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Minimally invasive surgery
 Robotic abdominoperineal resection, bilateral robotic groin node dissection and simultaneous perineal gracilis flap reconstruction for locally advanced node-positive anal squamous cell carcinoma
Mohammed Ali1,2orcid, Melanie Holzgang1orcid, Vivekanandan Kumar3orcid, Dhalia Masud4orcid, Sandeep Kapur1orcid, Ahmed El-Hadi1,5orcid, Dolly Dowsett1orcid, Irshad Shaikh1,6orcid
Annals of Coloproctology 2024;40(6):613-615.
DOI: https://doi.org/10.3393/ac.2023.00801.0114
Published online: December 2, 2024

1Sir Thomas Brown Colorectal Unit, Norfolk and Norwich University Hospital, Norwich, UK

2Department of Surgery, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia

3Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK

4Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK

5Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

6Department of Surgery, Norwich Medical School, University of East Anglia, Norwich, UK

Correspondence to: Mohammed Ali, MBBS, MEd, DIC Faculty of Medicine in Rabigh, King Abdulaziz University, P.O. Box 80155, Jeddah 21589, Saudi Arabia Email: Saudi.colorectal@gmail.com
• Received: January 2, 2024   • Revised: April 20, 2024   • Accepted: May 1, 2024

© 2024 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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In this video, we present a robotic abdominoperineal resection and bilateral groin dissection with perineal flap reconstruction for advanced node-positive squamous cell carcinoma (Supplementary Video 1). The aim of this publication is to demonstrate the clinical feasibility of performing these procedures as a simultaneous operation. Although the literature includes reports of concurrent colorectal robot-assisted operations [‎1–‎5], to our knowledge, no articles have described such concurrent approaches utilizing without a boom holding the arms (a so-called “boomless system”) like the da Vinci X (Intuitive Surgical Inc), which was employed in this study.
An 80-year-old man presented to Norfolk and Norwich University Hospital (Norwich, UK) with a good performance status and an American Society of Anesthesiologists (ASA) grade III. He had a history of radiotherapy for prostate cancer, which precluded further radiation treatment. Magnetic resonance imaging (MRI) revealed a 4-cm tumor with bilateral inguinal node involvement. Additionally, computed tomography (CT) of the chest, abdomen, and pelvis (CAP), as well as positron emission tomography, showed no evidence of distant metastasis. Colonoscopy results were normal, and punch biopsy confirmed squamous cell histopathology. Preoperative TNM staging of the cancer indicated a classification of cT2N1aM0.
Ethics statement
The patient provided consent for the publication of this report, and the video has not been previously presented elsewhere.
For this procedure, the surgical team included the following: (1) colorectal team A, responsible for performing the abdominal portion of the operation as well as operating the robot; (2) colorectal team B, responsible for operating on the perineal region; (3) a plastic surgeon, who handled the flaps and perineal reconstruction; and (4) a urologic surgeon, who performed bilateral groin lymph node dissection using the robotic system. Colorectal team B pre-marked the skin incision site for the plastic surgeon.
For the abdominal dissection phase of the procedure, we utilize 2 right-handed instruments. We insert a 12-mm port for initial access, along with a 5-mm AirSeal assistant port (Conmed Corp). The video presents a live demonstration of our port placement technique. Peritoneal dissection begins just above the sacral promontory, continuing until the inferior mesenteric artery is identified. If an end colostomy is planned, we take care to preserve the ascending left colic artery.
We then perform abdominoperineal excision of the rectum (APER), using a standardized process. Concurrently, the plastic surgeon is adeptly elevating the flaps in tandem. Specifically, a gracilis flap is utilized, which the surgeon will integrate with a right-sided advancement gluteal flap.
The plastic surgeon operates with ease and without hindrance from the robot. An adjustment occurs during the stapling phase, when we switch to 2 left-handed instruments and introduce a 12-mm robotic port at the umbilicus, enabling the use of a SureForm stapler (Intuitive Surgical Inc).
After stapling the proximal margin, we proceed with total mesorectal excision dissection. The loose peritoneal body is readily apparent. By this point, the abdominal portion of the procedure has been completed, allowing the perineal surgeons to work unimpeded. We utilize the Lone Star retractor (CooperSurgical Inc) and a headlamp to enhance visibility. The specimen is subsequently extracted perineally, after which the plastic surgeons are called back to complete the combined perineal reconstruction.
For the groin dissection, we utilize 3 arms of the robot. The video presents our standard setup for the left side, which can be mirrored on the right side by repositioning the assistant port to the opposite side. The procedure begins with gaining entry, inserting the Hasson port, and establishing the operative space. Subsequently, we introduce 2 robotic trocars. The assistant’s role is crucial during this phase of the procedure, facilitating dissection while minimizing instrument clashing. In the present case, we excised all the nodes en bloc, followed by a separate dissection of the deep compartment adjacent to the femoral vessels. Each specimen from the groin is extracted using an endoscopic bag. For this case, we chose a robotic approach based on the existing literature, which indicates lower morbidity and improved cosmetic outcomes compared to open and laparoscopic groin node dissections [‎6‎, 7].
Outcomes
The patient made an uneventful recovery and was discharged on postoperative day 7. The postoperative histopathology report indicated pT3, N1a (3/12 groin nodes), V1 (venous invasion), and LY1 (lymphatic invasion), with the resection margin of the primary tumor 0.4 mm from the inked margin. Consequently, the multidisciplinary team recommended the initiation of intensive surveillance.
Postoperative surveillance
The intensive surveillance protocol included multiple CT CAP and MRI pelvis scans, which ruled out any form of recurrence at the 18-month checkpoint. Additionally, no evidence of lymphoedema was observed up to the date of submission of this report.
This publication demonstrates the safety and feasibility of combined, simultaneous multispecialty operations using robotics and advanced surgical techniques, such as robotic-assisted APER with bilateral groin node dissection and flap reconstruction. Even with a boomless system such as the da Vinci X, multisite surgery and simultaneous operations are feasible.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Acknowledgments

The authors thank the patient for providing written informed consent for publication of her clinical information and video.

Author contributions

Conceptualization: all authors; Writing–original draft: MA, MH; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Supplementary Video 1.
Robotic combined surgery 2022.
Supplementary materials are available from https://doi.org/10.3393/ac.2023.00801.0114.
  • 1. Ravendran K, Abiola E, Balagumar K, Raja AZ, Flaih M, Vaja SP, et al. A review of robotic surgery in colorectal surgery. Cureus 2023;15:e37337. ArticlePubMedPMC
  • 2. McGuirk M, Gachabayov M, Rojas A, Kajmolli A, Gogna S, Gu KW, et al. Simultaneous robot assisted colon and liver resection for metastatic colon cancer. JSLS 2021;25:e2020.00108. ArticlePubMedPMC
  • 3. Imaizumi K, Kasajima H, Ito K, Fukasawa T, Odagiri M, Yamana D, et al. Hybrid robot-assisted abdominoperineal resection supported by simultaneous trans-perineal approach for anal gland adenocarcinoma with vaginal invasion: a case report. J Surg Case Rep 2023;2023:rjad334.ArticlePubMedPMCPDF
  • 4. Kaida S, Miyake T, Shimizu T, Takebayashi K, Yamaguchi T, Ishikawa K, et al. Experience and technique of simultaneous robotic resection for synchronous advanced gastric and rectal cancers: a case report. Surg Case Rep 2020;6:169.ArticlePubMedPMCPDF
  • 5. Dixon F, O’Hara R, Ghuman N, Strachan J, Khanna A, Keeler BD. Major colorectal resection is feasible using a new robotic surgical platform: the first report of a case series. Tech Coloproctol 2021;25:285–9. ArticlePubMedPMCPDF
  • 6. Elsamra SE, Poch MA. Robotic inguinal lymphadenectomy for penile cancer: the why, how, and what. Transl Androl Urol 2017;6:826–32. ArticlePubMedPMC
  • 7. Matin SF, Cormier JN, Ward JF, Pisters LL, Wood CG, Dinney CP, et al. Phase 1 prospective evaluation of the oncological adequacy of robotic assisted video-endoscopic inguinal lymphadenectomy in patients with penile carcinoma. BJU Int 2013;111:1068–74. ArticlePubMedPMCPDF

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        Robotic abdominoperineal resection, bilateral robotic groin node dissection and simultaneous perineal gracilis flap reconstruction for locally advanced node-positive anal squamous cell carcinoma
        Ann Coloproctol. 2024;40(6):613-615.   Published online December 2, 2024
        DOI: https://doi.org/10.3393/ac.2023.00801.0114
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      Robotic abdominoperineal resection, bilateral robotic groin node dissection and simultaneous perineal gracilis flap reconstruction for locally advanced node-positive anal squamous cell carcinoma
      Robotic abdominoperineal resection, bilateral robotic groin node dissection and simultaneous perineal gracilis flap reconstruction for locally advanced node-positive anal squamous cell carcinoma
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