1. Robotic LAR with Transanal Extraction Alessio Pigazzi City of Hope Duarte, CA

2. A history of Lap TA extraction -Franklin procedure First shown by Franklin in early 1990s for Recto/sigmoid resection. First shown by Franklin in early 1990s for Recto/sigmoid resection. Advantages: Advantages: Cosmetically pleasingCosmetically pleasing Lower hernia rateLower hernia rate Lower wound infectionLower wound infection Better anastomosis?Better anastomosis? Disadvantages Disadvantages Technically demandingTechnically demanding Oncologically safe?Oncologically safe?

3. Franklin’s transanal extraction

4. Anastomosis

5. Indications Can be done for Can be done for Benign diseaseBenign disease Selected cancersSelected cancers Avoid large tumors Avoid large tumors What about rectal cancer? What about rectal cancer?

6. Types of Rectal Transanal Resection Life within 8 cm of the outside world Low Anterior Resection Colorectal AA Inter Sphincteric Coloanal AA

7. 40 Intersphincteric resection vs 37 CAA 40 Intersphincteric resection vs 37 CAA 1990-2000 1990-2000 Same frequency, urgency, fragmentation Same frequency, urgency, fragmentation Wexner incontinence score higher in ISR Wexner incontinence score higher in ISR 10.8 ISR vs 6.9 CAA10.8 ISR vs 6.9 CAA Higher use of antidiarrheals in ISR Higher use of antidiarrheals in ISR

8. Double stapled AA

9. 13 patients 13 patients 11 transanal extraction11 transanal extraction 2 Transvaginal extractions2 Transvaginal extractions Complications :2 patients (15%)Complications :2 patients (15%) Anastomotic leak: 1Anastomotic leak: 1 Bleeding anastomosis:1Bleeding anastomosis:1 No report of incontinenceNo report of incontinence Surg Endosc, 2010

10. Robotic low anterior resection with TA extraction Potential to have Potential to have Superior cosmetic resultsSuperior cosmetic results Lower wound infection ratesLower wound infection rates Lowe hernia rateLowe hernia rate Better continence data than coloanal anastomosisBetter continence data than coloanal anastomosis

11. Robotic transanal extraction with double purse string aa.

12. City of Hope experience Double Purse String AA. 4 patients (3F;1M) 4 patients (3F;1M) Age: 58 Age: 58 Mean distance tumor anal verge: 8 cm Mean distance tumor anal verge: 8 cm Ileostomy:2 Ileostomy:2 Complications: None Complications: None Mean Wexner score: 3.5 (2-6) Mean Wexner score: 3.5 (2-6)

13. Conclusions Resection with transanal extraction ideal minimally invasive procedure Resection with transanal extraction ideal minimally invasive procedure Combines Open, LAP, Endoscopic skillsCombines Open, LAP, Endoscopic skills Robotic technology makes the procedure more applicable to low anterior resection Robotic technology makes the procedure more applicable to low anterior resection Preliminary data encouraging-more studies are needed Preliminary data encouraging-more studies are needed