Robotic Beyond Total Mesorectal Excision With Synchronous Perineal Flap Reconstruction: Feasibility and Early Outcomes

ABSTRACT Background Advanced rectal and anal malignancies often require dissections beyond total mesorectal planes for improved oncological outcomes. While minimally invasive techniques facilitate this approach, they result in larger perineal defects, creating reconstructive challenges. Robotic‐assisted surgery enhances precision, visualisation, and ergonomics, potentially optimising outcomes. However, data on robotics beyond total mesorectal excision (bTME) remain limited. This study evaluated robotic bTME and synchronous gracilis or PAP (profunda artery perforator) flap reconstruction. Methods This retrospective case series reviewed 10 patients with locally advanced or recurrent anorectal cancer who underwent elective robotic bTME with synchronous perineal gracilis or PAP flap reconstruction. Results Median operative time was 465 minutes. Gracilis flap harvest was concurrent. No major flap‐related complications or reoperations. R0 resection was achieved in 80%. At 1‐year, local recurrence was 0%, distant metastases 30%, and disease‐free survival 70%. Conclusion Robotics bTME with synchronous gracilis or PAP flap reconstruction is feasible, efficient, and oncologically safe.