Robot-assisted TME with coloanal anastomosis

Since total mesorectal excision (TME) was introduced in 1982 [1], it has become a standard procedure for the treatment of rectal cancer. For low rectal cancer, coloanal anastomosis (CAA) [2] after ultralow anterior resection (uLAR) or intersphincteric resection (ISR) [3] along with TME has provided positive functional, psychological, and oncological outcomes. These outcomes of surgical techniques are also owed to the development of anatomical knowledge and perioperative treatment [4]. Robotic systems offer surgeons several benefits, though there have been controversial issues. Recent reports have indicated that robotic surgery is feasible and safe compared to laparoscopic surgery [5-7]. Robotic surgery enables easier performance of intersphincteric dissection for very low-lying rectal cancer, especially when accompanied with unfavorable factors such as high body mass index or preoperative radiation, leading to satisfactory surgical, functional, and oncological outcomes compared to conventional laparoscopy [8]. It also provides earlier recovery of sexual and bladder functions [6], lower conversion rate, and shorter hospital stay [9]. Although multicenter, randomized prospective trials are needed, robot-assisted TME with CAA with or without ISR has potential benefits for low rectal cancer. In this chapter, the authors introduce the robotic approach of TME with CAA, which is performed with or without ISR. The procedures include patient positioning, trocar placement, docking, abdominal/pelvic phases, and useful technical tips as well as CAA and ISR.