Robotic interface for transabdominal division of the levators and pelvic floor reconstruction in abdominoperineal resection: A case report and technical description

Background: Extralevator abdominoperineal resection (APR) in a prone jackknife position was developed to avoid a positive circumferential resection margin, and its application led to lower rates of local recurrence. The paper describes a technique of robotic extralevator APR with transabdominal levator division followed by pelvic floor reconstruction with bilayered composite mesh. Methods: A 42-year-old man with low rectal cancer required APR that was performed in a lithotomy position with transabdominal division of the levators. After the perineal phase, the robot was redocked and a bilayered composite mesh was sutured to the pelvic inlet using robotic needle drivers. Results: The specimen had a cylindrical shape, and there was no surgical waist or perforation. Histology revealed a ypT2N0 tumor without circumferential margin involvement. Conclusions: The robotic interface can aid in APR by accurately transecting the levators from the top. Additionally, it allows suturing of mesh around the pelvic inlet to prevent perineal hernias.