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Page 2 of 12 Chen et al. Mini-invasive Surg 2018;2:43 I http://dx.doi.org/10.20517/2574-1225.2018.42

(95%) patients. Circumferential and distal resection margins were positive in 3 (5%) and 1 (1.6%) patients, respectively.
The sphincter preservation rate was 93.3% (56/60). The overall complication rate was 21.7% (13/60), with an
anastomotic leakage rate of 3.3% (2/60); most of these instances were mild and the patient recovered uneventfully.

Conclusion: The results demonstrate that robotic-assisted TME is safe and feasible for patients with low-lying rectal
cancer.

Keywords: Robotic-assisted total mesorectal excision, low-lying rectal cancer, R0 resection, circumferential resection margin

INTRODUCTION
In 2014, approximately 15,000 new cases of colorectal cancer were diagnosed in Taiwan, and in approxi-
[1]
mately 5,600 of cases, the patient died. Total mesolectal excision (TME) surgery, reported by Heald et al.
[2]
in 1982, has resulted in decreased 5-year local and overall recurrence rates. MacFarlane et al. reported the
importance of identifying the “holy plane”, that is, the surgeon’s dissection that will encompass the malig-
nancy and yet preserve autonomic neural function. Radiation therapy offers noteworthy benefits to many
patients with rectal cancer; preoperative radiation is superior to postoperative radiation. Preoperative
radiation combined with chemotherapy (chemoradiotherapy) is used for locally advanced rectal cancer.
A German study suggested that compared with postoperative chemoradiotherapy, preoperative chemora-
diotherapy improved local control and was associated with reduced toxicity, but did not improve overall
[5-7]
[3,4]
survival . We achieved similar results from other studies .
[8,9]
Laparoscopic rectal surgery was as safe as open surgery and resulted in improved recovery rates . How-
ever, the robotic system has several advantages over laparoscopic surgery, such as a high-definition three-
dimensional vision, smooth movement of instruments, and absence of surgeon tremor. Thus, this robotic
system can be anticipated to assist with dissections in the narrow pelvic cavity. Since the first robotic colon
[10]
surgery in 2002 , it is believed to have the potential to improve compliance with minimal invasive sur-
gery. For rectal cancers, robotic surgery has been demonstrated to be as safe and feasible as laparoscopic
and open surgical procedures [11-14] .

The unique anatomy of the rectum, with its retroperitoneal location in the narrow pelvis, makes surgical
access relatively difficult. The visceral endopelvic fascia, also known as fascia propria, is identified by a
loose areolar tissue that circumferentially separates the rectum and mesorectum from surrounding pelvic
structures. Removal of the rectum with the mesoretum intact ensures the complete removal of all lymph
nodes and lymphatics from the diseased rectum and thus prevents oncologic contamination of the pelvis
during surgery. In this study, we present the short-term oncological outcomes of patients with low-lying
rectal cancer who underwent complete robotic-assisted TME.

METHODS
Patients
The data included 60 patients with low-lying rectal cancer (adenocarcinoma) stages I-III who underwent
complete robotic-assisted TME with the da Vinci® surgical system at a single institution between July 2013
and April 2017. The study was approved by the institutional review board of our hospital. Informed con-
sent was obtained from each patient before performing the robotic surgery. All patients underwent routine
preoperative colonoscopy and abdominal and pelvic computed tomography (CT) or magnetic resonance
imaging for preoperative staging. Low-lying rectal cancer was defined as a tumor located at or less than
5 cm from the anal verge. Patients with T3, T4, or N+ rectal cancer received preoperative concurrent
chemoradiotherapy (CCRT). Furthermore, a 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) regimen