Hybrid Laparoscopic-Robotic Low Anterior Resection

  • Raul M. Bosio
  • Alessio PigazziEmail author


Minimally invasive rectal surgery is technically challenging because of a narrow and deep pelvis. As a direct consequence, the majority of rectal resections in the US are performed open or with a combined laparoscopic-open approach. The use of a robotic platform may facilitate minimally invasive rectal resection. Surgeons experienced in advanced laparoscopic techniques may find that the robot may enhance the ability to complete rectal procedures, offering patients the benefits of a minimally invasive technique including its enhanced recovery. It is noteworthy that a number of technical principles are common to various rectal procedures. Within this chapter, a detailed description of a hybrid laparoscopic-robotic low anterior resection is provided with emphasis on the technical aspects that allow surgeons to easily transition from one step to the next while achieving the goal of completing the procedure in a minimally invasive fashion.


Robotic Laparoscopic Hybrid Rectal surgery Low anterior resection Rectal cancer Total mesorectal excision 

Supplementary material

Video 23.1

In this video, the surgeon demonstrates his approach to hybrid laparoscopic-robotic low anterior resection. (MPG 1059830 kb)


  1. 1.
    Laparoscopically assisted colectomy is as safe and effective as open colectomy in people with colon cancer Abstracted from: Nelson H, Sargent D, Wieand HS, et al.; for the Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350: 2050–9. Cancer treatment reviews. 2004;30(8):707–9. doi: 10.1016/j.ctrv.2004.09.001.
  2. 2.
    Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J, et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol. 2009;10(1):44–52. doi: 10.1016/s1470-2045(08)70310-3.PubMedCrossRefGoogle Scholar
  3. 3.
    Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6(7):477–84. doi: 10.1016/s1470-2045(05)70221-7.PubMedCrossRefGoogle Scholar
  4. 4.
    Baik SH. Robotic colorectal surgery. Yonsei Med J. 2008;49(6):891–6. doi: 10.3349/ymj.2008.49.6.891.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Bianchi PP, Luca F, Petz W, Valvo M, Cenciarelli S, Zuccaro M, et al. The role of the robotic technique in minimally invasive surgery in rectal cancer. Ecancermedicalscience. 2013;7:357. doi: 10.3332/ecancer.2013.357.PubMedCentralPubMedGoogle Scholar
  6. 6.
    Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25(21):3061–8. doi: 10.1200/jco.2006.09.7758.PubMedCrossRefGoogle Scholar
  7. 7.
    Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg. 2010;97(11):1638–45. doi: 10.1002/bjs.7160.PubMedCrossRefGoogle Scholar
  8. 8.
    van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210–8. doi: 10.1016/s1470-2045(13)70016-0.PubMedCrossRefGoogle Scholar
  9. 9.
    Monson JR, Weiser MR, Buie WD, Chang GJ, Rafferty JF, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013;56(5):535–50. doi: 10.1097/DCR.0b013e31828cb66c.PubMedCrossRefGoogle Scholar
  10. 10.
    McKay GD, Morgan MJ, Wong SK, Gatenby AH, Fulham SB, Ahmed KW, et al. Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study. Dis Colon Rectum. 2012;55(1):42–50. doi: 10.1097/DCR.0b013e318239341f.PubMedCrossRefGoogle Scholar
  11. 11.
    Braga M, Frasson M, Vignali A, Zuliani W, Capretti G, Di Carlo V. Laparoscopic resection in rectal cancer patients: outcome and cost-benefit analysis. Dis Colon Rectum. 2007;50(4):464–71. doi: 10.1007/s10350-006-0798-5.PubMedCrossRefGoogle Scholar
  12. 12.
    Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010;11(7):637–45. doi: 10.1016/s1470-2045(10)70131-5.PubMedCrossRefGoogle Scholar
  13. 13.
    Laurent C, Leblanc F, Wutrich P, Scheffler M, Rullier E. Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg. 2009;250(1):54–61. doi: 10.1097/SLA.0b013e3181ad6511.PubMedCrossRefGoogle Scholar
  14. 14.
    Baek JH, Pastor C, Pigazzi A. Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study. Surg Endosc. 2011;25(2):521–5. doi: 10.1007/s00464-010-1204-x.PubMedCrossRefGoogle Scholar
  15. 15.
    Baek SJ, Al-Asari S, Jeong DH, Hur H, Min BS, Baik SH, et al. Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc. 2013;27(11):4157–63. doi: 10.1007/s00464-013-3014-4.PubMedCrossRefGoogle Scholar
  16. 16.
    Kwak JM, Kim SH, Kim J, Son DN, Baek SJ, Cho JS. Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum. 2011;54(2):151–6. doi: 10.1007/DCR.0b013e3181fec4fd.PubMedCrossRefGoogle Scholar
  17. 17.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol. 2010;17(12):3195–202. doi: 10.1245/s10434-010-1162-5.PubMedCrossRefGoogle Scholar
  18. 18.
    Scarpinata R, Aly EH. Does robotic rectal cancer surgery offer improved early postoperative outcomes? Dis Colon Rectum. 2013;56(2):253–62. doi: 10.1097/DCR.0b013e3182694595.PubMedCrossRefGoogle Scholar
  19. 19.
    Collinson FJ, Jayne DG, Pigazzi A, Tsang C, Barrie JM, Edlin R, et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis. 2012;27(2):233–41. doi: 10.1007/s00384-011-1313-6.PubMedCrossRefGoogle Scholar
  20. 20.
    Ahmed K, Khan MS, Vats A, Nagpal K, Priest O, Patel V, et al. Current status of robotic assisted pelvic surgery and future developments. Int J Surg. 2009;7(5):431–40. doi: 10.1016/j.ijsu.2009.08.008.PubMedCrossRefGoogle Scholar
  21. 21.
    Halabi WJ, Kang CY, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, et al. Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes. World J Surg. 2013;37(12):2782–90. doi: 10.1007/s00268-013-2024-7.PubMedCrossRefGoogle Scholar
  22. 22.
    Lin S, Jiang HG, Chen ZH, Zhou SY, Liu XS, Yu JR. Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer. World J Gastroenterol. 2011;17(47):5214–20. doi: 10.3748/wjg.v17.i47.5214.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Memon S, Heriot AG, Murphy DG, Bressel M, Lynch AC. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol. 2012;19(7):2095–101. doi: 10.1245/s10434-012-2270-1.PubMedCrossRefGoogle Scholar
  24. 24.
    Yang Y, Wang F, Zhang P, Shi C, Zou Y, Qin H, et al. Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann Surg Oncol. 2012;19(12):3727–36. doi: 10.1245/s10434-012-2429-9.PubMedCrossRefGoogle Scholar
  25. 25.
    Kang J, Hur H, Min BS, Lee KY, Kim NK. Robotic coloanal anastomosis with or without intersphincteric resection for low rectal cancer: starting with the perianal approach followed by robotic procedure. Ann Surg Oncol. 2012;19(1):154–5. doi: 10.1245/s10434-011-1952-4.PubMedCrossRefGoogle Scholar
  26. 26.
    Leong QM, Son DN, Cho JS, Baek SJ, Kwak JM, Amar AH, et al. Robot-assisted intersphincteric resection for low rectal cancer: technique and short-term outcome for 29 consecutive patients. Surg Endosc. 2011;25(9):2987–92. doi: 10.1007/s00464-011-1657-6.PubMedCrossRefGoogle Scholar
  27. 27.
    Peterson CY, McLemore EC, Horgan S, Talamini MA, Ramamoorthy SL. Technical aspects of robotic proctectomy. Surg Laparosc Endosc Percutan Tech. 2012;22(3):189–93. doi: 10.1097/SLE.0b013e31824be924.PubMedCrossRefGoogle Scholar
  28. 28.
    Rullier E, Denost Q, Vendrely V, Rullier A, Laurent C. Low rectal cancer: classification and standardization of surgery. Dis Colon Rectum. 2013;56(5):560–7. doi: 10.1097/DCR.0b013e31827c4a8c.PubMedCrossRefGoogle Scholar
  29. 29.
    Richardson DP, Porter GA, Johnson PM. Population-based use of sphincter-preserving surgery in patients with rectal cancer: is there room for improvement? Dis Colon Rectum. 2013;56(6):704–10. doi: 10.1097/DCR.0b013e3182758c2b.PubMedCrossRefGoogle Scholar
  30. 30.
    Tilney HS, Tekkis PP. Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Dis. 2008;10(1):3–15. doi: 10.1111/j.1463-1318.2007.01226.x; discussion 6.PubMedGoogle Scholar
  31. 31.
    Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med. 1988;81(9):503–8.PubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of California, Irvine School of MedicineOrangeUSA

Personalised recommendations