title: Robotic-assisted extralevator abdominoperineal resection in the lithotomy position: technique and early outcomes.
abstract: Extralevator abdominoperineal resection (E-APR) has been advocated as a superior procedure to achieve negative circumferential resection margins (CRMs) for sphincter-invading rectal cancers. An open total mesorectal excision is performed followed by perineal dissection with resection  of the levators in the prone position. We describe a novel minimally invasive robotic approach carried out in the lithotomy position. Using the robotic arms to dissect the rectum and divide the levator fibers at their origin, the dissection is carried out in the ischiorectal space as distally  as possible. From May to July 2011, six cases of robotic E-APR for rectal cancer were performed. The mean age was 54.5 years old. Mean operating time was 335 minutes. Mean estimated blood loss was 250 mL. There were no conversions to the open approach. A cylindrical specimen was obtained in  all patients without perforation. All CRMs were negative. Mean hospital stay was 5 days. Two patients developed perineal wound infections and one developed a small bowel obstruction postoperatively. Robotic-assisted E-APR performed in the lithotomy position is safe and feasible. Future studies  are needed to define the benefits of this technique.
authors.affiliation: Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California, USA.
authors.forename: Celeste Y
authors.initials: CY
authors.lastname: Kang
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Carmichael
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Friesen
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Stamos
authors.forename: Steven
authors.initials: S
authors.lastname: Mills
authors.forename: Alessio
authors.initials: A
authors.lastname: Pigazzi
mesh_terms: D000005:Abdomen / Q000601:surgery; D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D010502:Perineum / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D012371:Robotics; D016896:Treatment Outcome