1. Robotic Surgery for lesions 3-6 cm Alessio Pigazzi University of California, Irvine

2. Why robotic rectal surgery? Not a panacea Not a panacea Enables better access to deep pelvis Enables better access to deep pelvis Multiple instruments ( 4 rob+ 2 assistants) Multiple instruments ( 4 rob+ 2 assistants) Better retraction Better retraction Stable camera Stable camera

3. Goal: truly minimally invasive TME Hybrid Technique vs Totally Robotic Hybrid Technique vs Totally Robotic Mobilization of bowel, division of vessels and rectum intracorporeallyMobilization of bowel, division of vessels and rectum intracorporeally Small incision only for extraction and anvil insertionSmall incision only for extraction and anvil insertion Autonomic nerve preservationAutonomic nerve preservation Margin clearanceMargin clearance

4. Fully Robotic Technique Single docking Single docking Comes in from left hip and arms only are moved from port to portComes in from left hip and arms only are moved from port to port Dual docking Dual docking Cart comes in first from the side for the flexureCart comes in first from the side for the flexure Then comes in from the left hip for the pelvisThen comes in from the left hip for the pelvis

5. Hybrid procedure- preferred approach in heavy patients

6. Arm 1Arm 2 Arm 3 5 mm Assistant Port 8 mm Robot Port 12 mm Robot Camera Port Port placement

7. Mesorectal Excision 5 10 15

8. Different tumor location mandates operative approach Double Stapled? APR

9. How to divide rectum? Linear Linear TA inserted via open incision TA inserted via open incision Divide it with scissors- transanal extraction Divide it with scissors- transanal extraction

10. Robotic LAR at 5 cm

11. Transanal extraction/ double purse string

12. Multicentric study: Italy and USA

14. Survival No isolated local recurrences; 2 LR with distant metastases

15. Conclusion Robotic TME is safe and feasible Robotic TME is safe and feasible Makes reaching low pelvis easier Makes reaching low pelvis easier Robot is a misnomer cause it doesn’t do it alone Robot is a misnomer cause it doesn’t do it alone Extensive training and practice requiredExtensive training and practice required Good assistant neededGood assistant needed Laparoscopic and open skills requiredLaparoscopic and open skills required