VM88 - Simultaneous application of robotic surgery and TAMIS platform in context of sphincter preservation

Image or Table (Do Not add text here):

Purpose/Background: Surgical resection of low rectal cancers is challenging, especially in male patients with narrow pelvis, moreover achieving both sphincter preservation and optimal oncological outcomes is further more a challenge to colorectal surgeons .
Robotic surgery has been successfully used for some years for patients with rectal cancer with equivalent oncologic results. Minimally invasive robotic surgery achieves faster recovery . However, the application of robotic surgery simultaneously with TAMIS approach for treating patients with very low rectal cancers to achieve both negative margin and sphincter preservation is not commonly reported .

Methods/Interventions: video presentation for surgical approach

Results/Outcomes: In this Video in we present a 70-year-old gentelman presented in 2019 with bleeding per rectum, associated with alternating bowel habits. He had no obstructive symptoms and no weight loss.
Her past medical history ischemic heart disease, and his past surgical history was unremarkable. He has no family history of colorectal cancer.
On digital rectal examination he had palpable lesion 4 cm from anal verge on top of the sphincter, Abdominal and inguinoscrotal examinations were unremarkable.
His tumor markers were within normal (CEA: 1.7, CA19-9: 13.6), his other blood work up was within normal. Colonoscopy revealed the palpable lesion and biopsy showed moderately differentiated adenocarcinoma.
Staging computed tomography of chest, abdomen and pelvis showed no distant metastasis. Rectal MRI showed cT3c N2, threatened CRM, EMVI negative.
The case was discussed in colorectal MDT with plan for neoadjuvant chemoradiation, which was given in the period (7/10/2019-17/11/2019). Reassessment 10 weeks after neoadjuvant treatment showed very good but incomplete response, Hence MDT recommended surgical resection, however the patient declined surgery and didn’t follow up.
He returned 3 years later with tenesmus. examination, scope and Imaging showed regrowth of the tumor. There was no distant metastasis on restaging CT, MRI showed free CRM and MDT decided for surgery. The patient was counseled about surgery, and he was totally aversed to permanent stoma, Hence TME with coloanal anastomosis after obtaining negative margin was planned.
The surgery was started using Davinci XI system transabdominally until reaching pelvic floor, the trans-anal dissection was carried out using TAMIS platform. Intraoperative confirmation of free distal margin was assured using frozen section before concluding with handsewn coloanal anastomosis. Thw anastomosis was protected by loop ileostomy. He had a smooth post op course and was discharged on post op day 7 after being able to manage his stoma well. His final histopathology showed moderately differentiated adenocarcinoma ypT3, pN0 (0/16), the distal margin was free by 3.7 cm. There was lymphovascular and perineural invasions, hence MDT decided for adjuvant chemotherapy
On follow up, he had normal urogenital functions, was continent most of the times except few occasions of liquid stool. After completing his chemotherapy, he had closure of his ileostomy (10 months after index surgery), and his surveillance till 18 months showed no disease recurrence.

Conclusion/Discussion: This video demonstrates the benefit of combining robotic and TAMIS techniques in achieving optimal functional outcome, yet without jeopardizing the local oncologic control for challenging cases of low rectal cancer.