Robotic surgical approach for rectal cancer

Total mesorectal excision (TME) is the standard operation for mid-low rectal cancer. The advancement of minimally invasive surgery for rectal cancer has never been interrupted, from the conventional open surgery and laparoscopic surgery to robotic surgery and similarly from the conventional transabdominal approach to the transanal approach. All these approaches have focused on ensuring oncological control and meanwhile minimizing surgical trauma, preserving pelvic autonomic nerves, accelerating postoperative recovery and rehabilitation accordingly. In this review, we summarized the current progress of robotic TME for the treatment of rectal cancer and evaluated its safety and efficiency from the perspective of oncological and functional outcomes. The advantages behind robotic TME rely mainly on dealing with difficult rectal cancer cases. Besides, the robotic surgery system shortens the learning curve. However, the superiority of robotic surgery in preserving autonomic nerve has not been yet confirmed compared with laparoscopic surgery. We proposed the partial preservation of Denonvilliers' fascia during robotic TME, in order to enlarge the pelvic space, ensure the integrity of anterior mesorectum, and preserve the autonomic nerves. To date, there is still a lack of evidence regarding robotic taTME in the treatment of rectal cancer. However, several technical defects regarding taTME itself, including the residual of the terminal mesorectum, the sacrifice of distal rectal stump, and cancer cell dissemination due to airflow during dissection, need to be solved. The reported higher rate of local recurrence with multifocal pelvic side involvement and the anorectal dysfunction after taTME restrict its widespread performance.