Robotic‐assisted excision of a mesorectal sclerosing epithelioid fibrosarcoma in an obese patient: A video vignette

Mesorectal sclerosing epithelioid fibrosarcoma is an especially rare, low-grade subtype of fibrosarcoma characterized by few or no mitotic figures and minimal necrosis. Only a few individual case reports are reported in literature. Although it generally demonstrates slow progression, it may occasionally exhibit aggressive behaviour [1]. Due to its rarity, mesorectal epithelioid fibrosarcoma is often misdiagnosed, making imaging and histopathological correlation essential for accurate diagnosis. Surgical resection remains one of the primary treatment options and often requires careful preoperative planning to achieve clear margins while preserving pelvic function [2]. Because of its extreme rarity, no standardized treatment approach currently exists. In this video (S1), we demonstrate the robotic excision of a mesorectal sclerosing epithelioid fibrosarcoma. This case illustrates the advantages of robotic-assisted surgery in the deep pelvis, providing enhanced visualization and improved precision when navigating complex mesorectal anatomy. A 68-year-old obese man (BMI 42) underwent abdominal CT and MRI during routine follow-up, 2 years after resection of a clear cell renal carcinoma. Imaging revealed a solid, hypervascular lesion measuring 31.5 × 21.5 mm in the right mesorectum, with no radiologic evidence of rectal wall invasion. A CT-guided transgluteal biopsy using an 18G needle yielded a definitive diagnosis. Pneumoperitoneum was established at 12 mmHg using a Veress needle at Palmer's point. An 8-mm optical trocar was inserted via direct entry, followed by placement of additional three trocars under direct vision along the umbilical line. A 12-mm accessory port was positioned in the right flank. Abdominal exploration showed no macroscopic evidence of secondary lesions or free intraperitoneal fluid. The presence of significant visceral adiposity hindered small-bowel mobilization, despite Trendelenburg positioning with right-side tilt. To improve pelvic exposure, the mesosigmoid and terminal ileum were suspended to the abdominal wall using 2-0 PDS sutures. Posterolateral dissection of the rectum was performed along the holy plane (Figure 1), allowing optimal visualization of the lesion within the right mesorectum. The lesion was excised en bloc with meticulous haemostasis. The specimen was retrieved using an EndoBag through the accessory port, and all trocars were removed under direct vision. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Histopathological analysis confirmed a low-grade sclerosing epithelioid fibrosarcoma. Arcangelo Picciariello, Agnese Dezi and Leonardo Vincenti: Conceptualization; methodology; investigation; supervision; writing – original draft; writing – review and editing. No funding received. The authors declare no conflicts of interest. All procedures involving human participants were performed in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article does not contain any studies using animals. Informed consent was obtained from the participant included in the study. No new data sets were generated or analysed during the current study. All relevant data are included in the article and its supplementary materials. Data S1: Supporting Information. Video S1. This video shows a robotic-assisted excision of a mesorectal sclerosing fibrosarcoma using a multiport Da Vinci Xi platform in an obese patient. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.