EP932 - Dealing with the nuances of an existing colostomy in patients for robotic rectal cancer surgery

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Purpose/Background: The Philippine General Hospital (PGH), being an end-referral center, receives patients with advanced-stage rectal cancer needing proximal bowel diversion prior to treatment. Robotics has become an accessible approach to rectal cancer surgery in the country. Deviations from standard operative techniques arise in those with a prior stoma. We aimed to compare variations in robotic operative experience and outcomes between patients with, and without, a prior stoma.

Methods/Interventions: This is a 5-year retrospective review of 125 adult patients who underwent robotic rectal cancer surgery. The records of included patients were collected, reviewed, and classified based on the presence of a prior stoma. Operative technique with emphasis on trocar placement was reported. The duration of relevant steps of the procedure (e.g., docking and console time), identified technical difficulties, intraoperative blood loss, and hospital length of stay (LOS) were documented. Student t-test was used for statistical analysis. P-value was set at 0.05.

Results/Outcomes: Of the 125 cases, 9 had incomplete records and were excluded. Eighteen (15.5%) of the 116 included cases had previous stomas. Of these, 16 (88.9%), and 66 (67.4%) of the 98 without a stoma, received neoadjuvant therapy.
A statistically significant difference in docking time was seen in both groups. This statistical significance, however, was not seen when comparing console and total operative times, blood loss, and LOS.

Conclusion/Discussion: At PGH where more than 80% of rectal cancer cases are locally-advanced at the time of initial diagnosis, many require bowel diversion prior to treatment. Proper trocar placement is vital to allow for optimal triangulation and instrument maneuverability. The observed increase in docking time in the stoma group was due to specific modifications in trocar placement per patient to accommodate the stoma, which often is variable in location.
Adjustments to the standard trocar placement were done depending on stoma type. In patients with an RUQ stoma the optical port was placed left of the umbilicus. The assist port was moved inferolaterally with adequate distance from the right MCL port to prevent instrument clashing. In those with a stoma on the LLQ, the optical port was situated more to the right of the umbilicus, while the ports on the LUQ and LLQ were adjusted medially and inferolaterally, respectively. Adhesiolysis was performed prior to docking on some stoma patients, adding to the docking time.
Challenges encountered were intraperitoneal adhesions, obstruction of the field particularly those with a sigmoid colostomy, and impedance of the robotic arms’ range of motion. With careful trocar placement and adhesiolysis when necessary, operative times and short-term outcomes did not seem to be affected. No cases of a need for stoma takedown nor abandonment of the robotic approach were noted. The presence of a stoma is not a contraindication to robotic resection, but it does introduce operative complexity. Thus, specific refinements in robotic operative technique are essential to improve experience and outcomes in this population.