An elderly female patient presented with bleeding per rectum and progressive difficulty in passing stools for three months. There was no history of intestinal obstruction, severe abdominal pain, or significant weight loss.
She was a known case of diabetes mellitus and hypertension on regular treatment. Importantly, she had undergone mechanical mitral valve replacement 12 years earlier for severe pulmonary hypertension and was on long-term warfarin therapy. This made perioperative management particularly challenging, with careful balancing of thromboembolic and bleeding risks.
On examination, she was hemodynamically stable. Abdominal examination was unremarkable. Digital rectal examination revealed a growth approximately 8 cm from the anal verge, consistent with an upper to mid-rectal lesion.
After multidisciplinary discussion and cardiology clearance, she was planned for minimally invasive robotic surgery.
Robot-Assisted Surgical Management
The patient underwent Robot-Assisted Laparoscopic Low Anterior Resection with colorectal anastomosis using the Da Vinci X Surgical System.
Operative Details
Under general anaesthesia, the patient was positioned in a modified Lloyd-Davies position with appropriate padding. After sterile preparation, pneumoperitoneum was established, standard port placement was performed, and the robot was docked from the left side.
Intra-operatively, an upper to mid-rectal tumor was identified approximately 8 cm from the anal verge at the level of the peritoneal reflection. There was no evidence of peritoneal, hepatic, or pelvic metastasis.
A meticulous medial-to-lateral dissection was performed. The inferior mesenteric vessels were skeletonized and ligated with preservation of the left colic artery to maintain adequate perfusion. The left ureter and gonadal vessels were clearly visualized and carefully protected throughout.
Robotic total mesorectal excision was completed with an intact mesorectal envelope. The rectum was transected distal to the tumor using a linear stapler, ensuring an adequate margin. Bowel perfusion was assessed using indocyanine green fluorescence (Firefly mode), confirming good vascularity prior to reconstruction.
A tension-free circular stapled colorectal anastomosis was performed. Donuts were complete, and the air leak test was negative.
Hemostasis was well maintained, with a total estimated blood loss of approximately 30 mL, which is particularly notable given the patient’s requirement for chronic anticoagulation therapy.
The Robotic Advantage
Robotic technology provided several key advantages in this high-risk patient:
• 3D High-Definition Magnified Vision
The robotic platform provides stable, surgeon-controlled, high-definition three-dimensional visualization with significant magnification. This allows for clear identification of fine anatomical details and precise tissue planes. In rectal cancer surgery—especially within the confined and deep pelvic cavity—this enhanced view plays a crucial role in ensuring accurate dissection while minimizing inadvertent injury to surrounding structures.
• Precise Nerve Preservation
With improved visualization and highly articulated instruments, the surgeon is able to perform meticulous dissection in the correct avascular plane during Total Mesorectal Excision (TME). The pelvic autonomic nerves can be clearly visualized and preserved, significantly reducing the risk of postoperative complications such as urinary incontinence and sexual dysfunction. This precision contributes not only to better surgical outcomes but also to improved postoperative quality of life.
• Superior Dexterity in a Narrow Pelvis
The robotic system’s endo-wristed instruments replicate and even exceed the range of motion of the human hand, allowing for exceptional dexterity in tight anatomical spaces. This enables fine and controlled dissection around critical structures such as the ureter, hypogastric nerves, and pelvic plexus, while minimizing traction and tissue trauma. Such control is particularly beneficial in patients with challenging anatomy or comorbid conditions.
Post-Operative Course
The patient experienced a smooth and uneventful postoperative recovery, marked by early mobilization and excellent functional outcomes. Notably, there was no urinary dysfunction, underscoring the effectiveness of meticulous nerve preservation during surgery. The postoperative course remained free of anastomotic complications, and pain was well controlled throughout recovery. In view of the minimal intraoperative blood loss and her stable clinical progress, warfarin therapy was safely resumed at an early stage, thereby minimizing the risk of thromboembolic events associated with her mechanical mitral valve. She was subsequently discharged in stable condition, reflecting the success of the multidisciplinary perioperative care approach.
Final Histopathology Report
Moderately differentiated adenocarcinoma
Pathological Stage: pT3N0
Mesorectum: Intact
Proximal and distal margins: Free of tumor
Lymph nodes examined: 27
Nodes involved: 0/27 (all negative)
The specimen demonstrated an oncologically sound resection with adequate lymphadenectomy and clear circumferential and distal margins.
Conclusion
This case clearly demonstrates the advantages of robotic rectal surgery, especially in a high-risk cardiac patient with multiple comorbidities and the need for long-term anticoagulation.
The use of robotic technology provided enhanced 3D magnified visualization and superior precision, allowing meticulous dissection and effective nerve preservation. The procedure was performed with minimal blood loss, ensuring better intraoperative stability. Importantly, the surgery achieved oncologically sound outcomes, with clear margins and adequate lymph node clearance.
Another key benefit was the ability to safely resume anticoagulation early in the postoperative period, reducing the risk of cardiac complications. The patient experienced a smooth and uneventful recovery, highlighting the overall safety and effectiveness of the approach.
