monthly focus

surgical intervention video

Rectal cancer surgery carries an inherent risk of autonomic nerve injury and the robotic approach may eliminate the technical difficulties in preserving the autonomic nerves in total mesorectal dissection. This video demonstrates the technique of a fully robotic nerve-preserving total mesorectal excision for locally advanced rectal cancer. A 39-year-old male patient otherwise healthy was referred to our clinic after he presented with abdominal pain and rectal bleeding (BMI of 26). He underwent colonoscopy and was found to have an ulcerovegetan mass in the mid/distal rectum. Histopathology revealed a moderately differentiated adenocarcinoma. After he received long-term neoadjuvant CT/RT, the decision was made to perform a robotic total mesorectal excision with loop ileostomy. At initial exposure, the peritoneum was incised at the level of the sacral promontory, and the aortomesenteric window was opened up. The inferior mesenteric artery (IMA) was exposed and cleared at its origin from the aorta without injuring the inferior mesenteric plexus. In a medial-to-lateral fashion, dissection was continued to identify the inferior mesenteric vein. The inferior mesenteric vein was isolated at the inferior border of the pancreas. Dissection was continued through the anterior border of the pancreas to enter the omental bursa. Attention was turned to the pelvis after completion of the abdominal portion. Posterior pelvic dissection was performed along the fascia propria recti. The Holy plane was exposed at the level of the sacral promontory. Posterior dissection all the way down to the pelvic floor and levator ani muscles prevents inferior hypogastric plexus injury during lateral dissection. Once the mesorectum was fully mobilized, a colorectal anastomosis was performed. 

Fully robotic nerve-preserving total mesorectal excision (TME) for locally advanced rectal cancer

video lecture

In this oustanding 'how to' presentation, Professor Giuseppe Spinoglio demonstrates how he performs a robotic low anterior resection (LAR) with total mesorectal excision (TME, in a stepwise fashion. Preoperative setting, intraoperative steps, and tips and tricks for a successful resection are provided. 

da Vinci Xi™ low anterior resection with total mesorectal excision: a stepwise description

Résection antérieure basse avec excision totale du mésorectum par approche robotisée (da Vinci Xi™) : une description par étapes.

how to

Laparoscopic surgery for rectal cancer is a well-established approach. However, it should be performed by expert surgeons. The main limitations of laparoscopy include the loss of three‐dimensional view, the use of non-ergonomic instruments (thereby increasing the surgeon’s physiological tremor), the need for a video camera assistant and subsequent conflicts with the assistant during the dissection, and the reduced dexterity of movements. The robotic approach helps to overcome such limitations, facilitating the dissection and reducing the learning curve. Most importantly, the system allows the surgeon to control the high‐definition 3D camera, reducing physiological tremor and offering three extra degrees of movement using articulated instruments. This video shows an anterior rectal dissection using the da Vinci Xi™ surgical robotic system. All of the previously cited advantages of the robotic system can be appreciated. Of note, this video is enhanced by many didactic illustrations to help better understand the anatomy. 

Focus on robotic rectal surgery

da Vinci Xi™ low anterior resection with total mesorectal excision: a stepwise description

Fully robotic nerve-preserving total mesorectal excision (TME) for locally advanced rectal cancer

Low anterior resection (LAR) for T3 rectal cancer with the da Vinci Xi™ robotic surgical system: a step-by-step illustrated procedure

da Vinci Xi™ low anterior resection with total mesorectal excision: a stepwise description