Dynamic Article: Tandem Robotic Technique of Extralevator Abdominoperineal Excision and Rectus Abdominis Muscle Harvest for Immediate Closure of the Pelvic Floor Defect

BACKGROUND:Extralevator abdominoperineal excision for distal rectal cancers involves cylindrical excision of the mesorectum with wide division of the levator ani muscles. Although this technique has been shown to decrease local cancer recurrence and improve survival, it leaves the patient with a considerable pelvic floor defect that may require reconstruction. OBJECTIVE:We developed an innovative technique of robotic extralevator abdominoperineal excision combined with robotic harvest of the rectus abdominis muscle flap for immediate reconstruction of the pelvic floor defect. DESIGN:This was a retrospective review pilot study. SETTING:This study was conducted at a tertiary care cancer center. PATIENTS:Three patients who underwent robotic extralevator abdominoperineal excision with robotic rectus abdominis flap harvest for distal rectal adenocarcinoma were included. MAIN OUTCOMES MEASURES:Intraoperative and postoperative outcomes included operative time, intraoperative complications, length of hospital stay, wound complications, incidence of perineal hernia, persistent pain, and functional limitations. RESULTS:Three patients underwent this procedure. The median operative time was 522 minutes with median hospital stay of 6 days. One patient experienced perineal wound complication requiring limited incision and drainage followed by complete healing of the wound by secondary intention. The other 2 patients did not experience any wound complications. Longest follow-up was 16 months. None of the patients developed perineal hernias during this time period. LIMITATIONS:The small sample size and retrospective nature were limitations. CONCLUSIONS:This technique confers multiple advantages including improved visualization and dexterity within the pelvis and accurate wide margins at the pelvic floor. An incisionless robotic flap harvest with preservation of the anterior rectus sheath obviates the risk of ventral hernia while providing robust tissue closure of the radiated abdominoperineal excision wound. This technique may result in faster postoperative recovery, decreased morbidity, improved functional outcomes and cosmesis. Further studies are needed to prospectively analyze this approach (Supplemental Digital Content 1, video abstract, http://links.lww.com/DCR/A188).