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A 65-year-old male with a previous history of atrial fibrillation (treated with acenocumarol) and T2DM was diagnosed with an mriT3aN1 tumor 10cm from the anal verge. The CT Scan ruled out any liver or lung metastasis. Long course neoadjuvant therapy was administered with good tolerance, and no toxicity was developed. The patient had a BMI of 26 Kg/m2 and an ASA score of II.
With the patient in the Lloyd Davies position A, a total of 4 ports were placed in the abdomen as well as a transanal access platform. The transabdominal team used a visualization system that combined HD and fluorescence imaging, while the transanal team used a 3D camera with a flexible tip.
Radical surgical treatment was performed (ten weeks after finishing the neoadjuvant treatment) by a simultaneous laparoscopic transabdominal and transanal approach. A low anterior resection with trans-anal total mesorectal excision was carried out. The specimen was extracted through a Pfannenstiel incision as there was a size mismatch between the specimen and the patient’s pelvis (bulky mesentery and narrow pelvis). Combined work (Cecil approach) is crucial to improve the quality of the dissection in difficult anatomical planes.
Intravenous ICG pulses were administered to assess colon vascularization and to establish the suitable place to section the proximal margin (VID 1). They were also used to evaluate vascularization after performing the colorectal anastomosis (VID 2). A loop ileostomy was built as the patient had received preoperative radiotherapy and the anastomosis was low in the pelvis.
Surgery took 130 minutes and was uneventful. The patient started oral intake on the first postoperative day and left hospital 4 days after the procedure with no complications.
Pathological examination revealed almost full response to the preoperative treatment. It was an R0 specimen with a complete mesorectum.
