| BackgroundThe incidence of colorectal cancer is increasing year by year.According to the latest epidemiological survey,the incidence and mortality of colorectal cancer in China are among the top five malignant tumors,and The affected population is getting younger and younger.Non-metastatic rectal cancer is mainly treated by surgery.For a long time,abdominal perineal resection(APR)has been the main treatment for ultra-low rectal cancer(the distance from the anal margin≤5cm),to ensure radical and thorough resection of the tumor at the expense of the anus resection.Surgical trauma is severe,which causes a heavy blow to patients’ physiology and psychology.Therefore,how to preserve anal function under the premise of radical cancer treatment is one of the focuses of current rectal cancer surgery.In recent years,with the deepening of anatomical studies and the development and application of surgical instruments,intersphincteric resection(ISR)for low rectal cancer has been proposed and further developed,which improves the rate of anal preservation and brings new hope to patients with ultra-low rectal cancer.This operation method can extend the distal cutting edge of 1-2cm and the circumferential cutting edge of 2-5mm,so as to achieve maximum anal preservation.However,ISR is difficult to perform,especially in the case of pelvic stenosis,which requires high precision and requires high surgical techniques,and is limited in its promotion and application.In recent years,the application of Da Vinci robotic surgery system in rectal cancer surgery has been gradually increasing,and its advantages such as high accuracy have been fully demonstrated,which shows a broad application prospect.However,the application experience of Da Vinci robotic surgery system in ISR surgery for low rectal cancer is still limited.This paper provides a basis for the follow-up development by analyzing the clinical efficacy of robotic ISR after operation.ObjectiveClinical data of 43 patients at robot intersphincteric resection were collected in this study.To analyze the technical characteristics and short-term efficacy and complications associated with ultra-low anastomosis in robotic intersphincteric resection for rectal cancer.MethodsClinical data of 43 patients with low rectal cancer treated by robotic intersphincteric resection were collected in Southwest Hospital affiliated to Army Medical University between January,2015 and March,2019.Follow-up visits were conducted by outpatient and telephone.Observation indicators: gender,age,BMI,ASA score,preoperative CT,MRI and other imaging systemic and tumor assessment,intraoperative blood loss,operation time,defecation time,time to resume normal diet,postoperative hospitalization time,postoperative pathology,number of lymph nodes,distal resection margin,preoperative and postoperative anal function assessment.Complications include anal stenosis,inflammatory external hemorrhoids,incomplete ileus,rectovaginal fistula,anastomotic leakage,and newly developed rectal prolapse.The follow-up time was up to June 2019Results(1)The intraoperative and postoperative conditions: the operative time is 234.37±41.76 minutes.No patient was convered to open surgery.All patients underwent protective ileostomy.The blood loss was 64.77±22.33 ml,the tumor size was 1.93±0.67 cm,the lymph node dissection was 12.05±4.32,and the distal resection margin was 0.95±0.31 cm.All patients had negative distal and circumferential margins,and the R0 resection rate was 100%.There were 21 cases of total ISR(48.8%),6 cases of sub-total ISR(14.0%),and 16 cases of partial ISR(37.2)%.The proportion of complete abdominal path was 37.2%.Postoperative fluid time was 4.02±0.67 days.The postoperative hospital stay was 7.26±1.68 days.(2)The anal function of all ISR patients with completed closure of stoma for at least 3 months was evaluated,and the results showed that 22 patients had good fecal control.The anal pressure test results show that the mean anal static pressure was 47.7±7.9 mmHg before surgery,16.1±4.6 mmHg 3 months after surgery,21.6±5.7 mmHg 6 months after surgery and 28.6±6.4 mmHg 12 months after surgery.Detailed data of rectal maximum squeeze pressure(MSP)and maximum tolerable volume(MTV)are shown in table 3.All patients were followed up to June 2019,with an average follow-up of 28.2 ± 10.4 months.Recurrence and metastasis were found in 2 patients,and no recurrence or metastasis was found in the rest.(3)Complications related to ultra-low anastomosis:Postoperative anal stenosis,mainly membranous stenosis,was found in 19 patients(44.2%),requiring regular anal expansion.Postoperative edematous hemorrhoids were found in 14 patients(32.6%)and subsided at a median of 33 days after operation(range 16–64 days).Among the 10 patients with incomplete ileus,one patient returned the ileostomy in advance(35 days after operation)and in the remaining patients,the ileostomy was closed by elective surgery after conservative treatment.There were two cases of anastomotic leakage and one case of rectovaginal fistula,which was delayed fistula.No neorectal prolapse was found.Univariate Logistic regression analysis showed that Males are independent risk factors for anal stenosis(P=0.002),the incidence of edematous hemorrhoids was related to the operation time(P= 0.005).Complications were treated conservatively and no surgical mortality occurred.ConclusionDa Vinci Robot can expose and enter the internal and external sphincter space accurately in the narrow space of the pelvis during the intersphincteric resection of low rectal cancer and can maximize to dissociate accurately to the distal end by abdominal path.The operation is safe and feasible,and the short-term clinical effect is satisfactory.Postoperative complications associated with ultra-low anastomosis are common.Early prevention and active intervention can achieve better therapeutic effect. |
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