#295 AUTONOMIC NERVE PRESERVING ROBOTIC RECTAL SURGERY- ”RADICALITY WITH FUNCTIONALTY” Dr. K Agrawal

This is one of the 2023 KS International Innovation Awards videos selected for inclusion in the Vattikuti Foundation – ORSI Humans on the Cutting Edge of Robotic Surgery Conference, October 6, 7 & 8, 2023 in Ghent, Belgium. Posting does not imply that is has been selected as a Finalist, just that the content will be discussed at the Conference.

From the entry: AUTONOMIC NERVE PRESERVING ROBOTIC RECTAL SURGERY- ”RADICALITY WITH FUNCTIONALTY” Dr. Somashekhar SP, Dr. Ashwin KR, Dr. Rohitkumar C., Dr. Kushal Agrawal, Dr. Udayee Teja Bathala, Dr. Girish G., Dr. Darshan Patil, Dr. Aaron Marian Fernandes Aster International Institute of Oncology, Aster Hospital, Bengaluru, INDIA

INTRODUCTION- The adoption of total mesenteric excision (TME) and combined modality therapy has significantly improved the oncologic outcome for the patients with rectal cancer over the past 3 decades. Nonetheless, the improved survival was constantly in company with high incidence of organ dysfunction which severely compromises quality of life. In addition to the low anterior rectal (LAR) syndrome, urogenital dysfunctions due to intraoperative inadvertent pelvic autonomic nerve damage are well-recognized complications after rectal cancer surgery. In this video, we discuss the current understanding of anatomy, key zones at risk of nerve injury and our experience with robotic platform in rectal surgery.

METHOD– 54 year old gentleman, known c/o Carcinoma Mid Rectum cT3N1M0,Stage IIIB Received Total neo-adjuvant therapy in the form of 4 cycles of FOLFOX f/b SCRT f/b 2 cycles of FOLFOX.Post TNT- MRI- residual wall thickening in the mid-rectum extending from 6 cm from anal verge to 10cm. MRF involvement ROBOTIC LOW ANTERIOR RESECTION WITH TEMPORARY ILEOSTOMY, System used- DaVinci X

RESULTS– Total Docking time- 22 mins, Total console time- 116 mins, Total operative time- 13 mins,Total blood loss- 50 ml. POST OP RECOVERY- Post operatively, NG Tube was removed in OR, Patient was shifted to ward from recovery room.Single shot antibiotic, ERAS- Allowed oral liquids on the day of surgery, Port site dressing and Urinary Catheter removed on POD-1, Post-op physiotherapy and spirometry, Allowed soft diet on POD-1, Patient discharged on POD-2.

In our case series, foleys catheter removal was possible on POD1 in over 95% of the patient with re- catherization rate of approximately 4%.Post operative IPSS score for 97% was between 1- 7(mild).Although difficult to access the IIEF score for 78% male patient was between 17-25 and the FSFI scoring for approximately 60% female patient was more than 20, suggestive acceptable sexual function preservation.

CONCLUSION- -This video demonstrates detailed anatomy and risk areas of nerve injury during Total mesorectal excision. Robotic platform with magnified vision, stable camera, mechanical arms and endowrist technology provides great advantage in autonomic nerve preservation.

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