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Page 2 of 11 Abdalla et al. Mini-invasive Surg 2019;3:39 I http://dx.doi.org/10.20517/2574-1225.2019.38

Conclusion: RAAPR is feasible, with acceptable pathologic and short-term outcomes. The current literature does
not demonstrate significant differences between robotic and laparoscopic APR. Indeed, we cannot justify its use in
routine on the basis on the available evidence.

Keywords: Abdominoperineal resection, total mesorectal excision, robotic surgery, feasibility, rectal cancer, anal
cancer

INTRODUCTION
The frequency with which abdominoperineal resection (APR) is performed has dramatically decreased
over the last decade, mostly due to technical advances, the need for shorter distal margins, and oncological
[1,2]
therapeutic progress . Despite this, APR remains the appropriate approach for rectal cancers with
involvement of the sphincter complex or that cannot be removed with sufficient distal resection margins,
[2]
and for elderly with poor baseline functional status . Finally, APR remains the standard treatment for
[3]
persistent or recurrent squamous cell carcinoma of the anal canal after chemoradiotherapy .
[4]
Minimally invasive rectal surgery (MIRS) is a challenge . The reported high conversion rates and the
risks of positive circumferential resection margin (CRM) are thought to reflect the high level of difficulty
[5]
associated with MIRS . The fulcrum effect is one of the factors incriminated in the difficulty of MIRS,
[6]
as it results in reduced motion ranges, especially inside the pelvis . A robotic-assisted approach could
[7]
potentially overcome some of the limitations of conventional laparoscopic rectal surgery . However, few
studies focus on robotic-assisted APR (RAAPR), and most are retrospective. Thus, the aim of this study
was to provide a detailed description on the operative procedure, and to assess the feasibility, pathological,
and short-term outcomes of the first 20 RAAPR in a high-volume center.

METHODS
Patients’ selection and preoperative management
All consecutive patients undergoing RAAPR in our department from January 2013 to April 2018 were
prospectively included. Patients with distant metastases were not excluded. Preoperative tumor staging
assessment included colonoscopy; pelvic MRI; endorectal ultrasound when indicated; and thoracic,
abdominal, and pelvic injected CT scan. Neoadjuvant treatment was planned according to the French
[8]
guidelines after multidisciplinary staff discussion.
Postoperative care and follow-up
[9]
Histopathological mesorectal grade was classified according to Quirke et al. . All patients were started
on clear liquids at postoperative day 1, and then a soft diet on passage of gas in the stoma bag. Particular
attention was made to the perineal wound healing. Patients were discharged once their pain was controlled
on oral analgesics and when the healing of the perineal wound was considered satisfactory. No patient
was included in any “Enhanced Recovery After Surgery” protocol. Surgical complications were evaluated
[10]
during the 30-day postoperative period and were graded according to Dindo and Clavien .

Statistical analysis
Demographic data, operative parameters, and pathologic outcomes were recorded in a prospectively
collected database. Quantitative variables were expressed as means (± standard deviation) and qualitative
variables as frequencies (percentages). Statistical analyses were performed using SPSS (IBM SPSS Statistics,
Version 23 for Macintosh; IBM Corp., Armonk, NY, USA).