VM74 - Robotic Sacrectomy for Recurrent Rectal Cancer

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Purpose/Background: Rectal cancer recurs locally in up to 10% of patients undergoing resection for their primary cancer. Salvage requires extended resections, often with sacrectomy. In patients with sacral involvement, the entire conduit and rectal dissection, pelvic organ resection, mobilization of the ureters and great vessels can be accomplished robotically, with sacral transection performed through posterior approach, avoiding an abdominal incision and significantly minimizing the morbidity of this formidable operation. This is an innovative approach to a complex resection.

Methods/Interventions: A 35 year-old lady presented post low anterior resection for rectal cancer with central recurrence infiltrating S4 vertebra. She received concurrent proton based chemoradiotherapy with a partial response. She was counselled and consented for a Robotic Posterior pelvic exenteration with S3 down sacrectomy. Laparoscopy revealed localised disease. Standard robotic port configuration was used. The Colonic conduit was mobilised till the upper border of S3 vertebra; ureteric lateralisation and bilateral ligation of anterior division internal iliac arteries was performed. The internal iliac veins were dissected but not ligated, to prevent venous engorgement. Hysterectomy was completed, leaving the posterior vagina on the rectum. An end colostomy was created and ports were closed. Perineal dissection was performed with posterior vaginal transection and perianal incision. The S3 vertebral body identified using fluoroscopy in prone position. Sacrum transected through the mid body of S3, along with all ligamentous attachments and S3-S5 nerve roots, completing resection. Perineal defect and neovagina were reconstructed using bilateral gracilis myocutaneous flaps.

Results/Outcomes: The operative time and blood loss were 960 minutes and 2500ml, respectively. She recovered uneventfully and was walking unaided at the time of discharge 10 days from surgery. Pathology confirmed residual disease with negative soft tissue and bone margins. Adjuvant chemotherapy was administered. She remains disease free at one year post surgery.

Conclusion/Discussion: Surgery for recurrent rectal cancer is best undertaken by surgeons with mastery of pelvic surgery. Robotic surgery is a powerful tool which reduces morbidity, avoids and abdominal incision and achieves excellent oncological outcomes. We present a proof of principle concept which adds to the armamentarium of the surgeon dealing with recurrent rectal cancer.