Introduction

Rectal cancer represents one of the most technically demanding challenges in colorectal surgery. Despite advances in neoadjuvant chemoradiotherapy, intersphincteric resection techniques, and coloanal anastomosis, a significant proportion of patients with low rectal cancers require an abdominoperineal resection (APR), a procedure that entails complete excision of the rectum, anus, and surrounding sphincter complex, resulting in a permanent end colostomy.

First described by Ernest Miles in 1908, APR has undergone substantial evolution. The recognition that conventional APR was associated with unacceptably high rates of positive circumferential resection margins (CRM), intraoperative bowel perforation, and local recurrence prompted the development of the extralevator abdominoperineal resection (ELAPE), which removes the levator ani muscles en bloc with the specimen to achieve a cylindrical resection and improve the defined surgical planes and the CRM.[1][2]

The introduction of robotic surgery to colorectal practice has brought renewed interest in minimally invasive APR. The development of robotic platforms address many limitations of conventional laparoscopy in the narrow male pelvis, most notably the loss of degrees of freedom, instrument crowding, and camera instability.[3] Robotic surgery has been proven safe and superior to laparoscopic surgery in terms of safety, quality of surgical dissection and postoperative recovery.[4] This chapter provides a comprehensive examination of robotic-assisted APR: its rationale, preoperative workup, operative technique, management of complications, and the current evidence base supporting its adoption.