Robotic LAR with Transanal Extraction

Alessio PigazziCity of HopeDuarte, CA

A history of Lap TA extraction -Franklin procedure

First shown by Franklin in early 1990s for Recto/sigmoid resection.

Advantages:• Cosmetically pleasing• Lower hernia rate• Lower wound infection• Better anastomosis?

Disadvantages• Technically demanding• Oncologically safe?

Franklin’s transanal extraction

Anastomosis

Indications

Can be done for• Benign disease• Selected cancers

Avoid large tumors

What about rectal cancer?

Types of Rectal Transanal ResectionLife within 8 cm of the outside world

Low AnteriorResectionColorectal AA

InterSphincteric Coloanal AA

40 Intersphincteric resection vs 37 CAA 1990-2000 Same frequency, urgency, fragmentation Wexner incontinence score higher in ISR

• 10.8 ISR vs 6.9 CAA

Higher use of antidiarrheals in ISR

Double stapled AA

13 patients• 11 transanal extraction • 2 Transvaginal extractions• Complications :2 patients (15%)• Anastomotic leak: 1• Bleeding anastomosis:1• No report of incontinence

Surg Endosc, 2010

Robotic low anterior resection with TA extraction

Potential to have• Superior cosmetic results• Lower wound infection rates• Lowe hernia rate• Better continence data than coloanal

anastomosis

Robotic transanal extraction with double purse string aa.

City of Hope experience Double Purse String AA.

4 patients (3F;1M) Age: 58 Mean distance tumor anal verge: 8

cm Ileostomy:2 Complications: None Mean Wexner score: 3.5 (2-6)

Conclusions

Resection with transanal extraction ideal minimally invasive procedure• Combines Open, LAP, Endoscopic skills

Robotic technology makes the procedure more applicable to low anterior resection

Preliminary data encouraging-more studies are needed