Robot-Assisted Reduced Port TME with Low Colorectal Anastomosis

  • Ichiro Takemasa
  • Emi Akizuki
  • Tomomi Ueki
  • Toshihiko Nishidate
  • Kenji Okita
  • Tomohisa Furuhata


Advances in minimally invasive laparoscopic surgery have grown to reduced-port surgery (RPS). Single-incision laparoscopic surgery (SILS) is considered the ultimate RPS for improving cosmesis and reducing postoperative pain and the risk of abdominal wall morbidities. Several reports have described both superior short-term and similar long-term results of SILS for colorectal malignancies when compared with standard laparoscopic surgery. However, there are some limitations such as instrument collision and insufficient countertraction. In a recent attempt to overcome the technical issues in SILS, by combining the use of the da Vinci robotic surgical system with the single-incision platform, the recognized challenges are somewhat simplified. Only a few reports of single-port robotic surgery for rectal disease have been conducted; however, the current robotic arm and equipment are still rather bulky and have a limited intrapelvic range of motion. Pure single approach may be not suited for sufficient oncological clearance.

We have developed the novel approach for minimally invasive surgery for rectal malignancies with combination of the da Vinci robotic surgical system and the concept of RPS, which is robot-assisted reduced-port total mesorectal excision (RARPTME). Our procedure is well suited for good countertraction and smooth maneuverability and can provide improved cosmesis and theoretically reduced postoperative pain when compared with standard robotic surgery that usually needs at least six or more scars.

Herein, we describe our techniques for RARPTME with low colorectal anastomosis in detail. Our procedure makes standardization of safe and certain RARPTME possible.


Robotic surgery Reduced-port surgery Rectal cancer Low anterior resection 


  1. 1.
    Curcillo PG 2nd, Podolsky ER, King SA. The road to reduced port surgery: from single big incisions to single small incisions, and beyond. World J Surg. 2011;35:1526–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Takemasa I, Sekimoto M, Ikeda M, Mizushima T, Yamamoto H, Doki Y, Mori M. Video. Transumbilical single-incision laparoscopic surgery for sigmoid colon cancer. Surg Endosc. 2010;24:2321.CrossRefPubMedGoogle Scholar
  3. 3.
    Papaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery. 2011;50:820–7.CrossRefGoogle Scholar
  4. 4.
    Ramos-Valadez DI, Ragupathi M, Nieto J, Patel CB, Miller S, Pickron TB, Haas EM. Single-incision versus conventional laparoscopic sigmoid colectomy: a case-matched series. Surg Endosc. 2012;26:96–102.CrossRefPubMedGoogle Scholar
  5. 5.
    Kim SJ, Ryu GO, Choi BJ, Kim JG, Lee KJ, Lee SC, Oh ST. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011;254:933–40.CrossRefPubMedGoogle Scholar
  6. 6.
    Champagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC, Delaney CP. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg. 2012;255:66–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Takemasa I, Uemura M, Nishimura J, Mizushima T, Yamamoto H, Ikeda M, Sekimoto M, Doki Y, Mori M. Feasibility of single-site laparoscopic colectomy with complete mesocolic excision for colon cancer: a prospective case-control comparison. Surg Endosc. 2014;28:1110–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Hiraki M, Takemasa I, Uemura M, Haraguchi N, Nishimura J, Hata T, Mizushima T, Yamamoto H, Doki Y, Mori M. Evaluation of invasiveness in single-site laparoscopic colectomy, using “the PainVision system” for quantitative analysis of pain sensation. Surg Endosc. 2014;28:3216–23.CrossRefPubMedGoogle Scholar
  9. 9.
    Yun JA, Yun SH, Park YA, Huh JW, Cho YB, Kim HC, Lee WY. Oncologic outcomes of single-incision laparoscopic surgery compared with conventional laparoscopy for colon cancer. Ann Surg. 2016;263(5):973–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Katsuno G, Fukunaga M, Nagakari K, Yoshikawa S, Azuma D, Kohama S. Short-term and long-term outcomes of single-incision versus multi-incision laparoscopic resection for colorectal cancer: a propensity-score-matched analysis of 214 cases. Surg Endosc. 2015;30(4):1317–25.CrossRefPubMedGoogle Scholar
  11. 11.
    Hamabe A, Takemasa I, Uemura M, Nishimura J, Mizushima T, Ikeda M, Yamamoto H, Sekimoto M, Doki Y, Mori M. Feasibility of single-port laparoscopic surgery for sigmoid colon and rectal cancers and preoperative assessment of operative difficulty. J Gastrointest Surg. 2014;18:977–85.CrossRefPubMedGoogle Scholar
  12. 12.
    Haber GP, Autorino R, Laydner H, Yang B, White MA, Hillyer S, Altunrende F, Khanna R, Spana G, Wahib I, Fareed K, Stein RJ, Kaouk JH. SPIDER surgical system for urologic procedures with laparoendoscopic single-site surgery: from initial laboratory experience to first clinical application. Eur Urol. 2012;61:415–22.CrossRefPubMedGoogle Scholar
  13. 13.
    Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004;239:14–21.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Maeso S, Reza M, Mayol JA, Blasco JA, Guerra M, Andradas E, Plana MN. Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis. Ann Surg. 2010;252:254–62.CrossRefPubMedGoogle Scholar
  15. 15.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol. 2010;17:3195–202.CrossRefPubMedGoogle Scholar
  16. 16.
    Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek JH. Multicentric study on robotic tumorspecific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol. 2010;17:1614–20.CrossRefPubMedGoogle Scholar
  17. 17.
    White MA, Haber GP, Autorino R, Khanna R, Altunrende F, Yang B, Stein RJ, Kaouk JH. Robotic laparoendoscopic single-site surgery. BJU Int. 2010;106:923–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Rane A, Autorino R. Robotic natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery: current status. Curr Opin Urol. 2011;21:71–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port transumbilical surgery in humans: initial report. BJU Int. 2009;103:366–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Ragupathi M, Ramos-Valadez DI, Pedraza R, Haas EM. Roboticassisted single-incision laparoscopic partial cecectomy. Int J Med Robot. 2010;6:362–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Ostrowitz MB, Eschete D, Zemon H, DeNoto G. Robotic-assisted single-incision right colectomy: early experience. Int J Med Robot. 2009;5:465–70.CrossRefPubMedGoogle Scholar
  22. 22.
    Joseph RA, Goh AC, Cuevas SP, Donovan MA, Kauffman MG, Salas NA, Miles B, Bass BL, Dunkin BJ. “Chopstick” surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery. Surg Endosc. 2010;24:1331–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med. 1988;81:503–8.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Japan 2018

Authors and Affiliations

  • Ichiro Takemasa
    • 1
  • Emi Akizuki
    • 1
  • Tomomi Ueki
    • 1
  • Toshihiko Nishidate
    • 1
  • Kenji Okita
    • 1
  • Tomohisa Furuhata
    • 1
  1. 1.Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan

Personalised recommendations