Robotic-Assisted Abdominoperineal Resection

In 1908, Sir Ernest Miles reported his first attempt to develop a radical operation for rectal cancer, publishing his experience with abdominoperineal resection (APR). The introduction of the embriologically based concept of total mesorectal excision (TME) and the increasing use of intersphincteric resection in combination with neoadjuvant chemoradiotherapy have further contributed to improve oncological outcomes and have significantly reduced the need of APR even for low rectal cancers. Nevertheless, APR is still strictly indicated in patients with type IV low rectal cancer (<6 cm from the anal verge), defined as transanal tumors with external anal sphincter or levator ani muscle invasion. Though randomized trials have shown that minimally invasive TME is oncologically as safe as open surgery, it is technically a demanding procedure and has a steep learning curve. Robotic surgery, thanks to its technological advantages, may potentially overcome these limitations especially in lower mesorectal dissection and, potentially, in transabdominal levator ani transection. This might help to reduce CRM positivity and, ultimately, local recurrence rates for ultralow rectal cancer-requiring APR.