VM69 - Robot Assisted Total Proctocolectomy for Ulcerative Colitis with Rectal Carcinoma

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Purpose/Background: The standard for management of ulcerative colitis with concomitant cancer post radiotherapy based on the European Crohn’s and Colitis Organization (ECCO) and American Society of Colon and Rectal Surgeons (ASCRS) is a total proctocolectomy which may be performed by open or minimally invasive approach. Minimally invasive surgeries offer better cosmesis, less post-operative pain and fewer complications, minimizing the trauma of surgery. In comparing robotic versus laparoscopic surgical approaches, the robotic system offers a better dexterity of instruments, tremor filtration, stereoscopic 3d vision and an ergonomic operating environment and is advantageous in narrow spaces like the pelvis. The limitation of the robotic approach is the increased operative time due to docking time. Because of this, the da Vinci Xi model offers a laser-targeted rotating boom-mounted system for trocar positioning, allowing a reduction in operative time from re-docking. This is a report on our experience with robot assisted approach with rotating boom-mounted system for total proctocolectomy for ulcerative colitis with rectal carcinoma.

Methods/Interventions: We report a case of a 68-year-old male, known case of ulcerative colitis with unremarkable surveillance colonoscopy since 2006 maintained on prednisone, mesalazine and azathioprine presenting as acute exacerbation with rectal bleed. Colonoscopy and biopsy revealed circumferential thickening with stricture at 3cm from the anal verge and assessed as ulcerative colitis in flare (UCEIS 8, Montreal E1S1), Rectal adenocarcinoma 10cm from the anal verge who underwent 28 cycles of capecitabine with radiation therapy and subsequently underwent robot assisted total proctocolectomy with ileostomy. Final histopathology reveals Microscopic foci of residual adenocarcinoma with signet ring cell features involving the rectum with complete macroscopic mesorectal evaluation and all surgical margins negative for tumor. 2/32 pericolorectal nodes were positive for tumor. Acellular mucin involving the mucosa, submucosa, muscularis and perirectal soft tissues with chronic inflammation of ileum, cecum, ascending, transverse, descending and sigmoid colon.

Results/Outcomes: There was noted good post operative pain control with good cosmesis post-operatively hence discharge planning was initiated on third post-operative day with good diet tolerance, no surgical site infection and with oncologically adequate yield on biopsy.

Conclusion/Discussion: Robot assisted total proctocolectomy with laser targeted rotating boom-mounted system for trocar positioning with total intersphincteric resection is a feasible option for select patients that provides better outcomes including good post operative pain control, cosmesis with adequate oncologic resection outcomes and may be an option for select patient with ulcerative colitis with rectal cancer.