title: Dynamic Article: Tandem Robotic Technique of Extralevator Abdominoperineal Excision and Rectus Abdominis Muscle Harvest for Immediate Closure of the Pelvic Floor Defect.
abstract: BACKGROUND
  Extralevator abdominoperineal excision for distal rectal cancers involves cylindrical excision of the mesorectum with wide division of the levator ani muscles. Although this technique has been shown to decrease local cancer recurrence and improve survival, it leaves the patient with a considerable pelvic floor defect that may require reconstruction.
  
  
  OBJECTIVE
  We developed an innovative technique of robotic extralevator abdominoperineal excision combined with robotic harvest of the rectus abdominis muscle flap for immediate reconstruction of the pelvic floor defect.
  
  
  METHODS
  This was a retrospective review pilot study.
  
  
  METHODS
  This study was conducted at a tertiary care cancer center.
  
  
  METHODS
  Three patients who underwent robotic extralevator abdominoperineal excision with robotic rectus abdominis flap harvest for distal rectal adenocarcinoma were included.
  
  
  METHODS
  Intraoperative and postoperative outcomes included operative time, intraoperative complications, length of hospital stay, wound complications, incidence of perineal hernia, persistent pain, and functional limitations.
  
  
  RESULTS
  Three patients underwent this procedure. The median operative time was 522 minutes with median hospital stay of 6 days. One patient experienced perineal wound complication requiring limited incision and drainage followed by complete healing of the wound by secondary intention. The other 2 patients did not experience any wound complications. Longest follow-up was 16 months. None of the patients developed perineal hernias during this time period.
  
  
  CONCLUSIONS
  The small sample size and retrospective nature were limitations.
  
  
  CONCLUSIONS
  This technique confers multiple advantages including improved visualization and dexterity within the pelvis and accurate wide margins at the pelvic floor. An incisionless robotic flap harvest with preservation of the anterior rectus sheath obviates the risk of ventral hernia while providing robust tissue closure of the radiated abdominoperineal excision wound. This technique may result in faster postoperative recovery, decreased morbidity, improved functional outcomes and cosmesis. Further studies are needed to prospectively analyze this approach (Supplemental Digital Content 1, video abstract, http://links.lww.com/DCR/A188).
authors.affiliation: 1 Department of Surgery, Section of General Surgery, The University of Chicago Medicine, Chicago, Illinois 2 Carolinas HealthCare System, CMC Cosmetic and Plastic Surgery, Charlotte, North Carolina 3 Department of Surgery, Section of Colon and Rectal Surgery, The University of Chicago Medicine, Chicago, Illinois 4 Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland 5 Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland 6 Department of Surgery, Section of Plastic and Reconstructive Surgery, The University of Chicago Medicine, Chicago, Illinois.
authors.forename: Puneet
authors.initials: P
authors.lastname: Singh
authors.forename: Edward
authors.initials: E
authors.lastname: Teng
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Cannon
authors.forename: Brian L
authors.initials: BL
authors.lastname: Bello
authors.forename: David H
authors.initials: DH
authors.lastname: Song
authors.forename: Konstantin
authors.initials: K
authors.lastname: Umanskiy
mesh_terms: D000005:Abdomen / Q000601:surgery; D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017773:Pelvic Floor / Q000601:surgery; D010502:Perineum / Q000601:surgery; D010865:Pilot Projects; D019651:Plastic Surgery Procedures / Q000379:methods*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D017568:Rectus Abdominis / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D013524:Surgical Flaps; D016896:Treatment Outcome