eP496 - Combined Robotic and TaTME Approach in Revisional Colorectal Surgery After a Pelvic Anastomotic Complication: A Case-Series

Purpose/Background: Leak after a low colorectal anastomosis is a detrimental but well-described complication. Reoperative corrective pelvic surgery is extremely challenging due to anatomic distortion, significant scarring, chronic infection, and previous radiotherapy. Traditionally, anastomotic revisions are undertaken through open approaches with the associated high morbidity. Laparoscopic revisional approaches have been shown to be a safe option, yet conversion rates remain high. Regardless of the approach, one common and major challenge remains accessing the distal pelvis.
The robotic platform offers improved optics and articulating instruments enabling better pelvic dissection. Transanal approach provides direct access to the distal pelvis, beyond the problematic anastomosis in unviolated planes. Combining these approaches allows dissection planes to meet in the most hostile portion of the pelvis, potentially minimizing the risk of iatrogenic injury and conversion, while saving the anus. The purpose of this series is to describe the outcomes of this unique approach.Methods/Interventions: We retrospectively reviewed the prospectively maintained Mayo Clinic Robotics Database from 2018-2023, with inclusion criteria being combined robotic and laparoscopic transanal approach to revisional surgery after low colorectal anastomotic complication.Results/Outcomes: A total of 11 patients were identified. There were eight males and three females with a mean age of 56. The average BMI 29 and ASA score 3. The original operative indication for all patients was rectal adenocarcinoma. All patients received neoadjuvant chemoradiotherapy. Indications for revision included 10 chronic leaks and one large anastomotic vaginal fistula. All patients had a diverting loop ileostomy prior to revision surgery, and all were left in situ for the operation.

Mean operative time was 595 minutes and mean estimated blood loss of 236 ml. There were no operative conversions. Six patients underwent double purse string stapled anastomoses and five patients had hand-sewn anastomoses. The average length of stay was 4 days. Overall morbidity was 9%. The only complication (Clavien Dindo 3B) was a patient having a small anastomotic defect and successfully managed conservatively. All patients had successful closure of their loop ileostomy. The mean time until they had their reversal operation was 127 days. One patient was elected for permanent colostomy due to severe functional issues.Conclusion/

Discussion: Combined robotic and TaTME modalities are a promising approach in revisional corrective pelvic surgery for low rectal anastomotic complications. It is a promising approach with high rates of technical success and acceptable post-operative morbidity.

Keywords: Robotic surgery, TaTME, Colorectal surgery, Low anterior resection, revision, leakSummary of Patients' Characteristics and Operative Parameters