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Page 6 of 11 Abdalla et al. Mini-invasive Surg 2019;3:39 I http://dx.doi.org/10.20517/2574-1225.2019.38

Table 2. Intraoperative characteristics
Overall (n = 20)
Total operative duration in minutes (mean ± SD) 218.1 ± 52.5
Operative console time in minutes (mean ± SD) 96.2 ± 38.3
Proctectomy duration in minutes (mean ± SD) 96.2 ± 48.0
Perineal approach duration in minutes (mean ± SD) 50 ± 30
Number of robotic arms
3 arms (%) 4 (20)
4 arms (%) 16 (80)
Number of ports
4 ports (%) 3 (15)
5 ports (%) 2 (10)
6 ports (%) 14 (70)
7 ports (%) 1 (5)
Necessity of robotic arm realignment (%) 15 (75)
Number of robotic arm realignment
1 robotic arm realignment (%) 3 (15)
2 robotic arm realignments (%) 12 (60)
Splenic flexure mobilization (%) 3 (15)
Section of the inferior mesenteric vein (%) 6 (30)
Section of the inferior mesenteric artery (%) 11 (55)
Total mesorectal excision (%) 20 (100)
Specimen retrieval site
Perineal incision (%) 19 (95)
Supra-pubic incision (%) 1 (5)
Omental pedicle flap placement (%) 5 (25)
Associated procedures (%) 6 (30)
Pelvic drainage (%) 20 (100)
Conversion to open (%) 0
Intraoperative complications (%) 2 (10)
Bleeding (%) 1 (5)
Tumor effraction (%) 1 (5)
Intraoperative bleeding in mL (mean ± SD) 297.5 ± 420.0

and splenic flexure mobilization for three (15%) of them. Specimen retrieval was conducted through the
perineal incision in 95% of the patients and all had terminal colostomy. Associated omentoplasty was
performed in five (25%) patients. The following associated procedures were performed in six (30%) patients:
incisional hernia repair (n = 1), resection of an ovarian cyst (n = 1), partial resection of the posterior wall
of the vagina (n = 1), partial prostatectomy (n = 1), partial resection of the posterior wall of the prostatic
urethra and urethroplasty (n = 1), and partial sacrectomy (n = 1). No conversion to open surgery was
required in this series. Macroscopic intraoperative tumor effraction occurred in one patient (5%). Mean
intraoperative blood loss was 297 mL. Intraoperative variables and outcomes are summarized in Table 2.

Postoperative outcomes
One patient (5%) died at Postoperative Day 14 because of respiratory failure in the context of septic shock
secondary to a Clostridium difficile colitis. Morbidity rate was 60%, with seven (35%) medical complications
and nine (45%) surgical complications. Six patients (30%) presented a severe complication (Dindo-Clavien ≥
3), which required reoperation in five (25%). Perineal wound complication occurred in three (15%) patients
who presented complete disunion of the perineal wound and required iterative vacuum therapy until
complete healing. These three patients had undergone preoperative 45 Gy pelvic irradiation and two of
them had omental pedicle flap placement. The duration of hospital stay for these three patients was 29, 65,
and 66 days, respectively. Four (20%) patients presented pelvic abscesses, which were treated conservatively
by antibiotherapy. Two patients (10%) had ureteral fistula (one patient required reoperation and ureteral
reimplantation, and the other was conservatively treated by ureteral catheter placement). The mean hospital
length of stay was 20.4 days. Postoperative outcomes are summarized in Table 3.