A KS Robotic Surgery Awards Entry:
ROBOTIC TOTAL PELVIC EXENTERATION FOR LOCALLY ADVANCED RECTAL CANCER
Total pelvic exenteration for locally advanced rectal cancers is a major procedure with considerable morbidity. Laparoscopic approach is used in selected central tumors, in experienced centers but it has a long learning curve. In this case we have demonstrated the feasibility of robotic surgery for total pelvic exenteration.
Case Details: This is a 36 year old gentleman with a rectal adenocarcinoma starting 2cm from the anal verge. It was non metastatic but MRI showed gross invasion anteriorly into the prostatic stroma, along with bilateral lateral pelvic lymphadenopathy. He received neoadjuvant chemoradiation. Post neoadjuvant therapy he was taken up for total pelvic exenteration with bilateral lateral pelvic node clearance.
The port positioning was not different from the standard robotic rectal cancer resections. Dissection begins with creation of plane underneath the inferior mesenteric vein followed by medial to lateral mobilization of the rectum. The next step is posterior mobilization of the rectal tube. The lateral peritoneal cuts are extended over the external iliac vessels to facilitate the lateral pelvic node dissection. The lateral nodal dissection is done on both sides before the excision of the primary. The vascular supply to the bladder, prostate and seminal vesicles are divided. Ureters are divided close to the bladder and then mobilized to facilitate easy ureteroenteric anastomosis. Bladder is taken down and dorsal venous complex is identified, clipped and divided. Prostate is dissected off the pelvic floor. After this step the descending colon is divided and the mesentery is clipped to the abdominal wall. This provides adequate space for preparation of conduit and anastomosis. An umbilical tape and clips are used to mark the conduit. 60mm endostaplers are used to prepare the conduit (FireFly could have been used to identify the feeding vessels). Bowel continuity is established by side to side, stapled ileoileostomy. Uretero enteric anastomosis was done using Wallace technique. The excision is completed from perineal route. Ileal conduit and end colostomy are brought out on the abdominal wall as a final step.
Post operatively patient had stoma related complications, which prolonged the hospital stay.
Duration: 10hours Blood loss: 600 ml Hospital stay: 13 days
Conclusion: Robotic total pelvic exenteration is feasible for select cases of locally advanced rectal cancers. With experience the operative time can be reduced further.
Narrated robotic surgery video with photos and labeled robotic surgery clips. 07:51
(CAUTION: some surgical images are very graphic- viewer discretion is advised)