Robotic surgery after total neoadjuvant therapy for rectal cancer: pitfalls of beyond total mesorectal excision for patients with sidewall invasion

AimTotal neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) is rapidly spreading. The robotic surgical techniques to approach lateral invasion, such as that of the pelvic plexus, have not yet been established. In this technical note, we present a video illustrating a surgical technique for lateral invasion using our novel technique and discuss its pitfalls.MethodWe present the case of a 65-year-old man with LARC. Robotic surgery was performed after TNT using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical procedure was as follows: (1) D3 lymph node dissection around the inferior mesenteric artery using a medial-to-lateral approach; (2) rectal mobilization; (3) dissection of the ureterohypogastric fascia and ureter; and (4) combined resection of the hypogastric nerve and pelvic plexus. The key surgical point for sidewall invasion is the resection extent. Dividing the resection extent into three areas is important: zone A, which contains the pelvic plexus and is closest to the tumour; zone B, which contains the iliac vessels; and zone C, the most lateral zone, which contains the obturator nerves. This allows organ and function preservation by resecting only the smallest organ that truly requires R0 resection.ResultsThe operating time was 333 min, console time was 232 min, and blood loss was 0 mL. The circumferential resection margin was 10 mm, and an R0 resection was achieved.ConclusionWe introduced a novel approach for robotic surgery after TNT for LARC with sidewall invasion. This technique can be performed safely and may help standardize 'beyond total mesorectal excision'.