the sacrum are counted and the sacral body is transected at the S3-S4 level. This allows for a wide access to the lower pelvis and easy transection of the levators. The area of concern in the left posterior aspect can be directly approached. A short anterior dissection is performed in front of the sphincter muscle complex. The specimen is delivered and evaluated for quality. It has a clearly cylindrical appearance. The origin of the left levators is marked with hemoclips for a future surveillance. The omental pedicle flap is delivered and the wound is closed.