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Totally Robotic Low Anterior Resection

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Rectal cancer surgery is complex and technically challenging. This is largely because the surgical field is in the bony pelvis, a restrictive anatomical area. Robotic technology allows the surgeon to maneuver, despite these restrictions, in a more precise and safe way. From the surgeon’s point of view, the superior precision and dexterity of the four-arm da Vinci robotic system (Intuitive) give it a clear advantage over conventional laparoscopy. Robotic low anterior resection (LAR) is for patients who present with mid and low rectal cancers that do not invade the sphincters. A thorough understanding of the principles of total mesorectal excision (TME) and an adequate yearly volume of rectal surgical procedures are required to ensure patient safety and optimal perioperative and oncologic outcomes. Recent review of outcomes associated with robotic-assisted colorectal surgery, laparoscopic, and open surgical approaches indicates that robotic surgical approaches are safe and feasible with comparable short-term and long-term outcomes to open and laparoscopic procedures. In this chapter we describe our rationale, technique, and considerations for robotic LAR.


  • Rectal cancer
  • Total mesorectal excision (TME)
  • Low anterior resection (LAR)
  • Robotic total mesorectal excision (RTME)

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  • DOI: 10.1007/978-1-4939-1893-5_22
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Correspondence to Julio Garcia-Aguilar M.D., Ph.D. .

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In this video, the surgeon demonstrates his approach to totally robotic low anterior resection. (WMV 111692 kb)

Key Operative Steps

Key Operative Steps

  1. 1.

    Place the patient in modified lithotomy position.

  2. 2.

    Place the robotic trocars 8–10 cm apart to avoid collisions.

  3. 3.

    Divide the IMV near its insertion and perform medial to lateral mobilization of the left and sigmoid colon.

  4. 4.

    After identifying the ureter and gonadal vessels, the inferior mesenteric artery can be divided.

  5. 5.

    Retract the colon medially and open the white line of Toldt.

  6. 6.

    Perform the splenic flexure takedown.

  7. 7.

    Divide the mesentery of the descending colon.

  8. 8.

    Elevate the rectosigmoid junction and begin posterior dissection at the sacral promontory. Proceed along the areolar plane down to the rectococcygeal ligament.

  9. 9.

    Incise the peritoneal reflection anteriorly and continue dissection along the rectovaginal septum in women or Denonvillier’s fascia in men.

  10. 10.

    Laterally, dissection is medial to both ureters to the middle rectal vessels.

  11. 11.

    At the pelvic floor separate the rectum from the levator muscle.

  12. 12.

    Perform digital rectal exam to ensure location of tumor and then divide the rectum with a stapling device.

  13. 13.

    Once the rectum is divided, the robot is undocked and the specimen is extracted.

  14. 14.

    An anvil is placed in the proximal bowel and a laparoscopic anastomosis is created with a circular stapler.

  15. 15.

    A diverting loop ileostomy is created.

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Smith, J.J., Feo, L., Garcia-Aguilar, J. (2015). Totally Robotic Low Anterior Resection. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY.

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