Robotic assisted minimally invasive surgery has assumed an increasingly important role in the modern practice of surgery with expanding applications across surgical disciplines. The enhanced high-definition three-dimensional (3D) visualization accompanied by advanced instrumentation with fully wristed articulating dexterity makes robotic technology an ideal tool for operations requiring the finest precision. These attributes are especially pertinent in areas where anatomic constraints lead to limited exposure and maneuverability. While increasing adoption of the robotic platform has been witnessed in all general surgical procedures, nowhere has it been more pertinent than in deep pelvic surgeries. The pelvic cavity not only poses the aforementioned challenges in terms of surgical exposure and anatomic restrictions by the bony pelvis, but it also places the surgeon in considerable ergonomic strain whether an open or laparoscopic technique is used. The robot effectively mitigates some of these ergonomic challenges, making it an ideal tool for deep pelvic operations. Robotic technology should be considered an additional tool in the surgeon’s armamentarium, not that it should be used in an attempt to overcome inadequate experience or suboptimal technical skills.
It is important to bear in mind that the principles and guidelines inherent to open and laparoscopic surgical approaches remain essential to robotic assisted surgery. It is paramount that oncologic principles never be compromised for operative approach and in the use of advanced technology platforms. Specifically, the principles governing total mesorectal excision and distal margin clearance for open operations apply equally to the minimally invasive approaches. It is also critical to be aware that adequate training, skills competency, and experience with robotic technology are necessary to technical success and optimal patient outcomes.
The indications for robotic low anterior resection remain the same as those for laparoscopic and open approaches described in Chapters 63 and 66. These operations are typically performed for adenocarcinoma involving the rectum or rectosigmoid colon. On occasion, patients with other malignant (e.g., neuroendocrine, melanoma, sarcoma, and gastrointestinal stromal tumors, to name a few) or benign rectal tumors that are deemed too large for endoscopic removal may require low anterior resection.
In patients in whom proximal fecal diversion is likely, the need for preoperative stoma education and consultation with an enterostomal therapy team cannot be overemphasized. This consultation not only allows for optimal stoma-site identification but also provides patients with much-needed knowledge and helps to set postoperative expectations.
The exact location of the tumor, its relationship to the endoscopic tattoo, and its distance from the anal verge should be appreciated and clearly documented preoperatively. An endoscopy cart should be available in case an intraoperative endoscopic examination is needed for exact tumor localization and distal margin confirmation. For large tumors with multiorgan involvement, preoperative assembly of a multidisciplinary operative team is critical to avoid urgent intraoperative consultations and for operative planning to achieve optimal patient surgical outcomes.