Robotic Sphincter

Saving Surgery for low lying rectal cancer avoiding permanent stoma bag

• 71-year-old male patient presented with bleeding per rectum, changes in bowel habits and loss of appetite since last 3 months.
• On investigations further with Colonoscopy, MRI scan and PET Scan he was diagnosed to have stage 3 low lying locally advanced rectal cancer. Biopsy was Adenocarcinoma.
• He was started with combined radiation therapy and chemotherapy (NACTRT) to shrink the tumor and make feasible for sphincter saving surgery.
• He was reassessed with MRI scan and planned for surgery 6 weeks after completing NACTRT.

Treatment:

Following discussions with the Tumour Board, there was a good response to NACTRT and Robotic sphincter saving surgery (Ultra Low Anterior Resection) was planned for the patient.

It was a complex surgery which included rectal cancer removal (Total Mesorectal Excision – TME) ensuring tumor free distal margin with removal of the local lymph nodes. The surgery took around 6 hours. After the tumor was removed, ends of large intestine and anal canal were joined (anastomosis) avoiding permanent stoma bag.

The Patient had a smooth post-operative recovery, started walking on Day 1 of surgery, resumed oral feeds on Day 2 and was discharged 5 days after the surgery on 3rd March this year. He has completed his adjuvant chemotherapy and is leading a normal life today.

Discussion on the treatment:

Low lying Rectal cancer (within 5 cm from anal verge) surgery is challenging owing to its location within the pelvis especially in males/high BMI patients and relation to adjacent important structures including anal sphincter which controls the passing of stools. The case attains significance as rectal cancer is one of the commonest GI cancers in the country and permanent stoma bag after surgery is a major concern for majority of patients.

Keyhole surgeries (laparoscopic and robotic) have been used extensively in rectal cancer (large intestine) surgeries worldwide. The general advantage of these surgeries as compared to open surgery include lesser pain, small scars on abdomen and early resumption of normal activities.

The latest Robotic surgery systems (Da Vinci Xi) can improve surgical precision using wristed instruments with seven degrees of freedom (wrist like movement) and a stable three-dimensional (3D) better vision for the surgeon to perform rectal cancer surgeries and allows us to preserve the anal sphincter (avoiding permanent stoma bag); preserve nerves which supply the urogenital organs which can allow these patients to have a good urinary and sexual function after surgery.