Introduction: Robotic-assisted pelvic exenteration can offer a minimally invasive approach to a major pelvic multi-organ operation. It also highlights the multidisciplinary approach in locally advanced rectal cancer management. Patient and Methods A 49-year-old female presented with abdominal pain with hematochezia. CT demonstrated rectal wall thickening and colonoscopy revealed a circumferential rectal mass extending from the anal verge to mid rectum. Although coexisting gynecological malignancy was suspected given the size of the mass and proximity to the uterus, cervical biopsy revealed moderately differentiated adenocarcinoma concerning for the rectal cancer. Additionally, MRI demonstrated extensive involvement of vagina and cervix with perirectal nodal involvement(cT4N2bM0). After neoadjuvant FOLFOX followed by chemoradiation, she achieved complete clinical response on MRI, flexible sigmoidoscopy, and vaginal exam. She was offered posterior exenteration at that time, but she elected close surveillance. She developed a luminal recurrence in a year, for which she was offered posterior pelvic exenteration and partial vaginectomy with vaginal reconstruction with bilateral transverse gracilis flap.

Results: The operation was performed under general anesthesia and in lithotomy. DaVinci Xi with four robotic arms and two assistant ports were utilized. The procedure took 11 hours 27 minutes with robotic portion being 5 hours. Postoperative course was unremarkable except urinary retention, and she was discharged on the postoperative day 8. Final pathology revealed 0.7cm moderately differentiated adenocarcinoma with no lymph node metastasis(pT2N0) and negative margins.

Conclusion: This video demonstrates that robotic-assisted posterior exenteration and partial vaginectomy with transverse gracilis flap for vaginal reconstruction is technically feasible under a multidisciplinary surgical team.