Video Summary

This video presents a case of robotic abdominoperineal excision for rectal cancer performed by single docking. High ligation of IMA and intracorporeal division of levator muscles with the robotic instruments is performed. Precision surgery is performed in the avascular embryological plane with the use of monopolar diathermy. Cylindrical excision of the rectum is performed along with a cuff of vaginal wall for T4 rectal cancer followed by left pelvic lymph node dissection for extramesorectal nodes. The patient went straight to surgery without downstaging because she did not consent for neoadjuvant treatment. Key learning points and tips and tricks are highlighted during different phases of the operation.

Video

Teaching Points

1. Planning the operation
2. Standardized technique
3. Understanding of the anatomy and surgical planes
4. Tips to avoid common pitfalls

Critical Steps

1. Positioning and docking
   1. Avoid soft tissue injuries
   2. Prevent patient slipping
   3. Single docking approach from left hip
   4. Efficient docking to reduce time
   5. Enhanced ergonomics
2. Laparoscopic setup
   1. Staging
   2. Adequate exposure: DJ flexure and iliac vessels
   3. Use of a swab for retraction
3. Vascular dissection
   1. Start of dissection at the sacral promontory
   2. Anatomy of the ureter, hypogastric nerves, and iliac vessels
   3. Working in the “holy plane”
   4. Avoid traction injuries and bleeding
4. Colonic mobilization
   1. Identify the plane between the Gerota and mesocolic fascia
   2. Preserve the fascia
   3. Identify the ureter and gonadal vessels anatomy
   4. Effective use of assistant for optimal exposure
5. Total mesorectal excision
   1. Effective use of the third arm
   2. Structured approach to perform total mesorectal excision
   3. Preserve the mesorectal fascia
   4. Transabdominal suture for lifting and retraction of the uterus and bladder
6. Levator excision
   1. Identification of pelvic floor, levator muscles
   2. Intracorporeal division of levator muscles
   3. Cylindrical excision with robotic division of subcutaneous tissue and skin
7. Lateral node dissection
   1. Identification of key landmarks for lateral pelvic lymph node dissection
   2. Surgical approach to obturator fossa
   3. Excision of iliac nodes

Technical Pearls

• Safe patient positioning results in better ergonomics and avoids the risk of pressure injuries.
• Start of dissection at the sacral promontory is useful to identify superior rectal artery and hypogastric nerves.
• Be careful with high ligation of inferior mesenteric artery (IMA) on the aorta to avoid damaging the sympathetic plexus resulting in retrograde ejaculation.
• Inferior mesenteric vein is divided high under the DJ flexure. Be careful with the tension with inferior mesenteric vein to avoid avulsion and bleeding.
• Identify the ureter before division of IMA
• Remove tension off IMA before division between locking clips to reduce any risk of bleeding.
• Cylindrical excision of pelvic floor levator muscles can be safely performed with the use of wristed robotic instruments.
• Avoid coning in on the specimen.
• Lateral pelvic lymph node dissection requires thorough knowledge of vascular anatomy in the pelvic side wall and can be safely performed using a robotic platform.

Potential Areas for Injury or Complications

• During high ligation of IMA, avoid excessive traction that can result in avulsion of the vessel.
• Avoid injury to pancreas while entering the lesser sac with the inferior approach. It is possible to continue dissecting under the pancreas without realizing the mistake, and the surgeon can then encounter the splenic vein.
• Identify hypogastric nerves in the pelvis.
• In the lower third of the rectum, the presacral vessels are at risk of injury if correct surgical plane is not followed and can cause troublesome bleeding.
• Choose the correct plane of dissection anteriorly between seminal vesicles and Denonvilliers fascia.
• Protect the neurovascular bundles of Walsh at 2 and 10 o’clock position anterolaterally below the seminal vesicles, which can result in impotence and sexual dysfunction.
• Use of a pledget/swab in the left hand can protect the mesorectal fascia from injury.
• Protect ureter and major vessels from injury while performing lateral node dissection.