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Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
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Gene
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ry
Robotic intersphincteric resection and coloanal anastomosis: technical detail
R Mathew*, SH Kim*
AbstractIntroductionMinimally invasive surgery for colo-rectal diseases has dramatically cha-nged since the introduction of lapar-oscopic surgery. The frontline for m-inimally invasive surgery has furthe-r progressed since the advent of ro-botic surgery, with developments m-ore pronounced for rectal cancers e-specially considering the perceived technological advantages of robotic surgery over the laparoscopic meth-od. The intersphincteric resection f-or low rectal cancers pro-vides a ch-allenge for open approach and also for laparoscopic method. This paper discusses the method used for a robotic intersphincteric resection and coloanal anastomosis. MethodologyHere, we report a detailed operative technique for performing a robotic i-ntersphincteric resection and coloa-nal anastomosis.DiscussionSurgical intersphincteric resection is a realistic option for surgical treatm-ent of low rectal cancers.
IntroductionThe 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 co-lostomy and with perineum closed
off. In 1994, Schiessel described an alternative approach of intersphinc-teric resections (ISRs) for these low rectal tumours1, with acceptable short-term to medium-term results from oncological and functional perspectives. Subsequently, stud-ies have reported the safety, efficacy and satisfactory outcomes of this ISR approach2–5.
Since the advent of minimally inva-sive surgery, there has been increas-ing use of laparoscopic surgery for treatment of rectal cancers. For low rectal cancers, there have been pro-ponents for undertaking ISR lapa-roscopically, with evidence showing that it is safe, feasible and with ac-ceptable outcomes6–8, and that out-comes were comparable with open approach9.
Since the first robot-assisted colec-tomy was reported a decade ago10, robotic surgical systems have been utilised for undertaking colorec-tal 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 un-dertaking a robotic ISR. We describe technical aspects of our operative ap-proach to performing a robotic ISR and coloanal anastomosis.
MethodologyThe 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 anastomosisThere are generally two approaches for undertaking a robotic rectal can-cer surgery. The first one is a hybrid technique, with a combination of lap-aroscopic 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 depend-ing on the number of times the robot-ic patient cart needs to be re-docked. The three-stage technique12 and two-stage technique14 were initially de-veloped to aid the ease of dissection for various operative stages – colonic mobilisation, vascular pedicle liga-tion and pelvic dissection. However, since mid-2007, we have developed a single-stage totally robotic sur-gery without the need to re-dock the patient cart18. We use the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA).
Patient position and port placementOnce 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 cath-eterisation, 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
Page 2 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
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ts: n
one
decl
ared
. Al
l aut
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and
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man
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All a
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the
Asso
ciati
on fo
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ical
Eth
ics (
AME)
eth
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rule
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sure
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• LUQ and LIF ports should ideallybe just medial and just lateral tothe MC line respectively.
• Balloon port for optical port siteis preferable, especially for obesepatients.
• Assistant 5-mm port should beplaced medial to the MC line, as atoo lateral port can cause SB injuryduring instrumentation changes,as SB is usually dependant to theright side of the abdomen. The as-sistant port can be used to connectto a smoke extractor.
Patient cart placement and robot dockingThe patient cart is brought to pa-tient’s left side parallel to the left thigh. The central shaft of the pa-tient cart is aligned in an imaginary straight line with the umbilicus and left anterior superior iliac spine (ASIS) (Figure 2). The ports are then docked to the robot (Figure 3), in-cluding-optical zero degree robotic camera at the umbilical port and RIF port (robotic arm 1) for the surgeon’s right arm using monopolar curved scissors. The RUQ port is docked for the surgeon’s left arm and Maryland bipolar forceps are introduced here. A Cadiere grasper is used as the surgeon’s second left arm is used via the LUQ port.
instrumentation. Also, it is advis-able to place some cotton roll/gel padding between the right shoul-der of the patient and beanbag to prevent undue pressure on the patient shoulder from the vacu-um-hardened beanbags. The right shoulder is the area of maximum dependant pressure with patient tilt during operation.
• The knees should be slightly flexedin the Lloyd-Davies position, and then the whole leg positioned for the thigh to be flat with the pa-tient’s abdomen level. This again helps with ease of instrumenta-tion. In addition, the left leg should be less abducted, to provide more room for the robotic patient-side cart coming parallel to the left thigh of the patient.
• Although the port positions arepen-marked initially, following pneumoperitoneum creation that stretches the abdominal wall, the final port positions could be placed more outwards, if needed, especially in a thin patient to cre-ate more space between the ports. The placement site of the RUQ port should be carefully chosen in a way that it is not very close to the falciform ligament to prevent hindrance from this during instru-ment changes.
and a 5-mm assistant port (Figure 1). The initial approximate port positions are pen-marked on the abdomen prior to creation of pneumoperitoneum. The first port to be marked is the right-il-iac fossa (RIF) port near Mc-Burney’s point, which should ideally be at the eventual stoma site. The second port marking is at the right-upper quadrant (RUQ) just inferior to coastal margin at mid-clavicle (MC) line. The optical port site is marked at the umbilical region, but it is to be noted that this optical port placement is not necessarily at umbilicus itself, but can be either the superior/inferior side of umbilicus depending on the apex of the trian-gle, with RIF and RUQ port markings forming the base of the triangle. The next port is to be placed at the left up-per quadrant, just medial to MC and another port at left-iliac fossa (LIF), which would be at the corresponding level to RIF port site. Finally, an as-sistant port is placed at mid-point be-tween the RUQ and RIF ports. After the pen markings are made, all the ports are inserted, starting with the optical port using an open ‘Hassan’ technique. Pneumoperitoneum is initially set at 12 mm Hg. The patient is now placed in a 30° Trendelenburg tilt and a 15° left-side tilt upwards. Visual inspection of abdominal cavity and pelvis is done to assess any obvious evidence of distant metastatic disease. The greater omen-tum is retracted over and above the transverse colon, which is then sub-sequently pushed up superiorly. The small bowel (SB) is retracted medially and superiorly. A 10 × 10 cm gauze is used to help retain medial SB retrac-tion. These manoeuvres help visuali-sation of the root of the IMA pedicle. In addition, patient’s tilt helps keep SB and transverse colon retracted away using the help of gravity. Finally, pneu-moperitoneum is reduced to 8 mm Hg.
Further tips/pointers• The upper level of beanbags
should not exceed the patient level, as this could hamper the ro-botic arms or even the assistant
Figure 1: Port positions.
Page 3 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
uted
to c
once
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and
des
ign,
man
uscr
ipt p
repa
ratio
n, re
ad a
nd a
ppro
ved
the
final
man
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All a
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the
Asso
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on fo
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AME)
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arm movement required would be much greater than when the port is not too deep in order to create a similar angle of instru-ment tip movement inside the abdominal cavity. Second, an extra deep port placement may cause excessive traction on the abdominal wall.
• The full insertion of the threeworking instruments is to be done under direct vision, and eventu-ally directed closed enough to the start of the dissection area, which is at the inferior mesentery artery (IMA) pedicle.
• Diathermy settings: bipolar set-tings – 30 (standard), and monop-olar settings – 25 cutting (pure) and 25 coagulation (fulgurate).
• Before the start of the next stageof operation of undertaking ro-botic surgery, it is important to ensure that there is adequate space between all the robotic arms, particularly the shoulder and elbows. Also, once docked, the patient positions should not be changed without undocking completely.
Operative part, abdominal–colonic mobilisation, vascular pedicle ligationThe IMA pedicle is identified and the sigmoid mesocolon over IMA is lifted upwards using Cadiere forceps. The peritoneum at the base of the IMA is incised and dissected with monopo-lar scissors. Particular care is taken here to preserve the hypogastric nerve plexus. Dissection around ori-gin of the IMA pedicle is completed. The IMA is then divided near its ori-gin, after application of 10-mm robot-ic Hemo-O-Lok clips (Weck Closure System, Research Triangle Park, NC), with two clips applied proxi-mally on the patient’s side (Figure 4). Following this, Cadiere forceps are changed to hold the divided IMA pedicle of the mesocolic side. Dissec-tion is then continued superiorly to-wards the ligament of Treitz, and then
Figure 2: Patient-side robotic cart positioning.
Figure 3: Docking for abdominal part of operation.
Further tips/pointers• Depth of port insertions into the
abdominal cavity should not be
too deep for two reasons – once the port is too deep, due to ful-crum effect, the angle of robotic
Page 4 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
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sts:
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onfli
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ts: n
one
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l aut
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to c
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and
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man
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ratio
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nd a
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All a
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the inferior mesenteric vein (IMV) is identified and divided near the in-ferior pancreatic border ( Figure 5). Medial to lateral dissection is com-pleted, including dissection of the mesocolon away from the retroperi-toneum and Gerota’s fascia. The left ureter and gonadal vessels are iden-tified and preserved (Figure 6). The dissection is continued superiorly over the pancreas until the lesser sac is entered. Completion of lateral dis-section is commenced at the pelvic brim, at the ‘white line’, and working cephalad towards the splenic flexure. During this part of dissection, the assistant maintains an active retrac-tion of sigmoid colon medially. Once the proximal descending colon area is reached, the second left arm with Cadiere forceps is undocked to pre-vent external collision of the first and second left arm. Safe counter-traction is maintained by the first left hand Maryland forceps. The splenic flexure is then completely mobilised after di-vision of reno-colic and spleno-colic ligaments. The transverse mesoco-lon is opened just above the body of the pancreas to enter the lesser sac. Dissection is then completed after dividing the greater omentum, in the avascular plane, from the mid to dis-tal part of the transverse colon.
Further tips/pointers• Once the lesser sac is entered,
during completion of medial to superior/lateral mobilisation, the 10 × 10 cm gauze is placed at the lesser sac above the superior–lat-eral border of the pancreas. This gauze placement aids completion of splenic flexure mobilisation and dissection of the lesser sac from the superior side.
• In our opinion, splenic flexurecomplete mobilisation is neces-sary for obtaining adequate length for a tension free coloanal anasto-mosis. Likewise, the high ligation of IMA and IMV also helps in en-suring adequate length for a ten-sion free anastomosis.
Figure 4: IMA dissection and high division, along with hypogastric nerve preservation.
Figure 5: IMV division.
Operative part – pelvic TME dissection and intersphincteric dissectionBefore the start of pelvic dissection and TME, the two left-sided robotic arms from RUQ and LUQ are un-docked. These are then re-docked to the LUQ port (left arm, with Maryland grasper) and LIF port (second left
arm, with Cadiere forceps) (Figure 7). The position of the patient cart itself remains unchanged. This change of ports also allows the assistant to uti-lise the two upper right-sided ports, with the RUQ port used for cephalad retraction of rectosigmoid and right flank port with a sucker for both the suction/retraction purpose.
Page 5 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
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. Al
l aut
hors
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to c
once
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and
des
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man
uscr
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repa
ratio
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the
final
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All a
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the
Asso
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on fo
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AME)
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rule
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Figure 6: Medial to lateral mobilisation with identification and preservation of Left ureter and gonadal vessels.
The first step in pelvic TME dissec-tion starts with division of pelvic per-itoneum on the right side of the mes-orectum. Following this, dissection is started posteriorly in the TME plane. The Cadiere forceps retract the upper mesorectum anteriorly, whilst the Maryland forceps give counter-trac-tion to aid the sharp dissection, using right arm scissors, along the avascu-lar plane between the mesorectum and presacral fascia. Care is taken to preserve both the right and left bun-dles of hypogastric nerves (Figure 8). The dissection is continued up to the Waldeyers fascia (rectosacral fascia), and is then continued on the right lateral side with the Cadiere forceps moved to the right lateral side wall for counter-traction. The dissec-tion is then moved to the left side, with Cadiere forceps retracting the mesorectum medially and the first left arm Maryland forceps providing lateral counter traction (Figure 9). At this stage, the assistant’s left hand cephalad traction on rectosigmoid is enhanced by changing traction to a cotton tape tie on rectosigmoid. Sub-sequently, the anterior plane is dis-sected after dividing peritoneal re-flection and then continued through the Denovillier’s fascia in males/rectovaginal septal fascia in females (Figure 10). During anterior dissec-tion (Figure 11), Cadiere forceps may be used to give anterior trac-tion on the prostrate/vagina, whilst Maryland forceps may give posterior traction on the rectum. The posterior TME dissection is then completed through the Waldeyers fascia, and likewise the lateral attachments are divided, taking particular care to pre-serve the pelvic plexus in the lateral sidewalls. If the middle rectal artery is encountered during the lateral dis-section, these are divided after ap-plying Hem-O-Lok clips (Figure 12). The posterior dissection is then con-tinued, angled upwards to follow the sacral curve. It is to be noted that as the SB would obscure the right later-al plane, further posterior dissection
Figure 7: Docking for pelvic dissection.
down to the levator ani muscle is ap-proached from the left lateral plane, while the rectum is lifted up by the Cadiere graspers. The final part of TME dissection is completed circum-ferentially, to reach the pelvic floor muscle sling.
For the intersphincteric dissection, the puborectalis muscle sling is ex-posed laterally. The posterior anococ-cygeal ligament is divided (Figure 13). The Cadiere forceps are used to maintain lateral pelvic wall traction, whilst the Maryland forceps are used
Page 6 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
uted
to c
once
ption
and
des
ign,
man
uscr
ipt p
repa
ratio
n, re
ad a
nd a
ppro
ved
the
final
man
uscr
ipt.
All a
utho
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bide
by
the
Asso
ciati
on fo
r Med
ical
Eth
ics (
AME)
eth
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rule
s of d
isclo
sure
.
• Majority of the posterior TME dis-section is done from the left side,partly due to the reason that twoout of three robotic working armsare angling in from the left side.
• To not injure the bowel or breachthe mesorectum envelope – notethat traction on bowel/mesorectalfascia propria should primarily bemaintained by not pinching/hold-ing the tissues, but by maintainingretraction using the convexity ofMaryland forceps or the endowrist-ed flexed part of Cadiere forceps.
• In our opinion, progress during TMEdissection is better enabled by se-quential circumferential dissectionrather than undertaking completesegments one at a time, such as dur-ing the laparoscopic approach (e.g.complete posterior dissection, thenlateral part and finally anterior partin a laparoscopic approach)
• The ideal places to start the inter-sphincteric dissection is between9–11 o’clock and corresponding1–3 o’clock positions to quicklyand easily get into the blood-lessintersphincteric plane.
Perineal part – completion of intersphincteric dissection, coloanal anastomosisBoth legs are now put in the steep lithotomy position. The anal canal is opened up with stay sutures, start-ing at the 12, 3, 6 and 9 o’clock po-sitions. Further, stay sutures are placed along the clock positions. Moist gauze is inserted into the anal canal lumen after identifying the dis-tal level of tumour. The intersphinc-teric plane is injected with 20 ml of diluted adrenaline (1:200,000) in normal saline ( Figure 15). The level of dissection, 1 cm distal to the tumour, is marked circumferen-tially on anal canal mucosa (Figure 16). The dissection is started posteriorly, after dividing the anal mucosa and internal anal sphincter (IAS) at this level to reach the intersphincteric plane (Figure 17). This plane is then dissected circumferentially through
Figure 8: Posterior TME dissection with preservation of hypogastric nerves.
Figure 9: Left pelvic side wall dissection with preservation of lateral wall nerve plexus.
to maintain gentle traction on the external anal sphincter (EAS) to ex-pose the intersphincteric space. The curved right hand scissors are used for dissection within the intersphinc-teric space. This intersphincteric dis-section (Figure 14) is then continued distally and completed circumferen-tially. Haemostasis is ensured. The robot is now undocked.
Further tips/pointers• Take great care to preserve the
pelvic nerves, with particular ar-eas to note – the bilateral hypogas-tric nerves during the initial part of posterior TME dissection, pel-vic sidewall lateral nerve plexus at S2-4 level area, and also nerve complexes near the seminal vesicle area at 10 and 2 o’clock positions.
Page 7 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
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to c
once
ption
and
des
ign,
man
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All a
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Asso
ciati
on fo
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AME)
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via the abdominal wall. Although extraction through anus is possible when the tumour is very small, this is not advisable for big tumours or bulky mesorectum as this can damage the residual anal sphincter complex. In these situations, the specimen ex-traction is normally done via a small incision at the LIF site (at site of LIF port). The proximal area of intended colon division is then stapled, and the resected specimen is sent for histol-ogy. Two long stay-sutures are placed on both corners of the stapled end (so as to help in correct orientation of the bowel and not to have it twisted) and reinserted back into the peritoneal cavity. The stay sutures are held by long graspers and the stapled end of the colon brought out via anal canal. In case of per anal specimen extrac-tion, the specimen is gently pulled out from the anus (Figure 19), and proximal colon’s transection site is stapled. The orientation of proximal colon is ensured to avoid any mesen-teric twist. The pelvis is washed and haemostasis is ensured, and a drain is placed in the pelvis, which is brought out through the LIF site. A loop of ter-minal ileum is identified and brought out through the RIF port site inci-sion. The abdominal wounds are then closed, and finally, loop ileostomy is matured using vicryl stitches.
The anal canal cavity is washed again from the perineal side. Then, a side (colon)-end (anal canal) anasto-mosis is fashioned using interrupted 2/0 vicryl stitches that is placed circumferentially at regular inter-vals (Figure 20). Prior to tying these stitches, the anal canal stay sutures that were inserted at the start of the perineal procedure are cut to reduce the tension on anastomotic stitches. Haemostasis is ensured.
Further tips/pointers• Lone-star retractor can alterna-
tively be used instead of anal vergestay sutures.
• Gauze placed per anus at the startof the procedure helps prevent
Figure 10: Rectovaginal septal dissection.
Figure 11: Anterior TME view.
both lateral sides and then anteriorly (Figure 18). The anal canal mucosa, on the rectal side, is closed with vic-ryl stitches, after removing the pre-viously inserted per anal gauze. The ISR dissection is then completed all round to reach the peritoneal cavity.
The rectal end is pushed back into peritoneal cavity and anal canal area irrigated with warm water.
The anal canal is packed with gauze to prevent any leak when the subsequent pneumoperitoneum is re-created prior to specimen extraction
Page 8 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
uted
to c
once
ption
and
des
ign,
man
uscr
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repa
ratio
n, re
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nd a
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final
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All a
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the
Asso
ciati
on fo
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ical
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AME)
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sure
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intersphincteric dissection, as we believe this may lead to increased fibrosis thereby reducing function-al outcome.
• During the coloanal anastomosis,to try and incorporate part of the EAS into the anastomosis, as this may reduce subsequent possible anal mucosal prolapse.
• Try and excise, if possible, anyobvious external haemorrhoids noted at the end of the proce-dure. These, if left in-situ, can usu-ally become engorged and painful (maybe due to decreased venous drainage after an ISR), with symp-toms possibly lasting several days.
DiscussionThe first robot-assisted colectomy was reported by Weber et al. in 200210. In addition to this, robotic colorectal surgery had garnered in-terest, with several reported stud-ies showing acceptable results for both colon and rectal robotic resec-tions11–15. The perceived benefits of robotic surgery include the ability to undertake surgery in confined spaces such as the pelvis. Three-dimension-al views offer better visualisation and any hand tremor effects are de-creased. Despite these benefits, the use of robotic colorectal surgery has not been widespread, which has been a slightly different scenario from that of laparoscopic surgery. The possible explanations might be the increased operating costs, lack of training and experience associated with robotic surgery.
Studies evaluating robotic surgery for rectal cancer had reported early promising results16–20, and in addi-tion, results of comparative stud-ies with laparoscopic surgery have also shown that robotic surgery is not inferior to the laparoscopic ap-proach23–27. However, it is important to note that, these are only case se-ries or comparative studies, and no randomised, controlled trials have been completed to-date for rectal cancer surgery.
Figure 12: Left middle rectal artery clipping.
Figure 13: Division of anococcygeal ligament.
tumour cells spillage and also re-duces any enteric contamination of the intersphincteric space.
• The start of dissection within theanal canal is aimed at 1 cm distal to the tumour. This ensures that adequate distal resection margin is maintained, and also part of residual
IAS along with the remnant anal ca-nal mucosa helps with the function-al outcome. However, if the tumour is too low and near the dentate line, then dissection has to be started at the intersphincteric groove.
• Aim for minimal diathermy dis-section use during perineal
Page 9 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
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to c
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and
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ign,
man
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approach for the abdominal part and robotically for pelvic dissection28, an-d undertaking ISR with perineal diss-ection first followed by robotic appr-oach for the pelvis30. These varying t-echniques reveal that robotic ISR is still unique and is at a very early sta-ge of its development. There is limit-ed literature on undertaking totally robotic ISR. We describe here in det-ail various technical aspects of perfo-rming a robotic ISR and coloanal an-astomosis. Robotic ISR technique is still in its early stages of developme-nt, and further randomised, controll-ed studies are required to prove, the short-, medium- and long-term resul-ts, particularly from both the functio-nal and oncological perspectives.
ConclusionWith the above caveat, we believe the robotic ISR may be a realistic and feasible option for surgically treating low rectal cancers. In addition, the operative approach mentioned here offers a possible standardised approach in undertaking a robotic ISR and coloanal anastomosis.
AbbreviationsASIS, anterior superior iliac spine; EAS, external anal sphincter; IMA, in-ferior mesentery artery; IMV, inferior mesenteric vein; ISR, intersphincter-ic resection; LIF, left-iliac fossa; MC, mid-clavicle; MIS, minimally invasive surgery; RIF, right-iliac fossa; RUQ, right-upper quadrant; SB, small bow-el; TME, total mesorectal excision.
AcknowledgementWe thank Dr Kwak (Colorectal Sur-gery Division, Department of Surgery, Korea University Anam Hospital, Seoul, Korea) for help in providing few of the photos used as figures in this article.
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Figure 14: Pelvic floor with puborectalis, along with anal sphincters and intersphincteric space.
Figure 15: Anal stay-sutures, gauze insertion and dilute adrenaline injection.
The low rectal cancers provide a surgical challenge with ISR as a way of sphincter saving approach compared to an abdominoperineal resection. Although the open method1–5 and subsequently laparoscopic surgery6–9 is well reported in undertaking ISR, a robotic approach to undertake ISR may be the next logical progression from laparoscopic surgery for these
very low rectal cancers. There have been only few recent case series28–30 on robotic ISR, reporting acceptable early results, and a single comparative cases series31 showing comparable short-term results with a laparoscop-ic approach. However, the reported techniques are different from each other with variations, including using a hybrid technique with laparoscopic
Page 10 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
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g in
tere
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Figure 16: Per anal view prior to start of intersphincteric dissection.
Figure 17: Initial phase of intersphincteric dissection – perineal approach.
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Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
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non
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clar
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ct o
f int
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one
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man
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repa
ratio
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Figure 18: Intersphincteric plane – during perineal approach.
Figure 19: Specimen extraction per anus.
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Page 12 of 12
Methodology
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Mathew R, Kim SH. Robotic intersphincteric resection and coloanal anastomosis: technical detail. OA Robotic Surgery 2013 Apr 16;1(1):2.
Com
petin
g in
tere
sts:
non
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clar
ed. C
onfli
ct o
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ts: n
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Asso
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