# Robot-Assisted Multiquadrant Operation: Proctocolectomy and Abdominoperineal Resection Using the Da Vinci Xi for Familial Adenomatous Polyposis With Rectal Carcinoma

## TL;DR

A 38-year-old man with familial adenomatous polyposis and rectal cancer underwent robot-assisted surgery using the da Vinci Xi system, resulting in successful recovery with no recurrence over 24 months.

## Contribution

Demonstrates the successful application of robot-assisted proctocolectomy and abdominoperineal resection in a complex FAP case with rectal carcinoma.

## Key findings

- Robot-assisted surgery was successfully used for proctocolectomy and abdominoperineal resection in a FAP patient with rectal cancer.
- The patient had uneventful recovery and no recurrence of disease over 24 months of follow-up.
- Multidisciplinary collaboration improved outcomes in the management of this complex case.

## Abstract

Familial adenomatous polyposis (FAP) is a rare inherited disorder that is characterized by the formation of multiple adenomatous polyps in the colon that are precancerous. Diagnosis of the disease is of utmost importance in patients with a history of FAP, and prophylactic fibrocolonoscopies should be performed as early as the teenage years. This rare but significant genetic condition usually manifests in late adolescence or early adult years. The clinical case highlights the importance of a multidisciplinary approach and the need for early diagnosis and treatment in patients with FAP. The da Vinci Xi robotic system (Intuitive Surgical, CA, USA) has been successfully applied in multiquadrant operations such as total colectomy with abdominoperineal extirpation of the rectum.

We present the case of a 38-year-old man admitted to our clinic, the First Clinic of Surgery in University Hospital Saint Marina, Varna, Bulgaria, in late 2022 with complaints of blood in stool and abnormal defecation rhythm. The fibrocolonoscopy found a tumor formation at 4 cm of the anorectal junction, a second tumor formation at 10 cm, and multiple colonic polyposis. Biopsies taken from the suspected areas confirmed the presence of two rectal carcinomas and adenomatous polyposis in the remaining areas. Neoadjuvant radiotherapy and chemotherapy with capecitabine 1600 mg were performed. Persistent carcinoma was an indication for performing robot-assisted proctocolectomy combined with abdominoperineal resection of the rectum. The robotic platform we used was the da Vinci Xi, a single-docking patient platform with three boom repositioning. The patient was followed for 24 months postoperatively. Recovery was uneventful, with no major complications. The terminal ileostomy functioned well, and the patient adapted successfully to stoma care. During follow-up, no local or systemic recurrence of the oncological disease was observed, and surveillance imaging remained clear throughout the period.

This clinical case provides an important example of the multidisciplinary approach in the diagnosis and treatment of FAP. Neoadjuvant therapy, including radiotherapy and chemotherapy followed by robot-assisted surgery, demonstrates the significant potential of modern treatment approaches. Robot-assisted proctocolectomy is a relatively new approach whose advantages and disadvantages are yet to be explored. Collaboration between gastroenterologists, oncologists, radiologists, and surgeons is essential for the comprehensive management of such complex cases. Finally, this clinical case highlights the need for long-term surveillance of patients with FAP for early detection and management of potential recurrences or new disease.