Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona.
Dis Colon Rectum. 2020 Sep;63(9):1334-1337. doi: 10.1097/DCR.0000000000001715.
As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits.
After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect.
After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap.
This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
随着直肠癌的多学科治疗方法不断发展，新辅助放化疗后手术切除是一种常见的方法。机器人辅助腹会阴切除术在一定程度上变得越来越普遍，部分原因是骨盆内的可视化和器械移动性更好。腹会阴切除术后，会阴部伤口并发症仍然是一个重大风险。骨盆重建降低了这种风险，并且经常使用带蒂腹直肌肌皮瓣来实现这一点。传统的皮瓣采集需要剖腹术，这会导致腹直肌鞘和大的中线疤痕的破坏。机器人采集腹直肌进行腹会阴切除术后的骨盆重建是一种具有可预见益处的新方法。
在完成腹会阴切除术后，在侧腹部插入另外 2 个 trocar，然后将机器人重新定向到后腹壁。切开腹膜和后腹直肌鞘，并在矢状面上向上和向下进行解剖，以显露腹直肌。将肌腹从前腹直肌鞘分离。一旦识别出腹壁下动脉，就可以横断肌肉的上极。继续侧向分离可确保皮瓣的活动性，以便放置在骨盆内。获得适当的可达性后，机器人脱机，通过会阴缺损将皮瓣缝合到位。
放置 trocar 和重新定位机器人后，结直肠外科医生和整形外科医生在控制台交换位置。机器人皮瓣采集不需要剖腹术。前腹直肌鞘保持未受侵犯，患者避免了额外的中线疤痕。上述机器人辅助腹会阴切除术的优点，即增加了可视化和可操作性，在机器人采集该皮瓣时也同样适用。
这项技术是为接受腹会阴切除术的患者提供的另一种微创技术。了解这种新方法后，外科医生可以更好地根据患者的情况定制手术。
