Introduction

Pelvic multivisceral resection (MVT) is a surgical treatment for locally advanced pelvic malignancy. It is a major surgical procedure with significant morbidity. It could be a curative resection or a palliative procedure for symptom control.

Laparoscopic colorectal surgery is well established, and studies have shown better postoperative pain control, early start of bowel function, and reduced length of hospital stay when compared with open surgery.12 Kang et al have shown similar short-term outcomes of laparoscopic mid or lower rectal cancer surgery after neoadjuvant chemoradiotherapy.2 Limitations of conventional laparoscopy such as unstable camera view and limited dexterity in a narrow space, hinder deep pelvic dissection and the views in the pelvis may not be optimal.34

Robotic surgery is believed to extend the boundaries of laparoscopy due to its inherent features like stable camera platform, instruments with multiple degrees of freedom, three-dimension view, and excellent ergonomics.4 Compared with laparoscopy, these features are useful for deep pelvic dissection. Robotic pelvic surgery has been utilized by gynecology and urology with promising popularity for several indications other than rectal surgery.5 In a meta-analysis comparing robotic to laparoscopic resection, Sun et al have also described similar benefit with robotic surgery in rectal cancers—less postoperative complications, less conversion rates, better circumferential margin clearance, and lower length of hospital stay and is becoming a standard of care.6

Here, we describe our experience of robotic MVR (RMVR), focusing on feasibility and short-term outcomes.

Material and Methods

This retrospective study evaluates all patients who underwent RMVR for a colorectal primary at the colorectal and pelvic surgery unit of the Christie NHS (National Health Service) Foundation Trust (a tertiary referral center). The definition of MVR used was en bloc excision of rectal primary with any other visceral organ to achieve a clear margin. The decision for MVR was made through the pelvic multidisciplinary team (MDT) in all cases. Specifically, robotic colorectal surgery without any other visceral organ excisions was excluded from the study.

The da Vinci system (Intuitive Surgical Inc.) was used for all procedures (initially the da Vinci S system and, when available, the SI surgical systems). All MVRs were performed primarily by colorectal surgeon who was joined by an urologist and a gynecologist as and when needed. The team had documented extensive experience in laparoscopic and robotic surgery.

The steps of the procedure included insertion of the ports, control the inferior mesenteric artery pedicle, and mobilization of the left colon. This was followed by pelvic dissection to mobilize the rectum. Based on the extent of the multivisceral dissection required, the urologist or gynecologist joined the surgical team to ensure en bloc excision of the lesion. Depending on the extent of the perineal dissection, if a flap reconstruction was necessary a plastic surgeon also became part of the operating team.

Data on patient characteristics, preoperative tumor staging, preop chemoradiotherapy, and past abdominal surgery were analyzed. Postoperative complications were evaluated according to the Clavien–Dindo classification. Parameters of primary importance in the data analysis were conversion to open surgery, percentages of R0 resection, lymph node harvest, and immediate postoperative complications.

Results

Tumor and Patient Characteristics

A total of 102 patients underwent robotic colorectal resection during the period of 2012 to 2022. Of these, 24 underwent robotic-assisted MVR (23.5%). Majority of the patients were females (n = 17, 70.8%). Median age at the time of surgery was 66 years (minimum: 34 years, maximum: 79 years).

Preoperative tumor and patient characteristics are described in Table 1.

Table 1

Tumor and patient characteristics (

N

 = 24)

Tumor characteristics
Primary tumor location - Sigmoid colon - Upper and mid rectum - Lower rectum	2 (8.3%) 15 (62.5%) 7 (29.2%)
TNM stage
T
- T1	0
- T2	1 (4%)
- T3	6 (25%)
- T4	17 (71%)
N
- N0	6 (25%)
- N1	9 (37.5%)
- N2	9 (37.5%)
M
- M0	24
Neoadjuvant therapy given	22 (91.7%)
Presence of stoma (yes)	16 (66.7%)

Almost all the tumors were locally advanced rectal cancers. The majority of the tumors were either T3 or T4. One patient was referred to us with a suspicion of inflammatory lesion of the sigmoid colon involving the uterus and suspicious lung nodule. Repeat images at the MDT showed a thickened sigmoid with extensive diverticular disease and a possible fistula into the left fallopian tubes, showing air inside the uterus. The lung nodule has been resolved. As per the MDT discussion she underwent robotic high anterior resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy and defunctioning loop ileostomy. Histology confirmed diverticular disease without evidence of malignancy.

Pelvic radiotherapy: Twenty-two patients (91.7%) had received neoadjuvant chemoradiotherapy. Most patients had radiotherapy before referring to our center. Therefore, the median duration from the last dose of pelvic radiotherapy to surgery was 19 weeks, ranging from 10 to 156 weeks.

Previous stoma: While 16/24 (66.7%) had a stoma as part of their management, 12 (50%) of them also had a defunctioning stoma at the time of RMVR making the conventional port positioning a challenge (Fig. 1).

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Fig. 1: Port placement avoiding the stoma.

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The type of surgeries undertaken is shown in Table 2.

Table 2

Types of surgery

Primary surgery (N)	Other visceral organs resected
Posterior clearance (14)	Uterus and BSO (14) Loop of small bowel (1) Left external iliac LN excision (1) Bladder peritoneal excision (1)
High anterior resection (1)	Uterus and BSO (1)
APER (7)	Seminal vesicle excision (5)
	Posterior vaginectomy (2) Sacrectomy – S5 (1)
Low Hartmann's procedure (1)	Seminal vesicle excision (1)
Total pelvic exenteration (1)
Total (24)

Abbreviations: APER, abdominoperineal resection of the rectum; BSO, bilateral salpingo-oophorectomy; LN, lymph node.

Most excised visceral organs were uterus and ovaries followed by seminal vesicles and posterior vagina. Majority of the patients (62.5%) underwent posterior clearance (Fig. 2). This involves en bloc resection of rectum with uterus and salpingo-oophorectomy. Four of these patients required V-Y flap reconstruction of the perineum. Seminal vesicle excision along with abdominoperineal resection and preserving the bladder were done in 5 patients (thereby avoiding a total pelvic exenteration). One of these patients had a V-Y flap reconstruction of the perineum as well.

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Fig. 2: Specimen of posterior exenteration references; (A) View 1; (B) View 2.

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Conversion rate: All the cases were completed robotically. None of our patients required conversion to open surgery.

Histology: Nineteen patients had adenocarcinoma (79%). Complete resection (R0) was achieved in 15 patients (79%). In four patients surgery was R1 resection. Complete pathological response was seen in 4 specimens. The median lymph node harvest was 15 (range from 4 to 31).

Complications: Six patients (25%) had Clavien–Dindo 3 or above complications. This included pelvic collection needing radiological drainage3 and perineal wound/flap infection needing drainage under local anesthesia.3 No patients had a clinically significant anastomotic leak requiring resurgery. Our 90-day mortality rate was zero.

Discussion

For long, laparoscopy was the standard approach for rectal cancer surgery worldwide. Now its position is challenged by the robotic approach, which is gaining increasing popularity.7 Multivisceral pelvic surgery is a technically challenging procedure, and the open approach continues to be practiced in many centers (mainly due to a lack of availability of robotic/laparoscopic equipment and trained workforce). In this article, we have shown how the RMVR is feasible and safe for locally advanced rectal cancers.

In the past, minimal access surgery was plagued with the risk of conversion to open surgery, especially when the surgery was unplanned. When patients with rectal cancer are unexpectedly found to have tumor fixity to adjacent structures, extra-anatomical resection becomes necessary for a complete disease clearance and conversion to open surgery is required.289 A meta-analysis comparing robotic versus laparoscopy for low anterior resections has documented a low conversion rate in the robotic group.6 Similarly, none of the RMVR required conversion to open surgery in our series.

All our patients underwent RMVR after discussion in a pelvic MDT. The value of the discussion and insight obtained from the experts in the MDT cannot be overemphasized and the decision making is the key.

A standard linear port placement has been described for robotic rectal surgery. In our cohort, patients with previously placed defunctioning stoma made the port positioning a challenge. We were able to improvise by adjusting the port placement site based on the position of the stoma as well as intraoperative findings. Almost all our patients had received pelvic radiotherapy, which added to this challenge. Despite the common belief of difficult dissection in the postirradiated pelvis, we could do RMVR successfully in all our patients.

A significant challenge in locally advanced rectal cancer surgery is how to ensure complete resection—an important objective that commonly leads to conversion to open surgery. This has been reported in 15 to 26% in different studies.1011 In our series, R0 resection was possible in all apart from 4 patients and R1 resection in another 4 (16% each).

The MVR commonly involved uterus, ovaries, and seminal vesicles in our series. We believe this has helped in preserving the prostate and bladder, avoiding a urostomy and prevented the need of a total exenteration surgery. The anterior margins (for seminal vesicles) were negative for all our patients. Unfortunately, one patient had R1 resection due to a positive posterior margin.

Optimal management of locally advanced rectal cancer requires major surgical procedure that can be associated with significant morbidity. Sun et al have described lower complication rates in the robotic group versus laparoscopy group in low anterior resections.6 In our series, we had Clavien–Dindo 3 or more complications in 6 patients (25%), the common ones being pelvic collections and perineal wound complications. None of our patients had clinically significant anastomotic leak.

We acknowledge the limitations of our retrospective study. The number of patients was not very large, and we did not compare open or laparoscopy MVR. Finally, our focus was on short-term outcomes, and we cannot comment on any long-term results. We still feel that our data adds value to the emerging evidence on the role of RMVR in locally advanced rectal cancer.

Conclusion

RMVR is a technically safe and feasible approach for locally advanced colorectal cancer, with acceptable surgical complications.