VM62 - Robotic Low Anterior Resection with Para-Aortic Lymph Node Dissection

Purpose/Background: This is an instructional video submission that highlights the steps of a para-aortic lymphadenectomy for a locally advanced rectosigmoid colon cancer. We are presenting the case of a previously healthy 44 year old female who originally presented to medical attention with a large bowel obstruction requiring diversion with a loop ileostomy. Staging studies showed bulky paraaortic lymph nodes and she subsequently underwent pseudo-neuoadjuvant chemotherapy with fourteen cycles folfox and bevacizumab. After completion of systemic therapy restating studies including a PET-CT scan showed improved lymphadenopathy with no new sites of disease. She was reviewed at multi-disciplinary tumor boards and the decision was made to pursue surgical resection of her primary with extended lymphadenectomy. The boundaries of our nodal harvest are the left external iliac artery inferiorly, the left renal vein superiorly, the aorta medially and the left gonadal vein laterally.

Methods/Interventions: Robotic Low Anterior Resection With Para-aortic Lymph node Dissection

Results/Outcomes: Patient discharged home without complications on post-operative day 5.

Conclusion/Discussion: Only 1–2% of patients with colorectal cancer initially present with isolated abnormal para-aortic lymph nodes. This is a challenging scenario in colorectal cancer management due to the absence of comprehensive randomized controlled trials or multicenter studies assessing the effectiveness of surgical interventions in this context. In our video presentation, we introduce a robotic approach for managing locally advanced colorectal cancer with isolated paraortic lymphadenopathy. The video illustrates how robotic platform equips experienced surgeons with precision tools for intricate dissections in anatomically challenging areas. Our method, which combines robotic precision with preoperative indocyanine green (ICG) injection via a left-sided ureteric stent, enhances ureteric identification, thus reducing the risk of iatrogenic injury and complications during paraortic lymphadenectomy. The minimally invasive robotic approach also likely minimizes postoperative pain and discomfort. In conclusion, this approach represents a valuable adjunctive technique for specific colorectal cancer cases, serving as a crucial addition to the colorectal surgeon's skill set.