01 Sphincter preservation in a tumour 4 cm from the anal verge
Robotic ISR · Organ preservation- Presentation
- 41-year-old male, three months of tenesmus and bleeding, previously treated as haemorrhoids. DRE revealed a mobile posterior lesion at 4 cm. Biopsy: moderately differentiated adenocarcinoma. MRI: cT3b N1, mesorectal fascia not threatened, no EMVI.
- Diagnostic challenge
- Distance from the sphincter complex made abdominoperineal excision the default recommendation elsewhere. The patient's priority was avoiding a permanent stoma; the oncological priority was a clear circumferential resection margin in a narrow male pelvis.
- Surgical intervention
- Neoadjuvant chemoradiotherapy with restaging, followed by robotic total mesorectal excision with intersphincteric resection and hand-sewn coloanal anastomosis, protected by a temporary diverting ileostomy. The wristed instrumentation allowed dissection along the correct embryological plane deep in the pelvis with intact autonomic nerve preservation.
- Oncological outcome
- R0 resection, complete mesorectal grade, 16 nodes harvested, ypT2 N0. Ileostomy reversed at ten weeks. Continence acceptable at six months with a low-residue routine. Disease-free at last follow-up.
Distance from the verge alone should not decide the stoma conversation. Response to neoadjuvant therapy and the plane achievable robotically often move the goalposts.
02 Obstructing left-sided tumour in a patient unfit for emergency resection
Bridge to surgery · Staged approach- Presentation
- 68-year-old female presenting acutely with a two-day history of absolute constipation and distension. CT: obstructing sigmoid lesion with proximal dilatation, no perforation. Significant cardiac comorbidity and an unoptimised nutritional state.
- Diagnostic challenge
- Emergency resection in an unprepared, dilated colon in a physiologically fragile patient carries high anastomotic and mortality risk, and frequently ends in a permanent stoma.
- Surgical intervention
- Endoscopic self-expanding metal stent placement as a bridge, decompression and nutritional optimisation over three weeks, then elective robotic sigmoid colectomy with primary anastomosis and complete mesocolic excision.
- Oncological outcome
- Elective single-stage resection with no stoma, R0 margins, adequate nodal yield, discharge on day five. Adjuvant therapy commenced on schedule rather than after a delayed recovery.
In the obstructed but non-perforated left colon, buying three weeks converts an emergency Hartmann's into an elective, stoma-free operation.
03 Early-onset right colon cancer that redirected an entire family
Early-onset · Lynch syndrome- Presentation
- 34-year-old male, six months of fatigue and intermittent right iliac fossa discomfort, treated with oral iron for anaemia twice before referral. Colonoscopy: ulceroproliferative caecal lesion.
- Diagnostic challenge
- Anaemia had been treated without a source being sought. Family history revealed a mother with endometrial cancer at 46 and a maternal uncle with colon cancer at 50 — a pattern nobody had recorded.
- Surgical intervention
- Robotic right hemicolectomy with complete mesocolic excision and central vascular ligation, plus tumour mismatch repair immunohistochemistry and germline testing after counselling.
- Oncological outcome
- pT3 N1a, R0, 28 nodes. MLH1/PMS2 loss with a confirmed germline pathogenic variant. Four relatives entered surveillance colonoscopy; one had a high-risk adenoma removed within the first year.
Iron-deficiency anaemia is a symptom with an address. Finding it here did not just treat one patient — it changed the surveillance status of a family.
