The Coloanal Anastomosis

The goals of restorative surgery in low rectal cancer are three-fold, ensuring high-quality clinical outcomes by addressing and minimising the risk of anastomotic leak, ensuring optimal distal oncological clearance and proactively managing the long-term functional consequences of low anterior resection syndrome (LARS). I believe in practising the principles of evidence-based medicine and shared decision-making, discussing these key facets with my patients pre-operatively. This inevitably leads to personalised decision-making for my patients with rectal cancer, based on their values and priorities, whilst taking into account their tumour and clinical characteristics and the technical aspects of performing a coloanal anastomosis. This blog post highlights my approach to risk stratification, decision making and technical approaches to the coloanal anastomosis.

Risk Stratification

The first step is to provide patient-specific risk stratification for anastomotic leak. My preference is to use the Anastomotic Failure Observed Score (AFORS), which was validated through the TaTME registry in 1594 patients. This score calculates the risk of anastomotic leak based on five pre-operative risk factors; gender, body mass index, diabetes, smoking and tumour size. The score provides a cumulative score of 0-6 which corresponds to an AL rate of 6.3 – 50%. This provides me with a guide and I use this in conjunction with other established risk factors such as neoadjuvant treatment, cardiac comorbidity etc to inform the patient of their specific risk of anastomotic leak.

Figure taken from Ann Surg. 2019 Apr;269(4):700-711


The second key aspect of risk stratification is predicting the risk of longterm bowel dysfunction or LARS. I use the validated Polars score to provide patients with an insight into their risk of LARS. The Polars score uses key predictive factors to determine the risk of LARS including age, tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy. It is readily available on the Pelican website. Patient at high risk of LARS are enrolled into the BOREAL (Bowel Rehabilitation Programme) immediately post-operatively.

Distal Oncological Margin

With very low tumours, approximately 1-2cm from the anorectal junction, my preference is to employ a combined transanal and robotic approach. In these cases I prefer to start with a full thickness distal rectotomy transanally, this allows for a controlled distal oncological margin under vision. Following on from this, I dock my robot and perform my TME dissection aiming to join my two planes of dissection, following which I extract my specimen transanally and perform a coloanal anastomosis.

Coloanal Anastomotic Techniques

I think its important to have a range of coloanal anastomotic techniques in your armamentarium ranging from the traditional transabdominal double stapled anastomotic technique, to transanal single stapled anastomosis to hand sewn coloanal anastomosis and the delayed coloanal anastomosis. Again, I employ a very personalised approach to the anastomotic technique taking into account the risk of anastomotic leak, patient and tumour characteristics, distal oncological margin and functional consequences. From a technical perspective my choice of anastomotic technique is based on the distance of the lower border of the tumour from the anorectal junction and my ability to achieve a clear distal oncological margin. Check out my talk at the ROCS2022 symposium on coloanal anastomotic techniques to see my videos and understand my approach. You can also check out the recent ESCP Robotic Surgery webinar on ‘Anastomosis after rectal resection’ which showcases a range of anastomotic techniques.

Anastomotic techniques in low rectal have evolved significantly over the last few years. Understanding these techniques, their indications and implications is essential in delivering a high quality, cutting edge rectal cancer practice. Future technological advances coupled with an improved understanding of anastomotic leak and function will lead to improved clinical and functional outcomes for our patients with lower third rectal cancer.

Robotic Training For All Trainees…

As I come towards the end of my robotic fellowship in Bordeaux and prepare for my transition to consultant life I have found myself thinking about how I can take the skills and lessons I have learnt in robotic colorectal surgery and pass them onto those coming through surgical training behind me. I have seen first hand how an active robotic training programme can be inclusive of all trainees, irrespective of training grade, can help build and promote team ethos and can really invigorate trainees and the wider team. I have loved working alongside my French trainee team, all of whom have been my robotic bedside surgeons at some stage and who I have had the privilege to train in key component parts of robotic colorectal surgery. Replicating this back home in the UK will be challenging, but not impossible, given the growing interest in robotics amongst junior and senior trainees alike. However, I am aware that despite the enthusiasm and interest in robotic surgery the reality for many surgical trainees in the UK is that formal access and training opportunities are limited. The recently published Association of Surgeons in Training (ASiT) survey highlights that less than 12 per cent of trainees are exposed to robotic training, which is likely to reflect issues around access, volume and a lack of experienced trainers. However, as robotic surgery continues to grow and due attention is placed on developing structured and standardised training programmes, the number of trainees being exposed to robotics during surgical training will expand.

My fabulous French team au fait with the principles of robotic colorectal surgery

My personal feeling is that there is much to learn about robotic surgery, both inside and outside theatre, and that robotic training can be accessible to ALL surgical trainees, irrespective of training grade. I truly believe that maximising all available opportunities centred around robotic surgery will serve you well in the long run by improving your understanding of the principles of robotic surgery, opening doors to new networks and collaborations and ultimately providing you with the opportunity to gain technical skills. Here are just some of the ways ALL trainees can maximise their robotic training opportunities.

Surgical Societies

Over the last year or so, a number of trainee-led surgical societies have heavily featured robotics in their surgical conferences. The latest ASiT collaboration with Cambridge Medical Robotics (CMR) reflects this growing interest and is a step in the right direction in introducing robotic technology early into surgical training. I am reliably informed that this collaboration will be suitably targeted for novice robotic surgeons, which will be ideal for junior trainees. Similarly, a number of medical student surgical societies have featured robotic lectures across all surgical specialties as part of their annual meetings in recent times. Keep an eye out for these surgical society conferences as they are usually free, attract high quality robotic speakers and provide great soundbites for what robotic surgery has to offer across a multitude of surgical specialities.

Research Projects

Robotic surgery is ripe for research, with a number of emerging groups investigating various aspects of robotics, including training novice surgeons and curriculum development. There is plenty of opportunity to get involved in a variety of robotic projects, from collecting data to participating in simulation and training exercises. The Royal College of Surgeons RADAR (Robotic and Digital Surgery Initiative) Trainees committee, through its Technology Enhanced Surgical Training report, is due to start advertising research projects soon, which are ideally suited for medical students and junior doctors of all levels to get involved in. For those of you who are interested in pursuing a formal period of research, there are a steady trickle of MDs and PhDs being advertised in robotic surgery. The #advancecolorectal team is hoping to release a number of exciting robotic research projects over the next few months so keep your eyes peeled!

Online Resources

There are a multitude of online resources available for budding robotic surgeons, which range from online training resources provided by key industry providers to high quality educational videos on YouTube. The virtual ASiT x CMR Introduction to Surgical Robotics webinar provided the ideal spring board for medical students and junior doctors, and I’m sure there will be much more to come from this collaboration.


Robotic simulation is so important as it helps you get comfortable with the basic principles of robotics, allows you to handle the surgeon cart and builds muscle memory. This is the first key step in your robotic training pathway and its never too early to start! There are lots of exciting developments in simulation and robotic training outside of the theatre complex which are worth looking into including virtual, hands-on and cadaveric courses.

Robotic Trainers

There are some incredible, high volume, enthusiastic robotic surgeons dotted around the country. Seek them out and ask them how you can get involved in robotics or if they are in your region ask whether they would be happy to train you. I certainly did this during my surgical training as a ST7 at Sunderland and for my fellowship in Bordeaux. Just because a robotic surgeon hasn’t previously been a trainer doesn’t mean they can’t be one in the future! And, for those of you training in the North West of England I will be looking to train my surgical trainees using the principles of component based operating.

Operating Theatre

I would advise you to make the most of all the robotic surgical opportunities that come your way in theatre. Make the most of being in a robotic theatre by understanding the set-up, team dynamic, interplay between bedside and console surgeon. Take the opportunity to be a robotic bedside assistant and use this as an active learning opportunity by observing and understanding how the patient cart and surgeon console work and interact, building on your communication skills and develop specific problem-solving strategies for robotic surgery.

Be realistic

Ultimately, you have to be realistic with regards to your expectations of robotic training within the current climate. I found robotic training to be a real rollercoaster with highs and lows, including lulls in training periods due to a lack of an experienced trainer, however, despite this I was able to forge my own path and I truly believe so can you by having realistic expectations, a little bit of patience and maximising all those additional opportunities. Is robotics for ALL trainees? I think so I just think you have to change your mindset and approach to training in this arena.

Check out my previous blog posts highlighting how you can kickstart your robotic colorectal training and finesse your skills within dedicated, high volume robotic fellowships.

Spotlight on ROCS2021

The second Robotic Colorectal Surgery Symposium (ROCS2021) was hosted earlier this week as a hybrid event live from Ghent, Belgium. It was strange to be attending a conference after such a long time, however, the hybrid nature of the meeting allowed me the opportunity to meet with colleagues, both old and new, exchange ideas and network. The virtual component enabled the organising committee the opportunity to invite international robotic experts to ensure the most up to date and highest quality content was delivered from across the globe to our 600 registered delegates. Here is a round up of our exciting programme and some of my personal highlights!

From Right to Left: Deena Harji, Ellen Van Eetvelde, Anke Smits, Pieter Pletinckx

Our first session on ‘How to start a robotic colorectal program’ echoed three key themes across all our presentations; 1) stepwise progression, 2) standardisation of key steps and 3) team work. My key take home message from this session was that central to a successful robotic colorectal program is the team behind it; team training, empowerment and growth is essential for any robotic program to succeed. Other exciting developments highlighted in this session included using the principles of component-based robotic training to efficiently achieve competence and the presentation of the upcoming ESCP Colorobotica program for novice surgeons.

Robotic surgery has really enhanced peer-to-peer learning, and our second session on ‘Left sided and rectal resection’ provided some invaluable tips and tricks on splenic flexure mobilisation from Dr Anne Dubois and on approaching the difficult male pelvis from Dr Niels Thomassen. The recurring themes from our first session were reinforced, including, employing a standardised approach and breaking steps down into their key component parts to achieve technical perfection. However, its also important to have a Plan B if this doesn’t work and to appropriately evaluate your operative strategy and improvise where necessary.

Both Professor Quentin Denost and Dr John Marks highlighted the evolving nature of robotics for rectal cancer surgery, with Professor Denost highlighting the benefits of combining robotic and transanal approaches for low rectal cancer and Dr John Marks showcasing the merits of the single port robotic operating system both within the pelvis and transanally. These exciting developments will continue to push the boundaries in complex rectal cancer, allowing a greater proportion of patients a minimally invasive platform, coupled with sphincter-preserving approaches.

Our colonic session focused on the growing popularity and use of robotics for right hemicolectomy. The stable robotic platform, enhanced dexterity and ergonomics facilitates intracorporeal anastomosis in this setting, as was beautifully demonstrated by Dr Anke Smits, and is associated with quicker recovery, less pain and reduced post-operative ileus. The ensuing debate on the robotic approaches to CME by Mr Danilo Miskovic (Medial to Lateral) and Dr Paolo Bianchi (Suprapubic bottom-up) demonstrated that there is growing interest in CME as a technique overall and that the robotic approaches are irrelevant, what is most important is that a safe and oncological resection is carried out.

The final and concluding session of ROCS2021 shone the spotlight on the growing arena of ‘benign robotic colorectal surgery‘. This is an area that will continue to evolve as our adoption of robotic colorectal surgery becomes more widespread and is ripe for technical advancements, as demonstrated by Dr Eric Haas’ talk on the NICE procedure. However, the approaches to benign surgery have to be carefully considered as highlighted by Dr Marcos Gomez-Ruiz, whose talk on robotics in IBD surgery demonstrated the balance between robotic surgery and the potential morbidity in this cohort of patients. For me, this session was the most thought-provoking and technically stimulating, highlighting the benefits of robotics in the benign setting, whilst adding caution regarding patient selection, learning curve and clinical outcomes. The consensus from our experts was that benign robotic surgery is something to consider once you’re over your initial robotic learning; it may seem easy, but these can be some of the most challenging cases you may encounter.

I was fortunate enough to attend the inaugural ROCS2020 meeting in February 2020 as a delegate and am incredibly honoured to have transitioned to becoming a course director for ROCS2021 alongside the brilliant Ellen Van Eetvelde and Pieter Pletinckx. I am hugely grateful to Filip Muysoms for the invitation to join the ROCS team and to Intuitive Surgery for all their support in helping us deliver this conference. Please do catch up with all the FREE sessions on demand. I promise you there is something there for everyone! We are just at the start of a very exciting journey in delivering high-quality educational content on robotic colorectal surgery and we hope to come back next year even bigger and better, hopefully, with a live audience.

Robotic Colorectal Fellowships

There has been a huge surge in the popularity of robotic colorectal surgery fellowships in recent times. Robotic colorectal fellowships come in all shapes, sizes and locations. They provide an excellent opportunity to consolidate your minimally invasive skills, develop new robotic skills and gain insights into leading and developing your own robotic practice. However, the delivery of robotic fellowship training is not straightforward and you need to consider a number of key criteria before embarking on a robotic colorectal fellowship.

Are you ‘fellowship ready’?

The first thing to consider before embarking on an application for a robotic colorectal fellowship is whether you are ‘fellowship ready’? Have you got all the basic robotic skills to hit the ground running on day 1 of your fellowship? Being ‘fellowship ready’ means you have completed all pre-requisite online and simulator training modules, you can dock and undock the robot and are an effective bedside assistant. Demonstrating these skills will make you competitive at time of interview, but will also ensure that you can hit the ground running as a console surgeon. If you do not have access to a robotic platform during your training, you must factor this into your fellowship, and dedicate the early part of your fellowship on completing your simulation assessments and acquiring key robotic bedside skills.

Expert Centre and Trainer

The second key consideration is your centre and trainer. I would highly recommend selecting a robotic centre and trainer with expert recognition in robotics. Robotic colorectal surgery is a team sport; working for an expert robotic trainer, with a dedicated robotic team, including trained robotic assistants, in a centre with an established track recording of robotic training will accelerate your robotic learning curve. There are many important non-technical skills you will pick up in such an environment which will be important when you achieve independence and lead your own robotic programme. Of course, completing an robotic fellowship with an internationally renowned robotic expert as a trainer at a prestigious unit comes with many additional benefits including the opportunity to participate in high-quality and cutting edge research and innovation, networking within the robotic community and lifelong mentoring following completion.

The true measure of a successful trainer is the ability to pass their expertise onto their trainees and fellows. Speak to previous fellows to find out about their experiences, including, whether they went onto become independent robotic surgeons and were able to develop their own robotic program. It’s also important to speak to trainees in the unit, irrespective of their robotic experience, about their views and experiences of training; this is invaluable in identifying the training ethos of the unit and whether the environment is truly set up to deliver high quality surgical training.

Robotic Access

It’s important to understand the makeup of the proposed robotic fellowship you are applying for. Are you going into a dedicated robotic fellowship or is this a ‘hybrid’ minimally invasive fellowship consisting of laparoscopic and robotic surgery? The rate limiting factor to skills acquisition in robotic colorectal surgery is access to the robotic platform. Understanding how robotic surgery is delivered in your proposed centre is essential. Asking key questions such as the presence of a dedicated colorectal robot, the number of robotic colorectal trainers within the unit, the weekly colorectal robotic access and the number of dedicated robotic lists, how many robotic cases are done per list, the presence of a dual console and out of hours access to the robotic simulator will give you an insight into your anticipated access to the platform. I have experience of both shared access and dedicated colorectal robotic access, and have been successfully trained in both scenarios. The key to my success in robotic training has always been regular access with expert trainers and a dedicated robotic team who have invested in me and my training.

Case Volume

As in many walks of surgery, the volume-outcome relationship is highly relevant to robotic training, the more robotic cases you do, the more rapidly you will gain confidence in your robotic skills. The ‘golden bracket’ for the learning curve in robotic colorectal surgery is considered to be between 20-40 cases, however, from my own personal experience, this is just when you start to become comfortable with the robotic platform, becoming an expert is a much longer process. It’s, therefore, essential that you factor in case volume when selecting your robotic colorectal fellowship. My advice is to look at published datasets on robotic procedures and overall procedures to gain insight into the robotic volume at each centre. In the UK, the National Bowel Cancer Audit and NHS England Individual Surgeon Outcome Dataset will give you some insight into how many colorectal cancers the individual trainer and the individual hospital operate on per year. Similar datasets exist in Europe, for example, Le Point in France publishes the annual operative volume for all cancers. My fellowship centre, CHU de Bordeaux – Hôpital Haut-Lévêque, is reported to be the highest volume unit for colorectal cancer in France, having performed 216 rectal cancer resections and 164 colonic cancer resections in 2020. The Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and the Royal College of Surgeons of England take this one step further by advertising all training centres and the volume of training operations.

Specialist skills

The acquisition of specialist robotic colorectal skills during a fellowship, such as pelvic sidewall dissection, robotic pelvic exenteration, CME, ventral mesh rectopexy or robotic pouch surgery will add to your overall repertoire and enable you to offer additional expert skills during your own consultant practice. Increasing the complexity of robotic procedures you are trained on will develop your confidence and will help refine your operative skills. Acquiring additional skills beyond robotic colorectal resections is important, especially, as robotic colorectal surgery becomes more ‘mainstream’ and is offered by a greater proportion of surgeons and hospitals. My advice to you is to find a robotic centre and trainer that aligns with your subspecialist area with a robotic practice in this arena and go and work with them. I certainly combined my subspecialist interest of advanced pelvic maligancy and pelvic exenteration with my robotic interest and my experience has been the richer for it. Training in robotic pelvic exenteration has challenged my robotic skills, operative decision-making and understanding of complex multidisciplinary working.

Leaving your robotic colorectal fellowship as an accredited and independent robotic surgeon should be the goal. Leaving with the skills and ability to train others, including consultant colleagues, trainees and theatre staff is an additional bonus. This is a key skill, especially, if you are going to start and lead your own robotic program as a Consultant Surgeon. Garnering the skills to be able to develop your own robotic team during your fellowship will prove to be invaluable. Take the time to observe how your robotic trainer interacts with the rest of the robotic team, organises the robotic schedule and manages the team overall.

The verdict

Going on a dedicated robotic colorectal fellowship will no doubt accelerate your robotic training, however, choosing the right one is the key to ensuring appropriate and timely accrual of robotic skills under the guidance of an experienced robotic trainer. Personally, my ESCP/Intuitive Robotic Colorectal Fellowship in Bordeaux under the auspices of Professor Quentin Denost has been one of the most invaluable experiences of my life. I may be biased but my fellowship consists of all the component parts of what makes a robotic colorectal fellowship great with an expert trainer and centre, brilliant team, dedicated colorectal robotic access, high volume operating and the development of specialist skills. Alongside this, I get to live in one of the most beautiful parts of the world! But, don’t just take my word for it, here is my good friend Lena Ngu outlining the benefits of an ESCP/Intuitive fellowship in Barcelona and my brilliant trainer, Quentin Denost, outlining just how to deliver a high quality fellowship.

Robotic Colorectal Surgery Training

I started my robotic training in 2018 as a surgical trainee (ST7) at Sunderland Royal Hospital in the North East of England. Over the last few years I’ve learnt a huge amount as I’ve carved out my path in the field of robotic surgery. Here are my top ten tips for all surgical trainees wanting to pursue a career in robotics.

🤖 1. Good basic laparoscopic skills

Having good basic minimally invasive skills will serve you well when you come to transition your training from laparoscopic to robotic surgery. Good laparoscopic skills including psychomotor skills, spatial awareness and good tissue handling are easily applicable to the robotic setting. It is also widely accepted that laparoscopic proficiency can help flatten the robotic learning curve.

🤖 2. Robotic Mentors

A dedicated robotic mentor is an invaluable resource. Pick a mentor who is an established and accredited robotic surgeon, with a track record in training. Established robotic mentors can share a wealth of expertise with you beyond operative training, including, setting up and navigating a service, brokering relationships with industry and introductions to other robotic experts. The best mentors are generous with their knowledge, expertise and wisdom.

🤖 3. Industry Partners

At present robotic surgery training is largely driven by industry, although, this is beginning to change. Find out who your local robotic industry representative is and talk to them about the potential training opportunities available. There are many available online learning tools available through industry platforms to get you started and help you understand the essential fundamentals of robotic surgery.

Golam Farook and Deena Harji

🤖 4. Training Resources

There are a multitude of training resources available for robotic surgery outside of the theatre setting. The amazing Belgian robotic surgeon, Dr Ellen Van Eetvelde, once said, ‘you have to learn to operate with your eyes’ and I couldn’t agree more! There are a number of available platforms with high quality robotic training videos, these are well worth a look at. I would highly recommend the detailed, step-by-step procedural videos produced by Dr Mark Solimon.

There has also been a huge expansion in the availability of cadaveric and robotic simulation courses for surgical trainees over the last 12 months. I would recommend that you attend such a course when you are working in a robotic unit with appropriate surgical access as this will provide you with maximal benefit.

The European Society of Coloproctology launched their robotic colorectal surgery webinars earlier this year providing tips and tricks on a range of robotic scenarios from port placement to complete mesocolic excision. These are well worth a look.

🤖 5. Simulation

Robotic simulation is the first key step of your robotic training journey, providing you with an immersive introduction to the robotic platform. Do not underestimate the time it takes to complete all of the simulation exercises to the appropriate level. Complete these exercises in short, dedicated time blocks consisting of 60-90 minutes, after this fatigue sets in and affects your performance.

🤖 6. Robotic Test Drive

Understanding the fundamental principles of how the different components of the robotic platform work is essential. Book a robotic test drive with your industry representative or robotic trainer and go through the key features of how the platform works, including set-up and safety features.

🤖 7. Robotic Bedside Assistance

Robotic bedside assistance includes set-up, robotic docking, operative assistance, instrument exchange and adjustment of robotic arms as well as performing emergency undocking manoeuvres if required. Being an effective robotic bedside assistant provides you with key insights into the synergistic relationship between the surgeon console and the patient cart. Robotic bedside assistance will also help you develop key communication skills required between robotic assistant and console surgeon. These skills become invaluable as you progress from robotic bedside assistance to console surgeon and begin to direct your own assistant.

🤖 8. Component Learning

Break down each robotic operation into its component part following discussion with your trainer and aim to perfect each individual step. For example, low anterior resection is broken down into four key steps ; 1) lateral mobilisation, 2) IMA division, 3) TME and 4) splenic flexure mobilisation. Progress through each of these steps starting with the easiest and working towards the most complicated. Employing this approach will gradually build your confidence with the robotic platform and will help develop your operative skills.

🤖 9. Track your progress

Keep a record of all your robotic procedures including bedside assistant cases, robotic docking and operative procedures. Record all your operations and watch these back with your robotic trainer to identify keys areas for improvement. There are available platforms such as C-SATS on which you can upload your robotic videos for independent objective assessment from international robotic experts.

🤖 10. Robotic Fellowship and Opportunities

Robotic colorectal surgery is expanding in the UK and internationally, as a result, there are a number of well established, high volume dedicated robotic fellowships available. These are highly recommended to accelerate your robotic training as they provide trainer expertise, regular robotic access and volume. Keep a look out on relevant websites including the ASGBI, ESCP and ALSGBI. I can personally recommend the ESCP Robotic Fellowship at Hôpital Haut-Lévêque Groupe Hospitalier CHU Bordeaux under Professor Quentin Denost.

As robotic surgery and training continues to evolve so will the opportunities to get involved in robotic research, training and curriculum development. Make the most of these opportunities and get involved in initiatives such as the Royal College of Surgeons Robotic and Digital Surgery (RADAR) Initiative and its partnership initiative with the Association of Surgical Trainees Technology Enhanced Surgical Training.

Attendance at dedicated robotic conferences will keep you abreast of the latest developments in robotic surgery and will allow you to network with international robotic experts. The upcoming virtual Robotic Colorectal Surgery Symposium 2021 (ROCS2021) provides you with an ideal opportunity to do this. There are also a number of industry delivered symposia throughout the year, which are worth checking out.