Video Cylindrical Abdominoperineal Resection (APR): Role of Robotic Surgery Play Pause Previous Next 1 of 200 slides Volume Quality 720P 540P 270P Fullscreen Captions Transcript Chapters Slides Cylindrical Abdominoperineal Resection (APR): Role of Robotic Surgery Overview Dr. Umanskiy discusses Cylindrical Abdominoperineal Resection (APR): Role of Robotic Surgery KONSTANTIN UMANSKIY: When we think about the surgical treatment of rectal cancer, we think about our goals. And when I see a patient in clinic, I always tell my patients that number one goal for taking care of patients with any cancer is to save their life. When we talk about rectal cancer, saving life means preventing the patient from developing local recurrence. Also assuring that they have a disease-free survival, and ultimately, we're hoping that this will translate to overall survival. But what we are priding ourselves at the University of Chicago, pushing the envelope. We wanted to not only save the patient's life, but we want to preserve and maintain their quality of life. To many patients that means maintaining their ability to use their sphincter. And ultimately, preserve their body image. Also, patients who are survivors and who continue to lead normal lives become concerned where their sexual and bladder function gets disrupted, and therefore, we always put it as one of our priority lists. And finally, disability. Being able to do an unblocked resection and taking an obturator nerve might not provide a patient ability to walk well, and this is actually something that we have to keep in mind. So with these goals in mind, we're approaching our patients asking ourselves, when we approach a patient with a distal rectal cancer, very low rectal cancer, how low can we go? But the best question we should say is, not how low can we go. How low should we go? And if you look at this very risky maneuver by this limbo dancer is we can get burned if we go too low. What I mean by that is this. If the tumor resides very low in abutting the sphincter complex, as in this diagram, even with the masterful work of Dr. Catenacci and Dr. Liao, our medical and radiation oncologists, and the tumor shrinks, do really have the luxury of trying to scrape the tumor off the levator muscle complex and give the patient good oncological outcome? Can we obtain the good circumferential margins as mentioned by Dr. Posner so can we make sure that we're not leaving a tumor behind? Is the patient big, tall, and heavy with a rounded belly? Can we get low enough? Are we going to maintain sufficient splinter function so the patient can have a good control of their muscle fibers, and are they going to go to the bathroom 15, 20 times a day? Are their functional outcomes going to be sufficient? Or do we have a patient, as this unfortunate young woman who we took care of a few years ago, who has very large distal rectal cancer with a large lymph node sitting very close to the levators. And to get you oriented this, is an MRI image of a patient. This is her coccyx. This is her anterior abdominal wall with the rectus muscles. This is her rectum. And then you can see the surrounding area, mesorectum, where the tumor is located. To answer this question, we should use our surgical judgment, clinical judgment, to decide which patients benefit from sphincter sparing and which patients we have to resort to an operation that was proposed more than 100 years ago by Dr. Miles. For full disclosure, Dr. Miles was not the first surgeon to perform this operation. It was performed by many surgeons before him, including Dr. Mayo. But what he was concerned with is a high degree of recurrence. 54 out of 57 patients that he operated on using the conventional technique of extirpation of the rectum recurred in three years. He was very intelligent and wise surgeon who determined that the problem with the recurrence it not as much leaving the cancer itself behind, but leaving the cancer in the lymph nodes. And the cancer, that distal cancer, low cancers, are highly metastatic to the lymph node. And he noted that there was a zone of upward spread that needs to be addressed. And he proposed a technique that almost all of our abdominoperineal resection is based on with some modification. We always refer to it as the Miles technique. Even though it was a highly morbid operation, the patients had excellent recurrence-free survival, which was unheard of at that time. This concept with further advanced by Dr Dr. Bill Heald, who also was not the first one who popularized or developed the concept of careful, meticulous excision of the lymph node packet around the rectum. But he was the one who was a tireless advocate and spent enormous amount of time convincing the surgeons around the world that this is the technique that can decrease their local recurrence of cancer. His argument was that at the time, the technique of dissecting the rectum using a blunt technique which involved pushing the hand of a surgeon along the pelvic sidewall was disrupting the mesorectum, which is the envelope surrounding the rectum. He advocated a precise, meticulous surgical excision stained between fascia propria of the mesorectum and the presacral fascia, where this can be resulting in a complete excision. And this removal of intact envelope, what resulted in excellent recurrence-free outcomes. I want to point something out to you which I will be talking later in the talk. The anatomical concept of the mesorectum is such that it's really wide in the proximal and mid-rectum, but it naturally tapers off as the rectum comes toward the anus. And I will spend a little bit e more time discussing this topic as we progress. This is what I would call a classic abdominoperineal resection specimen would look, and I will will orient you a little bit here. On the right hand side, this is the sigmoid colon that goes into the rectum. This portion where the sigmoid and rectum join together, and the remainder is a rectum. Now you can see, there's a wide mesorectal envelope, and as I mentioned to you earlier, it tapers off where the rectum traverses the pelvic floor and opens into the anal canal. And most surgeons are able to take a significant chunk of ischioanal fat around the anus as they perform an APR. But the classic appearance of the specimen, is almost always, would involve what we would call a little bit of a waist at the point where the rectum goes through the levators. Once again, to emphasize the importance of negative circumferential margin, as Doctor Posner pointed out, if a surgeon has a margin of tumor that's less than one millimeter in size, we consider it a positive margin. And in that case, the local recurrence rates are upwards of 20%. However if the margin is greater than 1 millimeter, that recurrence drops down significantly to 5%, which we consider acceptable. And it is very important for us as surgeons to understand the relationship between the tumor and the sphincter complex and understand whether the sphincter can be preserved, should be preserved, or if the operation can be done safe oncologically with either an abdominoperineal resection technique or low anterior resection technique. So not surprisingly abdominoperineal resection, as the evolution of total mesorectal excision occurred, was dismissed as a quote, old operation, and people were coming to colorectal surgeons begging and asking for sphincter-preserving operation. And what emerged is a concerning statistics that was published by European group in Annals of Surgery in 2005 showing that patients treated by abdominoperineal resection surprisingly had a higher rate of positive circumferential margins. This table kind of tells the story if you look by time periods. This time period is in late '80s, early '90s, late '90s, and then the overall summary. And what you see here, the circumferential resection margin for abdominoperineal resection, this is at the peak of the period of adaptation of total mesorectal excision, was 43%, while the low anterior resection was 28%, 29%. This has dropped somewhat for the APR but not sufficiently if you compare it to the wide adaptation of low anterior resection where the positive margins were less than 20%. So the concern that was raised by the authors was such that we're not doing a good job as surgeons taking low rectal cancers. I have a speculation to address this. Why is it so? Well, in the early periods of far colorectal surgery, APR was offered to patients who had cancers higher up. Let's say 4 centimeters, 5 centimeters, from anal verge, and therefore, those could be considered easier operations for which APRs was performed. Nowadays, the patients who agree to abdominoperineal resection, which involves losing their sphincter and having a permanent colostomy, are those who have challenging cancers, most of them invading the sphincters. Therefore, we now are presented with the newer challenge of operating on patients who have local advanced cancers located in abutting the sphincter mechanism. And what European groups have started to advocate is a technique of what evolved as an extralevator abdominoperineal excision, also often referred to as ELAPR, or as I've often referred to it as a cylindrical APR. In this anatomical sketch, you see that the traditional abdominoperineal resection, or abdominoperineal excision, allows the surgeon to stay close around the sphincters, and then as soon as they are through the levators, which are these muscles here, they stay on the mesorectum. And that would result in the typical coned and waist-shaped specimen. The new approach mandates that the surgeon stay wide around the levators, taking them as close to the pelvic inlet as possible. And this was published by European group and more recently in 2014, they presented their experience. You saw the examples of how the total mesorectal excision looks when Dr. Posner demonstrated to you example of accurately performed TME. This is taking it a little next step further. I know that Dr. Cohen is grimacing. You don't like the images. Oh these are blurry. This is from European journals, so they don't have high resolution. So this is the images that come from some European countries. Anyhow, you can see here there's a waist, and with time, adaptation of this cylindrical APR of different centers across the Europe, they now perform a cylindrical APR without the waist. And interestingly enough, this technique has spread very rapidly around centers in Europe and is widely adopted now. The study that was published in British Journal of Medicine, excuse me, British Surgical Journal in 2010, confirmed their hypothesis that performing a cylindrical APR can achieve better results. Particularly, this graph tells most of that story that supports their data. The positive circumferential resection margin in extralevator APR has been less than 20% compared to upwards of 50% for standard APR. Now if we take a step back and ask ourselves, these numbers are surprisingly high, but it is what it is. And then perforation of the rectum was also decreased based on this new technique. As a result, this new technique has gained popularity. Where does a robotic surgery fit in? And again, I would like to thank Dr. Posner for setting me up for this. We at the University of Chicago have been adopting robotic surgery for the total mesorectal excision as our preferred technique of dissection, which allows us a very careful, meticulous excision of the rectum, with preservation of the nerves of sexual function. We can clearly visualize the structures of importance. This allows us to do by means of excellent 3D visualization, image stability. And what is very important, which I find extremely important, technical aspect as we advance in deeper into the pelvis, unlike laparoscopy, we do not have degradation of motion because the control of the instrument occurs electronically, and no matter how deep we are in the pelvis, we can still perform a precise dissection. The abdominoperineal resection seems to be a perfectly suited technique for minimally invasive approach because when it's done properly, the patient is left with virtually incision-less abdomen except for the scars from the ports and the ostomy, and actually it translates in improved pain control, improved chance of wound infection, and ultimately, hernia, and other complications. I would like to go through some of the steps of how we perform this operation and some of the steps in the setup. We use a da Vinci Si surgical platform, and with the newer hospital pavilion, we have a wonderful, spacious operating room where we have mobility and ability to maneuver our patient cart. Patient's placed in lithotomy position, this is a patient's lower extremities, and the head is here at the top of the screen. The robot is brought in between the patient's legs. I also would like to show you the setup that allows us to teach our fellows and the residents by means of dual console. It's similar to Driver's Ed where the surgeon who sits at one console, and the resident or trainee, who sits at another console, can you exchange the controls any time during the operation through the push of a button. And this is very easy and seamless way of doing this. Therefore, the communication is clear as we hear each other very well, and the ability to exchange our controls is clear, which allows our trainees to gain experience as we advance. When the robot is docked, this is a different view looking from the patient's right side here. The lower extremities are here, the head is here, and the robot is brought between the patient's legs. You can see the outstanding AV support that we have with monitors on the walls and projection of the screen as we're ready to start the operation. I want to show you a very brief clip of a video that we submitted to [INAUDIBLE], and we were awarded the first prize this year for this video of innovating technique of abdominoperineal resection with extralevator approach. To get you oriented, we begin our dissection. Starting posteriorly, the patient's lower extremities are away from our screen. You can see up on top the uterus. This is again the uterus, and we're going to the pelvis, performing the dissection down. Again, this is the front where this is the patient's uterus. This is the same 19-year-old patient that I showed you the MRI that we're performing the total mesorectal excision with extralevator abdominoperineal resection. Again, the initial portion of the operation begins posteriorly where we mobilize the mesorectum. The robot has very accurate control, tremor reduction, and it doesn't do justice, but when you actually look at an image live, it's 3D and very crisp and projects really well. This is us fairly low. You saw the image that Dr. Posner showed at the aspects of the total mesorectal excision performed laparoscopically. It's very similar in that regard. The pelvis is freed up, and you can see some fluid pooling when you look at the bottom. Anterior dissection is where the robot truly shines, developing a clean, accurate plane between the vagina and the mesorectum. So this is the video that I was going to show you for that segment to illustrate what we're doing. The specimen that we were able to obtain is compatible to what the European colleagues show, with this being the anus, and you can see the sutures where the anus have been closed. And there's no waist, and this is the sigmoid column. So is robotic surgery something that we should be afraid of? I don't think so. I think it's a good technique, and I think we can do many good things for our patients. This is an example of our patients. This is a girl who required total proctocolectomy with extralevator abdominoperineal resection. Since then, we have done five operations using not only the extralevator abdominoperineal resection, but also a specialized innovative closure, which Dr. Song will tell you about a little bit later in the day, of how to close a large pelvic floor defect using this technique. Thank you for your attention. Published June 2, 2015 Created by
