Robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy: technical considerations and case vignette

Abstract

When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less important for patient outcomes. We performed a minimally invasive approach to surgery for LARC invading the posterior vagina and sacrum. The patient was a 75-year-old lady who presented with a locally advanced rectal tumour staged T4N2 with invasion into the posterior wall of the vagina and coccyx/distal sacrum. We introduce a robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy using a purely perineal approach with no robotic adjuncts or intracorporal techniques. Final histology showed moderately differentiated adenocarcinoma invading the vagina and sacrum, ypT4b N0 TRG2 R0 and the patient entered surgical follow-up with no immediate intra- or postoperative complications. A literature review shows the need for more minimally invasive techniques when relating to major pelvic surgery and the benefits of a purely perineal approach include less expensive resource use, fewer training requirements and the ability to utilise this technique in centres that are not robotically equipped.

Keywords: Pelvic exenteration; Rectal cancer; Robotic surgery.

Fig. 1

T2 weighted axial (left) and sagittal (right) sections of the MRI that clearly show the rectal tumour involving S5 and posterior vagina.  Figure 2 Diagrammatic representation of port placement

Fig. 2

Diagrammatic sagittal section showing the everted rectum delivered through the perineal wound with the tumour dissected from the posterior vagina and pelvic side

Fig. 3

Diagrammatic view of Fig. 2 from the perineal viewpoint with the osteotome in position