Combining all forces: abdominoperineal resection in an obese male

In patients with rectal cancer, pelvic dissection is challenging. A complete total mesorectal excision (TME) is particularly difficult in a narrow and long pelvis often encountered in males. This difficulty is compounded in the obese. In addition to the open approach being morbid, laparoscopy has often proven difficult secondary to rigid instruments along with a steep learning curve. Robot assistance offers an advantage, however limitations are observed in abdominal colon dissection outside of the pelvis. As these individual modalities have their disadvantages, they each can contribute unique aspects in a combined or a hybrid approach to rectal tumors. Therefore, a multi-modal, combined approach, involving hand assist, laparoscopic, and robotic assistance, to a 5-cm tumor at the anal verge was applied to an abdominoperineal resection in an obese, male patient.

An obese 58-year-old male, BMI of 36 kg/m², with a 5-cm anal canal squamous cell carcinoma which recurred after Nigro protocol treatment, underwent a multi-modal abdominoperineal resection.

The approach to recurrent anal cancer is as that for rectal cancer. Hence, a hand port was placed to assist in colon mobilization, visceral mesenteric dissection, and to facilitate the laparoscopic division of the inferior mesenteric artery (IMA) at its origin. The robot was used for deep pelvic dissection and TME. The levators were divided in the perineal phase. A complete mesorectal excision was achieved and a cylindrical specimen was extracted.

An abdominoperineal resection with a multi-modal approach (hand assist, laparoscopic, and robotic) is safe and effective in resection of low rectal cancers especially in the narrow, obese, and male pelvis.