Video Summary

This video demonstrates a robotic APR with V-Y gluteal flap reconstruction for the perineal defect after resection of extramammary Paget disease of the anus. This video not only highlights the technical steps and pearls of a robotic TME for an appropriate, oncologic APR but also a reconstructive option that, when done correctly, can offer superb coverage for an enlarged or radiated perineal defect.

Video

Teaching Points

Patient preparation:

1. Evaluation by plastic surgeon for reconstruction option–preoperative marking as needed in holding room
2. Preoperative bowel preparation per institutional protocol
3. Preoperative education and marking for colostomy

Patient positioning:

1. Lithotomy or abdominal resection
2. Arms tucked and padded
3. Adequately secured (straps, tape, etc) for Trendelenburg positioning
4. Prone positioning for perineal dissection, specimen removal, and reconstruction/closure

Critical steps:

1. Abdominal portion:
   1. Appropriate robotic port placement for abdominoperineal resection (APR)
   2. Identify and preserve the left ureter and gonadal vessels
   3. High ligation of the vascular pedicle under no tension (inferior mesenteric artery for rectal pathology, superior rectal artery in this case for Paget disease)
   4. Adequate total mesorectal excision (TME), beginning posteriorly
   5. Place cottonoid/sponge posteriorly firmly in the most distal pelvis against the tip of the coccyx to act as the target point for subsequent peroneal entry at base of TME dissection
2. Prone/perineal portion:
   1. Ensure adequate perianal margin (disease specific, ie, Paget disease)
   2. Use Lone Star retractor to facilitate dissection and visualization
   3. Palpate and identify coccyx as target for posterior dissection–identify and remove sponge
   4. iv. Eviscerate specimen and carefully dissect anterior attachments (beware of prostate in males)
   5. Closure of defect–in this instance, with V-Y flap
   6. Preserve inferior gluteal arteries
   7. Obtain adequate enough mobilization for tension-free skin anastomosis

Technical pearls:

1. Always identify and preserve the left ureter during any left sided and/or rectal dissection.
2. Place a cottonoid/sponge in the deepest, posterior portion of TME dissection to help with identification of the correct plane when approaching from perineum later.
3. Send skin margins (if for Paget disease) before completing closure.
4. The use of the large hooks in the Lone Star retractor can offer superior retraction.
5. Have a primary and secondary (backup) plan for closing large perineal defects.

Potential areas for injury or complications:

1. Ureteral injury if not identified and protected
2. Inadequate TME
3. Potential for presacral bleeding during TME
4. Positive margin in Paget disease
5. Injuring necessary perforating vessels for gluteal flap