The robotic platform has several advantages over traditional minimally invasive surgery (MIS). A drawback of the robotic platform, however, is the lack of haptic feedback which can contribute to inadvertent tissue and vascular injury. During conventional MIS surgery, major vessel injury is considered to be an absolute indication for conversion to open.
We present a case of a patient undergoing elective robotic low anterior resection (LAR) for a rectosigmoid adenocarcinoma. During dissection of the inferior mesenteric artery (IMA), a traction injury to the IMA occurred leading to avulsion of the IMA off of the aorta. This was unable to be controlled with the robotic vessel sealing device leading to pulsatile arterial bleeding at the takeoff of the IMA from the aorta.
The arterial hemorrhage was successfully controlled without conversion to an open procedure within seven minutes of the injury. During this time, the patient was never unstable, placed on vasopressors, or transfused. A LAR with trans-rectal specimen extraction and intracorporeal anastomosis was completed. Total estimated blood loss for the entire procedure was 400 milliliters. The postoperative course was uncomplicated. Pathology revealed a pT4aN1 cancer (1 of 23 lymph nodes positive) for which the patient received adjuvant chemotherapy.
In this case, a lack of haptic feed contributed to a traction/avulsion injury to the IMA at its origin. The robotic platform, however, allowed for precise, efficient suturing of the vascular injury without conversion to an open procedure despite the unfavorable location of the injury and the dramatic bleed that resulted.