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Hybrid Laparoscopic-Robotic Low Anterior Resection

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Minimally invasive rectal surgery is technically challenging because of a narrow and deep pelvis. As a direct consequence, the majority of rectal resections in the US are performed open or with a combined laparoscopic-open approach. The use of a robotic platform may facilitate minimally invasive rectal resection. Surgeons experienced in advanced laparoscopic techniques may find that the robot may enhance the ability to complete rectal procedures, offering patients the benefits of a minimally invasive technique including its enhanced recovery. It is noteworthy that a number of technical principles are common to various rectal procedures. Within this chapter, a detailed description of a hybrid laparoscopic-robotic low anterior resection is provided with emphasis on the technical aspects that allow surgeons to easily transition from one step to the next while achieving the goal of completing the procedure in a minimally invasive fashion.


  • Robotic
  • Laparoscopic
  • Hybrid
  • Rectal surgery
  • Low anterior resection
  • Rectal cancer
  • Total mesorectal excision

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  • DOI: 10.1007/978-1-4939-1893-5_23
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Correspondence to Alessio Pigazzi M.D., Ph.D. .

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In this video, the surgeon demonstrates his approach to hybrid laparoscopic-robotic low anterior resection. (MPG 1059830 kb)

Key Operative Steps

Key Operative Steps

  1. 1.

    The patient is placed on the operating room table in modified lithotomy position and secured to prevent movement when the bed is changed to different positions.

  2. 2.

    The abdominal cavity is accessed and insufflated. Ports are placed after insufflation is complete.

  3. 3.

    The abdomen is thoroughly explored to rule out metastatic disease.

  4. 4.

    The inferior mesenteric vessels are identified then divided and the mesocolon is dissected away from retroperitoneal structures in a medial-to-lateral fashion. Care is taken to identify and protect the ureter.

  5. 5.

    The lateral attachments along the line of Toldt are divided and the splenic flexure is then mobilized.

  6. 6.

    Once the colon has been mobilized, the ureter identified, and the inferior mesenteric vessels divided, the robotic portion of the procedure begins.

  7. 7.

    rTME starts at the sacral promontory as the avascular plane between the EVF that contains the mesorectum and the endopelvic parietal fascia is entered. As dissection starts, it is important to identify the hypogastric nerves in this area and gently dissected them away from the operating field.

  8. 8.

    Dissecting as far distal as possible in the posterior plane makes identification of the lateral stalks and dissection in the anterolateral areas easier.

  9. 9.

    As the peritoneal reflection is opened anteriorly, precise sharp dissection helps prevent injury to the seminal vesicles and prostate in men and the vaginal wall in women. As dissection progresses, the lateral stalks are divided.

  10. 10.

    The distal rectum is then transected at the desired level with a stapler. The robot is then undocked.

  11. 11.

    A Pfannenstiel incision is then made and the specimen delivered into the operative field. The proximal margin of resection is then divided with a stapler.

  12. 12.

    A circular stapler is used to create the colorectal anastomosis. Anastomotic integrity is checked and then the trocars are removed and all incisions are closed.

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Bosio, R.M., Pigazzi, A. (2015). Hybrid Laparoscopic-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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