eP192 - Synchronous Robotic Bowel Resection and Liver Metastasectomy for Metastatic Rectal Cancer

Purpose/Background: The aim of this study is to present a series of cases of synchronous colorectal and liver resection using the Da Vinci Si robotic system. We look on the advantages, limitations, and how it can mitigate postoperative complications and possibly shift outcomes compared to a combined open surgery or a staged robotic approach.Methods/Interventions: A retrospective case series was done for this study. All cases were collected from the Integrated Surgical Information System and the Philippine General Hospital Electronic Medical Records system. All patients were collected from January 2021 to October 2023.Results/Outcomes: Average age of the cases was 56.75 years old. Three of the cases had normal BMI. Two patients had an ECOG status of 2. Hypertension was noted in two cases. All patients in this study were diagnosed with rectal adenocarcinoma with all their liver masses found on the right lobe. Two patients had the lesions on segment VI of the liver, while the other two had lesions on segments 4B and 7. Two patients received neoadjuvant therapy.
The rectal resection starts with the patient positioned in modified lithotomy Trendelenburg position with the right side angled down to allow the small bowels to fall towards the right upper quadrant by gravity. The patient cart is situated at the left lower portion of the operating table. A Veress needle is used for insufflation of the abdomen. The camera port is made 19cm above the symphysis pubis. A RLQ port is marked 2cm medial and superior to the anterior superior iliac spine (ASIS) and 12cm from the camera port. Another port is made at the contralateral side 12 cm from the camera port. A 12mm laparoscopic assist port is also marked 8-10cm above the RLQ robot port. Another robotic port is marked 12cm above the LLQ port.
To accommodate for liver resection, the table is rotated to where the head of the patient is nearest and parallel to the robot’s boom. The patient is re positioned in a reverse Trendelenburg position. The 12mm laparoscopic assist site is used by the hepatobiliary service for one of the robotic arms. An additional site is placed at the LUQ, lateral to the previously used robotic port. To prevent desufflation, any unused sites are closed temporarily by sutures.

There were no case converted to an open surgery. All surgeries started with rectal resection first. The average length of stay (LOS) was 7.5 days, while the postoperative LOS was a mean of 5.5 days.
One patient had trouble in voiding postoperatively. He would be sent home with a foley catheter and prescribed cholinergics. Another patient experienced hospital acquired pneumonia requiring intravenous antibiotics.Conclusion/

Discussion: Robotic surgery has been shown to reduce length of stay and intraoperative blood loss. Thus, it is paramount to be thorough in assessing the feasibility to proceed to the 2nd phase of surgery when a significant blood loss has been already incurred during the 1st phase of resection. An average of 5.5 days post operative LOS is a strong indicator of the advantages of robotic surgery compared to open procedure especially during complex synchronous resections.
This case series review supports the potential advantages of a synchronous resection from a practical and technical perspective. Further study is still required to able to determine any treatment or overall benefits.Patient and Cart locations during Colorectal resection, PGH 2023Patient and Cart Locations during Liver Resection, PGH 2023Port Placement in synchronous colorectal and liver resections using the Da Vinci Si systemPurple circle represents the port created during liver resection. Red circle represents the usual site of the robotic arm during rectal resection. The 12mm lap port is also used during liver resection. PGH, 2023.Baseline Characteristics and postoperative outcomes Three of the four cases were compliant with their surveillance and post operative management plans. Case A and C are one year post surgery without any signs and symptoms of disease recurrence.
Case D is on the 3rd cycle of chemotherapy (Capecitabine + Oxaliplatin). Case B died two months postoperatively who suffered a fatal arrythmia.