Robotic Total Mesorectal Excision for Rectal Cancer

Abstract

Aims: Total Mesorectal Excision (TME) for rectal cancer is one of the most widespread and performed robotic procedures. The video shows some technical details of a full robotic TME. Methods: A 12-mm optical port is inserted in the right flank. Four 8-mm robotic trocars are inserted along a straight line that is parallel to and about 4 cm cranial to the costofemural line, maintaining a 6-8 cm distance between each port. An additional 8-mm robotic port is placed in the left flank. Dissection starts on the posterior aspect of the mesorectal envelope: The right lateral and the anterior planes are then subsequently dissected up to the seminal vescicles in a counterclockwise fashion. The left lateral pelvic fascia is then dissected up to its lower portion to allow for the identification of the pelvic nerve plexus and to gain access to the 'bare rectum area'. Dissection is then completed anteriorly on the lower portion of the Denonvillier's fascia and circumferentially below the reflection of the mesorectal fascia to gain access to the levator ani plane. Rectal transection is performed with 45-mm robotic staplers after evaluation of rectal stump perfusion with the integrated fluorescence imaging system. Results: Mean total operative time was 265 minutes and the conversion rate was 2.5%. The mean length of hospital stay was 6.9 days. According to Clavien-Dindo classification, 30-days minor postoperative complications (grade I and II) and 30-days major postoperative complications (grade III and IV) were 16.1% and 8.4% respectively. Anastomotic leakage rate was 5.9% and reintervention was needed in 8.4% of the cases. Mean number of nodes retrieved was 20, the mean distal resection margin was 2.8 cm and 2.5% of patients had an involvement of circumferential resection margin. Conclusions: Robotic platform ensures several technical advantages to perform TME with high-quality specimens.