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Abdalla et al. Mini-invasive Surg 2019;3:39 I http://dx.doi.org/10.20517/2574-1225.2019.38 Page 5 of 11

Table 1. Preoperative characteristics
Overall (n = 20)
Male (%) 9 (45)
Age in years (mean ± SD) 68.5 ± 14.1
Age ≥ 75 years (%) 7 (35)
2
BMI in kg/m (mean ± SD) 24.5 ± 5.0
2
BMI > 30 kg/m (%) 2 (10)
2
BMI < 18 kg/m (%) 1 (5)
ASA score ≥ 2 (%) 17 (85)
History of prior abdominal surgery (%) 8 (40)
Indication of APR
Low rectum adenocarcinoma (%) 18 (90)
Epidermoid carcinoma of the anal canal (%) 2 (10)
Pretreatment T4 tumor (%) 5 (25)
Neoadjuvant treatment 17 (85)
Chemotherapy (%) 1 (5)
Radiotherapy (%) 4 (20)
Radio-chemotherapy (%) 12 (60)
BMI: body mass index; APR: abdominoperineal resection

circumferentially around the rectum, the pelvic portion of the dissection was completed. The proximal
portion of the colon was stapled and cut with an endostapler. A standard incision through the abdominal
wall was then created at the intended colostomy site; the distal colon was brought through this incision;
and the end colostomy was fashioned.

Perineal procedure
The perineal procedure was performed as previously described for open approach, in the lithotomy
[11]
position (except for one patient, for whom it was performed in prone position because of hip dysplasia) :
an elliptical incision was made around the anus outside the sphincter muscles. The ischiorectal fat was
dissected until the levators plane was identified and cut. The section of the anococcygeal ligament gave
access to the presacral space and the abdominal cavity. The specimen was extracted through the pelvic
incision. Omentoplasty could be placed in the pelvic cavity at this point. The drains were positioned, and
the perineal wound was closed.

RESULTS
Patients’ characteristics
From January 2013 to April 2018, we performed a total of 428 robotic procedures, among which 294
colorectal resections (68.7%), including 20 consecutive RAAPR. We included nine men (45%). Mean age
2
was 68.5 ± 14.1 years and mean BMI was 24.5 ± 5.0 kg/m . Eight (40%) patients had prior abdominal
surgery (appendectomy in four patients, cholecystectomy in three patients, and suture repair of a
perforated duodenal peptic ulcer in one patient). The majority of patients underwent APR for low rectum
adenocarcinoma and 17 (85%) patients received preoperative treatment. Demographic data are summarized
in Table 1.

Operative characteristics
All patients underwent robotic-assisted rectal resection with TME and cylindrical extralevator APR
with total excision of the levator muscle. The mean total operating duration was 218.1 ± 52.5 min. Mean
operative console time was 96.2 ± 48.0 min and perineal approach duration was 50 ± 30.0 min. Four
robotic arms were used in 80% of the cases. Six ports were used in 70% of the patients. Fifteen (75%)
procedures required robotic arm realignment. Six (30%) patients with fatty mesocolon required left colonic
mobilization with section of the inferior mesenteric vein at its ending at the bottom edge of the pancreas,