Robotic Assisted Abdominoperineal Resection – Extended TME

The concept of total mesorectal excision (TME) was the most important event in surgery for rectal cancer in the last two decades, decreasing both local recurrence and overall survival. Occasionally the disease is not confined within the TME, even after neoadjuvant therapy; thus requiring a surgical approach beyond the standard TME plane to enable complete resection of the tumor. Purpose: To demonstrate feasibility of robotic assisted abdominoperineal resection with extended total mesorectal excision in a patient with large cell neuroendocrine carcinoma of rectum.

Material & Methods: A 37-year-old gentleman was diagnosed with large cell neuroendocrine carcinoma. He received radiation of 50G in 25 fractions and concurrent 5 cycles of cisplatin and etoposide. Patient, then underwent robotic assisted abdominoperineal resection – extended TME approach with single docking ,single phase daVinci Xi system using 5 ports( 4 robotic and one assistant port). Results: Total operative time was 400 minutes which included docking time of 60 minutes. Postoperative course was uneventful and patient was discharged on the 5th post operative day. Post op Histopathology revealed large cell neuroendocrine carcinoma. All margins were free. Four of the 17 nodes dissected were involved by the tumor.

Conclusions: Although total mesorectal excision is the gold standard for rectal cancers, it may be essential to go beyond the mesorectal plane in certain unique situations such as the one demonstrated in this video. Pre operative assessment of the extent of disease along with identifying the challenges prior to surgery are essential to obtain complete resection.