Robotic Total Pelvic Exenteration

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The goal of surgery with curative intent for locally advanced rectal cancer is an R0 resection. To achieve this, multidisciplinary management is essential. This includes appropriate neoadjuvant treatment, followed by extended surgical resection beyond the total mesorectal excision plane as necessary to achieve clear margins.1 En bloc resection of adjacent organs and dissection of regional lymph node basins may be required if these are involved. However, extended resections are technically demanding procedures, and, although laparoscopic extended rectal cancer surgery has been reported to be feasible, oncological outcomes remain undefined.2 It is of vital importance that the access method and technique utilized do not compromise the relevant oncological planes of the operation, and, to this end, some authors have hypothesized that the robotic-assisted approach may offer several technical advantages over laparoscopy, including better pelvic visualization and dissection, particularly in more difficult cases.3 The first report of robotic pelvic exenteration for locally advanced rectal cancer was published in 2014.4 We recently published our own experience with extended robotic resection for rectal cancer including 36 patients who underwent robotic multivisceral en bloc resection, and/or extramesorectal lymph node dissection and demonstrated that, in selected patients, the procedure can be performed safely with acceptable morbidity, clear resection margins, and intact circumferential planes.5
This video demonstrates robotic dissection for a total pelvic exenteration and lateral pelvic lymph node dissection in 1 such patient with locally advanced adenocarcinoma of the distal rectum and bilateral side wall adenopathy status post long-course neoadjuvant chemoradiation and consolidative chemotherapy. An end colostomy, ileal conduit urinary diversion, and a minimally invasive vertical rectus abdominis myocutaneous flap were fashioned as part of the reconstruction. See Video at
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