Robotic Pelvic Exenteration

  • Songphol Malakorn
  • Tarik Sammour
  • George J. ChangEmail author


There has been significant growth in the use of robotic surgery for rectal cancer worldwide. Emerging data appears to support the feasibility of robotic surgery for T4 rectal cancers with comparable short-term oncologic outcomes. The advantages of robotic surgery over conventional laparoscopic surgery include better pelvic visualization by 3-D-adjustable cameras and more degrees of freedom with wrist-articulated instrumentation, thus achieving more precise dissections. These benefits may compensate for some of the limitations of conventional laparoscopic surgery, especially during complex pelvic dissection. In carefully selected cases, the robotic approach may expand our ability to offer minimally invasive surgery to this subset of locally advanced rectal cancer patients. In this chapter, we clarify a step-by-step approach of robotic pelvic exenteration for T4 rectal cancers.


Rectal cancer Adenocarcinoma of the rectum Pelvic exenteration Robotic surgery Minimally invasive surgery for rectal cancer Colorectal cancer 

Supplementary material

Video 29.1

Video demonstrates a step-by-step approach for robotic total pelvic exenteration in a patient who had low rectal cancer with prostatic invasion (MOV 662715 kb)


  1. 1.
    Jemal A, Ward EM, Johnson CJ, et al. Annual report to the nation on the status of cancer, 1975–2014, featuring survival. J Natl Cancer Inst. 2017;109(9).
  2. 2.
    O’Connell JB, Maggard MA, Liu JH, et al. Are survival rates different for young and older patients with rectal cancer? Dis Colon Rectum. 2004;47:2064–9.CrossRefGoogle Scholar
  3. 3.
    Russell MC, You YN, Hu CY, et al. A novel risk-adjusted nomogram for rectal cancer surgery outcomes. JAMA Surg. 2013;148:769–77.CrossRefGoogle Scholar
  4. 4.
    Govindarajan A, Coburn NG, Kiss A, et al. Population-based assessment of the surgical management of locally advanced colorectal cancer. J Natl Cancer Inst. 2006;98:1474–81.CrossRefGoogle Scholar
  5. 5.
    Gannon CJ, Zager JS, Chang GJ, et al. Pelvic exenteration affords safe and durable treatment for locally advanced rectal carcinoma. Ann Surg Oncol. 2007;14:1870–7.CrossRefGoogle Scholar
  6. 6.
    Levy M, Lipska L, Visokai V, et al. Quality of life after extensive pelvic surgery. Rozhledy v chirurgii: mesicnik Ceskoslovenske chirurgicke spolecnosti. 2016;95:358–462.Google Scholar
  7. 7.
    Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013;100:1009–14.Google Scholar
  8. 8.
    Valentini V, Coco C, Rizzo G, et al. Outcomes of clinical T4M0 extra-peritoneal rectal cancer treated with preoperative radiochemotherapy and surgery: a prospective evaluation of a single institutional experience. Surgery. 2009;145:486–94.CrossRefGoogle Scholar
  9. 9.
    Smith JD, Nash GM, Weiser MR, et al. Multivisceral resections for rectal cancer. Br J Surg. 2012;99:1137–43.CrossRefGoogle Scholar
  10. 10.
    Monson JR, Weiser MR, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013;56:535–50.CrossRefGoogle Scholar
  11. 11.
    Lehnert T, Methner M, Pollok A, et al. Multivisceral resection for locally advanced primary colon and rectal cancer: an analysis of prognostic factors in 201 patients. Ann Surg. 2002;235:217–25.CrossRefGoogle Scholar
  12. 12.
    Akiyoshi T. Technical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer. World J Gastroenterol. 2016;22:718–26.CrossRefGoogle Scholar
  13. 13.
    Akiyoshi T, Nagasaki T, Ueno M. Laparoscopic total pelvic exenteration for locally recurrent rectal cancer. Ann Surg Oncol. 2015;22:3896.CrossRefGoogle Scholar
  14. 14.
    Nakamura H, Uehara K, Arimoto A, et al. The feasibility of laparoscopic extended pelvic surgery for rectal cancer. Surg Today. 2016;46:950–6.CrossRefGoogle Scholar
  15. 15.
    Bretagnol F, Dedieu A, Zappa M, et al. T4 colorectal cancer: is laparoscopic resection contraindicated? Color Dis. 2011;13:138–43.CrossRefGoogle Scholar
  16. 16.
    Martinez-Perez A, Carra MC, Brunetti F, et al. Pathologic outcomes of laparoscopic vs open mesorectal excision for rectal cancer: a systematic review and meta-analysis. JAMA Surg. 2017;152:e165665.CrossRefGoogle Scholar
  17. 17.
    van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14:210–8.CrossRefGoogle Scholar
  18. 18.
    Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet (London, England). 2005;365:1718–26.CrossRefGoogle Scholar
  19. 19.
    Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6:477–84.CrossRefGoogle Scholar
  20. 20.
    Clancy C, O’Leary DP, Burke JP, et al. A meta-analysis to determine the oncological implications of conversion in laparoscopic colorectal cancer surgery. Color Dis. 2015;17:482–90.CrossRefGoogle Scholar
  21. 21.
    Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC trial group. J Clin Oncol Off J Am Soc Clin Oncol. 2007;25:3061–8.CrossRefGoogle Scholar
  22. 22.
    Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314:1346–55.CrossRefGoogle Scholar
  23. 23.
    Colombo PE, Bertrand MM, Alline M, et al. Robotic versus laparoscopic total mesorectal excision (TME) for sphincter-saving surgery: is there any difference in the transanal TME rectal approach?: a single-center series of 120 consecutive patients. Ann Surg Oncol. 2016;23:1594–600.CrossRefGoogle Scholar
  24. 24.
    Shin US, Nancy You Y, Nguyen AT, et al. Oncologic outcomes of extended robotic resection for rectal cancer. Ann Surg Oncol. 2016;23(7):2249–57.CrossRefGoogle Scholar
  25. 25.
    Malakorn S, Sammour T, Pisters LL, Chang GJ. Robotic total pelvic exenteration. Dis Colon Rectum. 2017;60:555.CrossRefGoogle Scholar
  26. 26.
    D’Annibale A, Pernazza G, Monsellato I, et al. Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg Endosc. 2013;27:1887–95.CrossRefGoogle Scholar
  27. 27.
    Mills JT, Burris MB, Warburton DJ, et al. Positioning injuries associated with robotic assisted urological surgery. J Urol. 2013;190:580–4.CrossRefGoogle Scholar
  28. 28.
    Malakorn S, Sammour T, Bednarski B, et al. Three different approaches to the inferior mesenteric artery during robotic D3 lymphadenectomy for rectal cancer. Ann Surg Oncol. 2017;24:1923.CrossRefGoogle Scholar
  29. 29.
    Ibrahim AE, Sarhane KA, Pederson JC, et al. Robotic harvest of the rectus abdominis muscle: principles and clinical applications. Semin Plast Surg. 2014;28:26–31.CrossRefGoogle Scholar
  30. 30.
    Beyond TME Collaborative. Surgical and survival outcomes following pelvic exenteration for locally advanced primary rectal cancer: results from an international collaboration. Ann Surg. 2017;269(2):315–21.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Songphol Malakorn
    • 1
    • 2
  • Tarik Sammour
    • 2
    • 3
  • George J. Chang
    • 2
    Email author
  1. 1.Department of Colorectal Surgery, Faculty of MedicineChulalongkorn UniversityBangkokThailand
  2. 2.Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Colorectal Unit, Department of SurgeryRoyal Adelaide Hospital, University of AdelaideAdelaideAustralia

Personalised recommendations