This project was supported by the National Natural Science Foundation of China (No. 81870380) and the Shaanxi Province Science Foundation (2020ZDLSF01-03 and 2020KWZ-020).

This protocol complies with the guidelines of the Ethics Committee of the First Affiliated Hospital of Xi &#39;an Jiaotong University (No. 2019ZD04).
1. Preoperative preparation, patient position, and anesthesia
<ol>
	<li>Ensure appropriate dietary management before operation.
	<ol>
		<li>Prescribe a preoperative oral carbohydrate drink to be consumed at bedtime and 4 h prior to surgery. 
		NOTE: This was allowed based on the enhanced recovery after surgery (ERAS) proto...

<ol>
	<li>Fantus, R. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facility-level+analysis+of+robot+utilization+across+disciplines+in+the+National+Cancer+Database.">Facility-level analysis of robot utilization across disciplines in the National Cancer Database.</a> Journal of Robotic Surgery. 13 (2), 293-299 (2019).</li><li>Akiyoshi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Results+of+a+japanese+nationwide+multi-institutional+study+on+lateral+pelvic+lymph+node+metastasis+in+low+rectal+cancer+is+it+regional+or+distant+disease.">Results of a japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer is it regional or distant disease.</a> Annals of Surgery. 255 (6), 1129-1134 (2012).</li><li>Fujita, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mesorectal+excision+with+or+without+lateral+lymph+node+dissection+for+clinical+stage+II/III+lower+rectal+cancer+(JCOG0212):+A+multicenter,+randomized+controlled,+noninferiority+trial.">Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): A multicenter, randomized controlled, noninferiority trial.</a> Annals of Surgery. 266 (2), 201-207 (2017).</li><li>Yamaguchi, T., Kinugasa, Y., Shiomi, A., Tomioka, H., Kagawa, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+laparoscopic+versus+open+lateral+lymph+node+dissection+for+advanced+lower+rectal+cancer+(vol+30,+pg+721).">Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer (vol 30, pg 721).</a> Surgical Endoscopy and Other Interventional Techniques. 30 (2), 729 (2016).</li><li>Yamaguchi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oncological+outcomes+of+robotic-assisted+laparoscopic+versus+open+lateral+lymph+node+dissection+for+locally+advanced+low+rectal+cancer.">Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer.</a> Surgical Endoscopy and Other Interventional Techniques. 32 (11), 4498-4505 (2018).</li><li>Gustafsson, U. O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+perioperative+care+in+elective+colorectal+surgery:+enhanced+recovery+after+surgery+(ERAS((R)))+society+recommendations:+2018.">Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS((R))) society recommendations: 2018.</a> World Journal of Surgery. 43 (3), 659-695 (2019).</li><li>Brind'Amour, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Canadian+guidelines+on+the+management+of+colorectal+peritoneal+metastases.">Canadian guidelines on the management of colorectal peritoneal metastases.</a> Current Oncology. 27 (6), 621-631 (2020).</li><li>Watanabe, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Japanese+society+for+cancer+of+the+colon+and+rectum+(JSCCR)+guidelines+2016+for+the+treatment+of+colorectal+cancer.">Japanese society for cancer of the colon and rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer.</a> International Journal of Clinical Oncology. 23 (1), 1-34 (2018).</li><li>Professional Committee of Robotic Surgery, C.C.C.o.C.M.D.A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+and+Laparoscopic+Surgery+Committee+of+Chinese+Research+Hospital,+A.+[Chinese+expert+consensus+on+robotic+surgery+for+colorectal+cancer+(2020+edition)].">Robotic and Laparoscopic Surgery Committee of Chinese Research Hospital, A. [Chinese expert consensus on robotic surgery for colorectal cancer (2020 edition)].</a> Zhonghua Wei Chang Wai Ke Za Zhi. 24 (1), 14-22 (2021).</li><li>Napoli, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-Assisted+Radical+Antegrade+Modular+Pancreatosplenectomy+Including+Resection+and+Reconstruction+of+the+Spleno-Mesenteric+Junction.">Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction.</a> Journal of Visualized Experiments. (155), e60370 (2020).</li><li>Shi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+feasibility+and+safety+of+third+space+robotic+and+endoscopic+cooperative+surgery+for+gastric+gastrointestinal+stromal+tumors+dissection+:+A+new+surgical+technique+for+treating+gastric+GISTs.">Clinical feasibility and safety of third space robotic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumors dissection : A new surgical technique for treating gastric GISTs.</a> Surgical Endoscopy and Other Interventional Techniques. 33 (12), 4192-4200 (2019).</li><li>Sung, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+cancer+statistics+2020:+GLOBOCAN+estimates+of+incidence+and+mortality+worldwide+for+36+cancers+in+185+countries.">Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.</a> CA Cancer Journal for Clinicians. 71 (3), 209-249 (2021).</li><li>Heald, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+approach+to+rectal+cancer.">A new approach to rectal cancer.</a> British Journal of Hospital Medication. 22 (3), 277-281 (1979).</li><li>Jiang, T. Y., Ma, J. J., Zheng, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Controversies+and+consensus+in+transanal+total+mesorectal+excision+(taTME):+Is+it+a+valid+choice+for+rectal+cancer.">Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer.</a> Journal of Surgical Oncology. 123, 59-64 (2021).</li><li>Di Saverio, S., Stupalkowska, W., Hussein, A., Fearnhead, N., Wheeler, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+ultralow+anterior+resection+with+intracorporeal+coloanal+stapled+anastomosis+for+low+rectal+cancer+-+is+robotic+surgery+or+transanal+total+mesorectal+excision+always+needed+to+achieve+a+good+oncological+and+sphincter-sparing+dissection+-+a+video+vignette.">Laparoscopic ultralow anterior resection with intracorporeal coloanal stapled anastomosis for low rectal cancer - is robotic surgery or transanal total mesorectal excision always needed to achieve a good oncological and sphincter-sparing dissection - a video vignette.</a> Colorectal Diseases. 21 (7), 848-849 (2019).</li><li>Sylla, P., Rattner, D. W., Delgado, S., Lacy, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=NOTES+transanal+rectal+cancer+resection+using+transanal+endoscopic+microsurgery+and+laparoscopic+assistance.">NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.</a> Surgical Endoscopy and Other Interventional Techniques. 24 (5), 1205-1210 (2010).</li><li>Larsen, S. G., Pfeffer, F., Korner, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Norwegian+moratorium+on+transanal+total+mesorectal+excision.">Norwegian moratorium on transanal total mesorectal excision.</a> British Journal of Surgery. 106 (9), 1120-1121 (2019).</li><li>Koedam, T. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transanal+total+mesorectal+excision+(TaTME)+for+rectal+cancer:+effects+on+patient-reported+quality+of+life+and+functional+outcome.">Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome.</a> Techniques in Coloproctology. 21 (1), 25-33 (2017).</li><li>Baik, S. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+total+mesorectal+excision+for+the+treatment+of+rectal+cancer.">Robotic total mesorectal excision for the treatment of rectal cancer.</a> Journal of Robotic Surgery. 1 (1), 99-102 (2007).</li><li>Gavriilidis, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+vs+laparoscopic+total+mesorectal+excision+for+rectal+cancers:+has+a+paradigm+change+occurred?+A+systematic+review+by+updated+meta-analysis.">Robotic vs laparoscopic total mesorectal excision for rectal cancers: has a paradigm change occurred? A systematic review by updated meta-analysis.</a> Colorectal Diseases. 22 (11), 1506-1517 (2020).</li><li>Prete, F. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+versus+laparoscopic+minimally+invasive+surgery+for+rectal+cancer:+A+Systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Robotic versus laparoscopic minimally invasive surgery for rectal cancer: A Systematic review and meta-analysis of randomized controlled trials.</a> Annals of Surgery. 267 (6), 1034-1046 (2018).</li><li>Qiu, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+oncological+outcomes+in+robotic+versus+laparoscopic+approach+for+rectal+cancer:+A+systematic+review+and+meta-analysis.">Long-term oncological outcomes in robotic versus laparoscopic approach for rectal cancer: A systematic review and meta-analysis.</a> International Journal of Surgery. 80, 225-230 (2020).</li><li>Kapiteijn, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+radiotherapy+combined+with+total+mesorectal+excision+for+resectable+rectal+cancer.">Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.</a> New England Journal of Medicine. 345 (9), 638-646 (2001).</li><li>Ogura, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neoadjuvant+(Chemo)radiotherapy+with+total+mesorectal+excision+only+is+not+sufficient+to+prevent+lateral+local+recurrence+in+enlarged+nodes:+Results+of+the+multicenter+lateral+node+study+of+patients+with+low+cT3/4+rectal+cancer.">Neoadjuvant (Chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: Results of the multicenter lateral node study of patients with low cT3/4 rectal cancer.</a> Journal of Clinical Oncology. 37 (1), 33-43 (2019).</li><li>Emile, S. H., Elfeki, H., Shalaby, M., Sakr, A., Kim, N. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcome+of+lateral+pelvic+lymph+node+dissection+with+total+mesorectal+excision+in+treatment+of+rectal+cancer:+A+systematic+review+and+meta-analysis.">Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis.</a> Surgery. 169 (5), 1005-1015 (2021).</li><li>Hajibandeh, S., Hajibandeh, S., Matthews, J., Palmer, L., Maw, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+survival+and+functional+outcomes+after+total+mesorectal+excision+with+or+without+lateral+pelvic+lymph+node+dissection+in+rectal+cancer+surgery.">Meta-analysis of survival and functional outcomes after total mesorectal excision with or without lateral pelvic lymph node dissection in rectal cancer surgery.</a> Surgery. 168 (3), 486-496 (2020).</li><li>Laparoscopic surgery committee of the endoscopist branch in the chinese medical doctor, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+surgery+committee+of+colorectal+cancer+committee+of+chinese+medical+doctor,+A.+and+Colorectal+surgery+group+of+the+surgery+branch+in+the+chinese+medical,+A.+[Chinese+expert+consensus+on+the+diagnosis+and+treatment+for+lateral+lymph+node+metastasis+of+rectal+cancer+(2019+edition)].">Laparoscopic surgery committee of colorectal cancer committee of chinese medical doctor, A. and Colorectal surgery group of the surgery branch in the chinese medical, A. [Chinese expert consensus on the diagnosis and treatment for lateral lymph node metastasis of rectal cancer (2019 edition)].</a> Zhonghua Wei Chang Wai Ke Za Zhi. 22 (10), 901-912 (2019).</li><li>Podda, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multidisciplinary+management+of+elderly+patients+with+rectal+cancer:+recommendations+from+the+SICG+(Italian+Society+of+Geriatric+Surgery),+SIFIPAC+(Italian+Society+of+Surgical+Pathophysiology),+SICE+(Italian+Society+of+Endoscopic+Surgery+and+new+technologies),+and+the+WSES+(World+Society+of+Emergency+Surgery)+International+Consensus+Project.">Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project.</a> World Journal of Emergency Surgery. 16 (1), 35 (2021).</li><li>Fung, T. L. D., Tsukada, Y., Ito, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Essential+anatomy+for+total+mesorectal+excision+and+lateral+lymph+node+dissection,+in+both+trans-abdominal+and+trans-anal+perspective.">Essential anatomy for total mesorectal excision and lateral lymph node dissection, in both trans-abdominal and trans-anal perspective.</a> Surgeon. , (2020).</li></ol>

Nothing to disclose.

Colorectal cancer (CRC) is one of the most common cancers worldwide13. Among them, more than a third are rectal cancer. Due to the higher postoperative functional requirement and the sophisticated neuro- and fascial anatomy of the pelvis and perineum, the best surgical approach for rectal cancer, especially low or ultralow rectal cancer, is still under great debate. Since its first report in 1979, total mesorectal excision (TME) has been the standard surgical technique for the treatment of resecta...

Since their approval for clinical use by the United States Food and Drug Administration in 2000, da Vinci surgical robots have been increasingly utilized across different surgical specialties1. The robotic surgical system has the advantages of using flexible multijoint arms, a high-quality three-dimensional camera, tremor filtration, and greatly improved ergonomics, which can minimize the invasiveness of the operation and thus making it ideal for complex procedures.
For decades, total mesorectal excision (TME) has been the standard for the treatment of resectable rectal cancer. However, for advanced (T3/T4) rectal cancer located below the peritoneal reflection, lateral pelvic lymph node (LPLN) metastasis is a major cause of local recurrence after surgery2. Clinical evidence clearly shows that lateral pelvic lymph node dissection (LPLND) could significantly reduce the local recurrence rate3. Compared with the open procedure, robot-assisted TME and LPLND have been associated with less blood loss, fewer blood transfusions and fewer postoperative complications4. In addition, the long-term outcomes are not significantly different between the two procedures5. The results of these reports indicate that robot-assisted LPLND may be a feasible modality for locally advanced rectal cancer. However, it should be noted that robot-assisted TME and LPLND are complex procedures and should be performed by an experienced surgeon.
Herein, a standard systematic approach to robot-assisted TME and LPLND is described step by step. This procedure was developed at the center having experience in performing more than three thousand robotic procedures6. In addition, this approach was based on normal anatomical characteristics; rare anatomical variations should be noted.
We present the case of a 64-year-old male patient who had intermittent hematochezia for approximately 3 months. Digital rectal examination revealed that a mass was located on the anterior and right lateral wall of the rectum, 5 cm from the anus. An enhanced computed tomography (CT) scan and endoscopic ultrasound (EUS) revealed lower rectal cancer with internal iliac lymph node metastasis. Colonoscopic biopsy confirmed the presence of moderately differentiated adenocarcinoma. The preoperative evaluation suggested that the clinical stage was cT3N+M0. Accordingly, we decided to perform robot-assisted TME and LPLND. Patient consent was obtained prior to performing these procedures.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0 Silk suture</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Secure the anvil</td>
		</tr>
		<tr>
			<td>12mm Trocar</td>
			<td>Medtronic (Minneapolis, MN)</td>
			<td>NONB12STF</td>
			<td>Assistant port 1</td>
		</tr>
		<tr>
			<td>19 Fr drain</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Pelvic drain</td>
		</tr>
		<tr>
			<td>2-0 Silk suture</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Close skin incisions</td>
		</tr>
		<tr>
			<td>2-0 V-Loc sutures</td>
			<td>Covidien (Dublin, Ireland)</td>
			<td>VLOCL0315</td>
			<td>Barbed Absorable Suture</td>
		</tr>
		<tr>
			<td>4-0 PDS</td>
			<td>Ethicon (Somerville, NJ)</td>
			<td>SXPP1A400</td>
			<td>Synthetic Absorbable Suture</td>
		</tr>
		<tr>
			<td>8mm Trocar</td>
			<td>Medtronic (Minneapolis, MN)</td>
			<td>NONB8STF</td>
			<td>Assistant port 2</td>
		</tr>
		<tr>
			<td>Bipolar forceps</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470172</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Cadiere grasping forceps</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470049</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Circular stapler</td>
			<td>EzisurgMed (Shanghai, China)</td>
			<td>CS2535</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr>
			<td>Da Vinci Si</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>N/A</td>
			<td>Surgical Robot</td>
		</tr>
		<tr>
			<td>Da Vinci Xi</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>N/A</td>
			<td>Surgical Robot</td>
		</tr>
		<tr>
			<td>Hem-o-lok ligation clip</td>
			<td>Weck (Morrisville, NC)</td>
			<td>544995</td>
			<td>Ligation of vessel</td>
		</tr>
		<tr>
			<td>Laparoscopic single use linear cutting stapler</td>
			<td>EzisurgMed (Shanghai, China)</td>
			<td>U12M45</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr>
			<td>Large needle driver</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470006</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Monopolar scissors</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470179</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Ribbon retractor</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Control movement of rectum</td>
		</tr>
		<tr>
			<td>Specimen Bags</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Extract specimen</td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Saline drop test</td>
		</tr>
	</tbody>
</table>

robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The detailed perioperative information of the case presented in the video is shown in Table 1 and Figure 3. The procedure was performed in April 2019 by the corresponding author using the da Vinci Si Robot system. The estimated blood loss during the operation was 90 mL, and no transfusions were required. Postoperative management adhered to the principles of ERAS. After the first defecation on the 6th day after the operation, we administered a meglumine diatrizoate enema and ...

Watch this Scientific Journal Video about Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer at JoVE.com

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision, and lateral pelvic lymph node dissection for locally advanced rectal cancer located below the peritoneal reflection. This protocol complies with the guidelines of the Ethics Committee of the First Affiliated Hospital of Xi'an Jiaotong University. We present the case of a 64-year-old male patient who had intermittent hematochezia for approximately three months.Digital rectal examination revealed that a mass was located on the interior and right lateral wall of the rectum, five centimeters from the anus. An enhanced computed tomography scan and endoscopic ultrasound revealed lower rectal cancer with internal iliac lymph node metastasis. Colonoscopic biopsy confirmed the presence of moderately differentiated adenocarcinoma.Accordingly, we decided to perform a robot assisted total mesorectal excision, and lateral pelvic lymph node dissection. Patient consent was obtained prior to performing these procedures. Induce general anesthesia.Place the patient in all Lloyd Davis position, and secure them carefully to the operating table. Ensure that the legs are carefully padded in stirrups, and that both arms are tucked at the side. Ensure that the primary surgeon operates from the robotic console, and customizes their settings.Have an assistant laparoscopic surgeon stand on the right side of the patient. Have a nurse stand on the left side of the patient. Place the robotic, and assistant ports as depicted in figure.Place each trocar after making transverse skin incision. Set visual port. Make a 12 millimeter incision 2 to 3 centimeters above of the umbilicus, and slightly to the left, and set a 12 millimeter trocar as a visual port.Set three robotic arm ports. Place trocar after making transverse 8 millimeter skin incisions for each trocar. Place arm 1 in the right McBurney's point.Place arm 2 in the midclavicular line at the level of the visual port. Place arm three in the left interior axillary line at the level of the visual port. Set two assistant ports.Place a 12 millimeter assistant port 1 in the right midclavicular line at the level of the visual port. Place an 8 millimeter assistant port 2 approximately 1 to 2 centimeters above the pubic symphysis. Chapter three.Total mesorectal excision. Section one. Mobilize the left colon.Retract the descending and sigmoid colon medially by cardiere grasping forceps in R 3 to expose the left paracolic sulci. Release the physiological adhesions of the descending, and sigmoid colon along the paracolic sulci with monopolar scissors in R 1. Incise the peritoneum along the paracolic sulci.Dissect the descending colon from superior to inferior with monopolar scissors in R 1 until the ureter is exposed to mobilize the lateral side of the descending, and splenic flexure colon. Place a piece sterile gauze near the ureter as an indicator. Grasp and keep elevating the sigmoid colon with its mesentery forward, using cardiere grasping forceps in R 3.Tension the mesentery with a bipolar grasper in R 2, and forceps in the assistant's hand, then recognize the white line of Toldt's fascia. Incise the peritoneum along the white line. Separate along this plane toward the lateral paracolic sulci with monopolar scissors in R 1 to mobilize the sigmoid colon.Afterwards, create a tunnel between the medial and a lateral compartments under the guidance of the indicator gauze that was set previously. Continue to develop this plane downward to the sacral promontory using electrocautery, and combined sharp, and blunt spreading to dissect rapidly to completely mobilize the descending and sigmoid colon. Section two.Transect the inferior mesenteric artery and inferior mesenteric vein. After mobilizing the sigmoid colon, grasp, and keep elevating the sigmoid colon with forceps in R 3 to expose the aorta. Dissect along the aorta superiorly with monopolar scissors in R 1 to expose the inferior mesenteric artery.Change the instrument in R 1 from monopolar scissors to harmonic scalpel. From the root of the inferior mesenteric artery, separate the lymphatic tissue from the vessel with an ultrasonic scalpel in R 1 until the left colic artery appears. Continue to separate the lymphatic tissue from the left colic artery with the harmonic scalpel in R 1.Recognize the inferior mesenteric vein, and the descending branch of the left colic artery. Have the assistant surgeon clip the inferior mesenteric artery below the origin of the left colic artery with a large locking clip, then transect with the harmonic scalpel to minimize bleeding. Have the assistant surgeon clip, and transect the inferior mesenteric vein, and the descending branch of the left colic artery.Section three. Perform pelvic dissection of the rectum. Use a ribbon retractor to lift the rectum.Place the grasping forceps in A 2 by the assistant surgeon, and control the movement of the rectum by gripping the ribbon retractor. Change the instrument in R 1 to monopolar scissors. Lift the rectum forward with cardiere grasping forceps inserted through the posterior margin of sigmoid colon to expose the sacral promontory, then dissect into the retrorectal plane between the mesorectal fascia and pre-hypogastric nerve fascia with monopolar scissors in R 1.Develop along this plane, and separate the mesorectal fascia from pre-hypogastric nerve fascia using monopolar scissor in R 1 until the level of the levator ani muscle is reached. Note, the integrity of the mesorectal fascia should be retained. Incise the peritoneum, and open the lateral mesorectal plane close to the rectum with monopolar scissors in R 1.Have the assistant surgeon move the rectum to the other side. Change the instrument in R 1 to harmonic scalpel. Carefully dissect and develop this plane until the level of the levator ani muscle is reached.Repeat this step for the contralateral side. If it seems difficult to operate consider dealing with the interior plane first. Incise the peritoneum 1 centimeter above the reflection of the visceral peritoneum with the harmonic scalpel in R 1.After incising the reflection of the visceral peritoneum, identify the seminal vesicles and Denonvilliers'fascia that cover the posterior wall of the seminal vesicle. Continue to develop the plane between Denonvilliers'fascia and mesorectal fascia until the level of the levator ani muscle is reached with the harmonic scalpel in R 3. Note, in women, dissection should be performed between the vaginal posterior wall, and the mesorectal fascia.Surgeons should avoid damaging the thin vaginal posterior wall. At this time, conduct a digital rectal examination trans anally to confirm that the dissection has proceeded past the distal margin of the tumor, and that there are appropriate margins for resection. Chapter four.Lateral pelvic lymph node dissection. Starting on the left, incise the peritoneum just lateral to the ureter with the harmonic scalpel in R 1. Extend the incision up to the vas deferens.Identify the left ureter at the level of its crossing with the iliac vessels, then mobilize the ureter and move it to the medial side with forceps in R 3. Avoid complete skeletonization of the ureter if possible. Let the ureter and pre-hypogastric nerve fascia become the medial plane of the lateral node dissection.From the lateral to the external iliac artery, separate the lymphatic tissue surrounding the external iliac artery, and vein with the harmonic scalpel in R 1. Retract the external iliac vein laterally with the aspirator in the assistant's hand. At the bifurcation of the internal, and external iliac artery, separate lymphatic tissue with the harmonic scalpel in R 1, and identify the obturator nerve and umbilical artery.At the lateral wall, completely release the lymphatic tissue from the surface of the psoas, and internal obturator muscles. Retract the umbilical artery, and the vesicle hypogastric fascia medially with the aspirator in the assistant's hand. Separate lymphatic tissue from the vesicle hypogastric fascia.Let the umbilical artery and vesicle hypogastric fascia become the medial wall of dissection of obturator nodes. Carefully separate the lymphatic tissue from fascia and nerve along the obturator nerve with the harmonic scalpel in R 1, and identify the obturator artery and vein, which are the branches of the internal iliac artery and vein. Carefully isolate the obturator artery, and vein to avoid injury.Retract the ureter and pre-hypogastric nerve fascia medially with the aspirator in the assistant's hand. Completely release the lymphatic tissue from fascia with a harmonic scalpel in R 1. Identify and isolate the 2 to 3 superior vesicle arteries which are the branches of the umbilical artery.Avoid ligating all superior vesicle artery branches to minimize urinary dysfunction. At least one superior vesicle artery should be preserved especially when bilateral LPL and D is performed. Continue to dissect the lymphatic and fatty tissue distally with the harmonic scalpel in R 1, until meeting the vas deferens.Remove the lymphatic adipose tissue as a single specimen from the fossa using a sterile specimen bag. If necessary, repeat these steps on the right to complete the right side dissection. The procedure we present in video was performed in April, 2019, by the corresponding author using the DaVinci C robot system.The estimated blood loss during the operation was 90 milliliters, and no transfusions were required. Post operative management adhered to the principles of enhanced recovery after surgery. After the first defecation on the sixth day after the operation, we administered a meglumine diatrizoate enema, and performed x-ray radiography to determine whether anastomotic leakage occurred.We then removed the drain after confirming no evidence of leakage. The patient did not report any urinary or sexual dysfunction during follow up. The pathologic examination of the specimen indicated adenocarcinoma with moderate differentiation.No positive lymph nodes were detected in any of the 19 mesorectal nodes or 18 lateral lymph nodes. We recommended that the patient receive adjuvant chemotherapy. Until January, 2021, the patient still remained without any evidence of recurrence or metastasis.At our center, this robotic technique has been performed in 89 patients. All procedures were successfully completed under robotic assistance without conversion to open surgery. The detailed information is shown in table.In conclusion, this robotic technique is safe, and feasible for patients with locally advanced middle low rectal cancer. This technique enables better exposure of complicated anatomic structures, and can reduce unanticipated injury. Following the development trend of minimally invasive surgery, an appropriate selection of surgical indications, and a radical understanding of anatomic structures are critical factors of successful procedures.In addition, we suggest appropriately individualized adjustments based on the preferences, and experiences of individual surgeons.

robot-assisted-total-mesorectal-excision-lateral-pelvic-lymph-node

Research

JoVE Journal

Medicine

5.3K ビュー.  The First Affiliated Hospital of Xian Jiaotong University. 本明細書に記載されるロボット技術は、ロボット支援総メソレクタル切除術に対する段階的なアプローチと、腹膜反射の下に位置する局所進行直腸癌に対する横骨盤リンパ節解離を詳述することを目的とする。この議定書は、西安交通大学第一附属病院の倫理委員会のガイドラインに準拠しています。約3ヶ月間間欠性ヘマトチェアジアを有していた64歳の男性患者の症?...