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Updated: Jun 6, 2026
Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer
Published on: February 12, 2022
A new application of the four-arm standard da Vinci® surgical system: totally robotic-assisted left-sided colon or
Dean Chi-Siong Koh1, Charles Bih-Shou Tsang, Seon-Hahn Kim
1Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore. surkohd@nus.edu.sg
Background:
The key to successful rectal cancer resection is to perform complete total mesorectal excision (TME). Laparoscopic TME can be challenging, especially in the narrow confines of the pelvis. Robotic-assisted surgery can overcome these limitations through superior three-dimensional (3-D) visualization and the increased range of movements provided by the endowrist function. To date, all totally robotic resections of the rectum have been described using da Vinci® S or Si systems. Due to the limitations of the standard system, only hybrid procedures have been described so far.
Aim:
To evaluate the feasibility and short-term outcomes of performing totally robotic-assisted laparoscopic colorectal resections using the standard da Vinci® system with a fourth arm extension.
Methods:
The standard system was docked from the patient's left hip. Four 8-mm robotic trocars were inserted. Upon completion of phase 1 (pedicle ligation, colonic mobilization, splenic flexure takedown), the two left-sided arms are repositioned to allow phase 2 (pelvic dissection), enabling the entire procedure except for the distal transection and anastomosis to be performed robotically.
Results:
Twenty-one robotic procedures were performed from August 2008 to September 2009. The mean age of the patients was 61 years (13 males). The procedures performed included seven anterior resections, seven low anterior resections, five ultralow anterior resections, one abdominoperineal resection, and one resection rectopexy. The majority of the cases were performed in patients with colon or rectal cancer. Operative time ranged from 232 to 444 (mean 316) min. Postoperative morbidity occurred in three patients (14.3%) with no mortalities or conversions. Average hospital stay was 6.4 days. Mean lymph node yield for the cases with cancer was 17.8.
Conclusions:
The standard da Vinci® system with four arms can be used to perform totally robotic-assisted colorectal procedures for the left colon and rectum with short-term outcomes similar to those of conventional laparoscopic techniques.
