Robotic-assisted Transanal Total Mesorectal Excision The Key Against the Achilles’ Heel of Rectal Cancer? Cristiano G. S. Huscher, MD, PhD, FACS, FRCS,∗ Frederic Bretagnol, MD, PhD,† and Cecilia Ponzano, MD∗ R. J. Heald1 wrote in the Editorial of Tech Coloproctology 2013, “I predict that 2013 will be the year of endoscopic transanal approaches to radical low rectal dissection and anastomosis.” He made reference to some authors as Leroy et al,2 Lacy et al,3 and Atallah et al,4 who concluded that the rectal dissection from below was much easier than either minimal invasive or open surgery from above. Preliminary published results on this approach suggest oncologic equivalence relative to conventional or laparoscopic total mesorectal excision (TME). Although neoadjuvant chemoradiotherapy has become the standard of care for locally advanced mid and low rectal cancer resulting in improved oncological outcome, it is demonstrated that optimal surgery with TME is the mainstay of curative treatment but is a demanding technique that may influence outcomes.5 The macroscopic quality of TME is an important factor related to postoperative local and overall recurrences.6 Damage to the mesorectal cylinder is an indication of incomplete excision of the tumor and consequently increases the risk of local recurrence. But, even in experienced hands, TME can be challenging, particularly in an obese male patient with visceral obesity, increasing the risk of incomplete mesorectal excision. In contrast, Heald1 noted that the combination of the transanal approach, the use of a gastight seal for anus or anorectum, and direct “holy plane” dissection around the mesorectum from below revolutionized the practice of rectal cancer surgery. Atallah et al4 highlighted that distal rectal dissection was simplified and this had significant potential for improving the quality of surgical resection in the setting of the difficult pelvis. The same authors7 presented their data of 20 patients with rectal cancer who underwent transanal TME, with a median follow-up of 6 months. The minimum threshold of 12 nodes was achieved in 80% of cases, and macrocopic assessment of mesorectal excision was considered as complete in 89% of cases. Leroy et al2 pushed the limits of minimally invasive surgery, recently publishing the first case of pure transanal NOTES TME with retroperitoneal sigmoid mobilization called PROGRESS (Peri-Rectal Oncologic Gateway for Retroperitoneal Endoscopic Single Site Surgery). The authors concluded that it could pave the way for a new era in pure transanal NOTES for rectal surgery. We aimed to perform this procedure using the robotic procedure to assess the feasibility and the operative results. From January to April 2014, 7 patients (4 women and 3 men) with rectal cancer underwent a hybrid technique combining robotic transanal TME and laparoscopic abdominal procedure (vessels division and colon mobilization). The mean (range) age was 63.2 ± 9.7 (48–74) years and the body mass index was 29.9 ± 6.1 (21.5–37.5) kg/m2 . According to the American Society of Anesthesiologists (ASA) grade, the

From the ∗ Oncologic Surgery, Ospedale Rummo, Benevento, Italy; and †Digestive Surgery, Foch Hospital, Suresnes, France. Disclosure: The authors declare no conflicts of interest. Reprints: Frederic Bretagnol, MD, PhD, Digestive Surgery, Foch Hospital, 40 rue Worth, 92151 Suresnes, France. E-mail: [email protected]. C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright  ISSN: 0003-4932/15/26105-e0120 DOI: 10.1097/SLA.0000000000001089

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patients’ health status was considered ASA 1 (n = 4), ASA 2 (n = 1), and ASA 3 (n = 2). The median (range) tumor distance from the anal verge was 20 (10–65) mm. Patients were staged according to the TNM classification following endorectal ultrasonography, abdominal-pelvic computed tomography, and pelvic magnetic resonance imaging. Preoperative tumor stage included T2 (n = 5) and T3 (n = 2) without any suspected lymph nodes metastasis. No neoadjuvant chemoradiotherapy was given. Robotic-assisted transanal surgery for TME (da Vinci Si Surgical System; Intuitive Surgery, Sunnyvale, CA) was performed with a hybrid approach: We started with the laparoscopic abdominal procedure including both mesenteric inferior vein and artery ligation, complete mobilization of the splenic flexure and the descending colon down to the promontory. The second step was the transanal procedure: The legs were brought up, and the sleeve portion of the GelPOINT Path Transanal Access Platform (Applied Medical Inc, Rancho Santa Margarita, CA) was positioned and secured with sutures to the skin. We started the distal circular dissection 1 cm above to the dentate line to free 2 cm of the rectum and the distal rectal stump was sutured closed to avoid any fecal contamination. The robotic single port was then secured to the sleeve and the robotic cart was docked along the patient’s right to enable the robotic arms to swing over the abdomen and be directed transanally. The port device was connected to insufflation (CO2 ) with the setting of 20 mm Hg. Robotic tools included a bipolar forceps in the left arm and a monopolar hook in the right arm. TME was started on the anterior side of the rectum dividing the Denonvilliers fascia or rectovagina fascia with a 0-degree camera. Then, using a 30-degree camera, the posterior space was dissected, followed by the lateral side, leading to the opening of the Douglas pouch. Then, the rectosigmoid specimen was pushed into the abdominal cavity, achieving the final upper dissection. Robotic arms were removed and the specimen was extracted transanally. A purse-string suture was used to close the rectal stump, and reconstruction was performed using a conventional stapled side-to-end coloanal anastomosis. A pelvic drain was placed systematically in the pelvis, and a temporary loop ileostomy was performed in all patients. The mean (range) overall operative time was 165.7 ± 54.4 (85– 120) minutes including the transanal procedure [55.5 ± 12.4 (40–75) minutes]. The vaginal septum was easily dissected free in all women and the Denonvilliers fascia in all men. The “holy plane” was found in all patients properly using the monopolar hook. Macroscopic assessment showed complete mesorectum in 6 cases and nearly complete mesorectum in 1 case. The mean (range) number of lymph nodes was 14 ± 3 (10–20). A R0 resection was achieved in all patients. The mean (range) distal margin was 27 ± 20 (10–65) mm, and circumferential margin was 3.2 ± 1.8 (1.4–5) mm. Postoperative TNM stage was pT1N0 (n = 2), pT2N0 (n = 2), pT3N0 (n = 2), and pT3N1 (n = 1). All patients were postoperatively included into an enhanced recovery program. The analgesic intake (range) was 1.8 ± 0.6 (1–3) days. Mortality was nil. No patient developed a clinical anastomotic leakage. Only 1 patient, at day 2, presented rectal bleeding requiring the transfusion of blood units without reoperation. The mean (range) hospital stay was 4.8 ± 0.6 (4–6) days. With a mean (range) follow-up of 2.5 (2–3.5) months, all patients had stoma closure. Annals of Surgery r Volume 261, Number 5, May 2015

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Annals of Surgery r Volume 261, Number 5, May 2015

To our knowledge, this is the largest report of both feasibility and preliminary results of 7 patients undergoing a robotic-assisted transanal TME. We demonstrated the feasibility with satisfactory pathological data and operative results. Moreover, even if improvements such as superior visualization and magnification are harder to quantify, we had the subjective feeling to perform high quality of TME dividing the Denonvilliers septum anteriorly, the rectosacral fascia low down, and recognizing the neurovascular bundles running behind the presacral fascia on the right and left sides. Another advantage of this technique is that it could result in fewer conversions from laparoscopic to open procedures and consequently fewer complications. Regarding technical aspects, transanal TME seems to be a promising alternative procedure to the abdominal approach, especially in obese male patients with narrow pelvis. Improved visualization of the anatomy including mesorectal plane and plexuses might secure quality of surgical resection, oncologic outcomes, and sexual function far better in the future. Moreover, we think that robotic surgery could provide technical advantage over laparoscopic surgery including a 3-dimensional view, improved dexterity, reduced tremor, enhanced ergonomics, and a stable camera view. Robotic surgery and transanal TME are both potential developing areas in rectal cancer surgery. Transanal TME could lead to a better quality of surgical resection. Robotic surgery allows a more comfortable stand for the surgeon, minimizing some technical

 C 2015 Wolters Kluwer Health, Inc. All rights reserved.

Letter-Preliminary Report/Technique

difficulties and potential conversions to open surgery. Combining the 2 procedures could improve results of cancer rectal surgery. Of course, more data are required to determine if there is a true advantage to conventional abdominal laparoscopic TME.

REFERENCES 1. Heald RJ. A new solution to some old problems: transanal TME. Tech Coloproctol. 2013;17:257–258. 2. Leroy J, Barry BD, Melani A, et al. No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg. 2013;148:226– 230. 3. Lacy AM, Adelsdorfer C, Delgado S, et al. Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study. Surg Endosc. 2013;27:339– 346. 4. Atallah S, Nassif G, Polavarapu H, et al. Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration. Tech Coloproctol. 2013;17: 441–447. 5. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery. The clue to pelvic recurrence? Br J Surg. 1982;69:613–616. 6. Nagtegaal ID, van de Velde CJ, Marijnen CA, et al. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257– 9264. 7. Atallah S, Martin-Perez B, Albert M. Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol. 2013;13;1095–1097.

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Robotic-assisted transanal total mesorectal excision: the key against the Achilles' heel of rectal cancer?

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