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The Pelvis-First Approach for Robotic Proctectomy in Patients with Redundant Abdominal Colon

  • Yun Yang
  • Songphol Malakorn
  • Kelly Maldonado
  • Brian K. Bednarski
  • Colleen M. Kiernan
  • Selvi Thirumurthi
  • George J. Chang
  • Y. Nancy YouEmail author
Colorectal Cancer
  • 16 Downloads

Abstract

Background

Robotic surgery is increasingly performed for low rectal cancer.1 A redundant sigmoid colon makes retraction and pelvic dissection challenging. We present a ‘pelvis-first’ approach to robotic proctectomy where pelvic dissection occurs prior to colonic mobilization.

Methods

A 26-year-old woman was diagnosed with a clinical T3N1 rectal adenocarcinoma at 3 cm from the anal verge. The patient had Lynch syndrome, with a germline mutation in the PMS2 gene. A near-complete clinical response was observed after neoadjuvant chemoradiation (NCRT), and the patient wished to delay surgery and permanent colostomy. Additional FOLFOX was administered and led to a complete clinical response. After 2.5 months of watchful delay of surgery, the tumor regrew, and the patient then underwent robotic abdominoperineal resection (APR).

Results

Initial exploration revealed a highly redundant sigmoid colon. A pelvis-first approach was undertaken. The colon was left tethered and outside of the pelvis during the pelvic dissection. The levator ani was divided transabdominally. Vascular dissection and left colon mobilization were completed after pelvic dissection.2 The specimen was removed transanally, obviating the need for abdominal incision. An end colostomy was created laparoscopically, and the perineum was closed primarily after omental flap. The patient recovered without complications.

Conclusions

The ‘pelvis-first’ approach to proctectomy is advantageous for patients with a highly redundant sigmoid colon. Transabdominal division of the levator ani during APR ensures excellent circumferential margin. Although Lynch syndrome-associated rectal cancer can show excellent response to NCRT,3 patients undergoing watchful delay of surgery require close monitoring and prompt triggering of salvage proctectomy when tumor regrowth is observed.4,5

Notes

Disclosures

Yun Yang, Songphol Malakorn, Kelly Maldonado, Brian K. Bednarski, Colleen M. Kiernan, Selvi Thirumurthi, George J. Chang, and Y. Nancy You have declared no conflicts of interest.

Supplementary material

Supplementary material 1 (MP4 149810 kb)

References

  1. 1.
    Sammour T, Malakorn S, Bednarski BK, et al. Oncological outcomes after robotic proctectomy for rectal cancer: analysis of a prospective database. Ann Surg. 2018;267(3):521–6.CrossRefGoogle Scholar
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    Malakorn S, Sammour T, Bednarski B, You YN, Chang GJ. Three different approaches to the inferior mesenteric artery during robotic D3 lymphadenectomy for rectal cancer. Ann Surg Oncol. 2017;24(7):1923.CrossRefGoogle Scholar
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    de Rosa N, Rodriguez-Bigas MA, Chang GJ, et al. DNA mismatch repair deficiency in rectal cancer: benchmarking its impact on prognosis, neoadjuvant response prediction, and clinical cancer genetics. J Clin Oncol. 2016;34(25):3039–46.CrossRefGoogle Scholar
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    Snyder RA, Hu CY, Cuddy A, et al. Association between intensity of posttreatment surveillance testing and detection of recurrence in patients with colorectal cancer. JAMA. 2018;319(20):2104–15.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Yun Yang
    • 1
    • 2
  • Songphol Malakorn
    • 2
  • Kelly Maldonado
    • 2
  • Brian K. Bednarski
    • 2
  • Colleen M. Kiernan
    • 2
  • Selvi Thirumurthi
    • 3
  • George J. Chang
    • 2
  • Y. Nancy You
    • 2
    Email author
  1. 1.Department of General SurgeryChinese PLA General HospitalBeijingChina
  2. 2.Department of Surgical Oncology The University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of Gastroenterology Hepatology and NutritionThe University of Texas MD Anderson Cancer CenterHoustonUSA

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