Abstract
Background
Colorectal carcinoma with synchronous liver metastasis represents a complex oncological challenge. Advances in minimally invasive surgery have enabled simultaneous resection of primary colorectal tumors and metastatic liver lesions with acceptable morbidity and favorable oncological outcomes.
Case Presentation
We report a case of a 64-year-old male diagnosed with recto-sigmoid adenocarcinoma with solitary hepatic metastasis, managed successfully with robotic-assisted anterior resection and laparoscopic hepatic metastasectomy in a single operative setting.
Conclusion
Simultaneous minimally invasive resection of primary colorectal malignancy and liver metastasis is feasible, safe, and oncologically sound in selected patients, offering faster recovery and reduced hospital stay.
Keywords
Recto-sigmoid carcinoma · Liver metastasis · Robotic surgery · Anterior resection · Hepatic metastasectomy · Colorectal cancer
Introduction
Colorectal cancer is among the leading causes of cancer-related morbidity and mortality worldwide. Approximately 20–25% of patients present with synchronous liver metastases at diagnosis. Surgical resection remains the cornerstone of curative treatment.
With the advent of robotic platforms and advanced laparoscopic techniques, combined resection of colorectal primaries and liver metastases has become increasingly feasible, allowing improved visualization, precise dissection, and enhanced postoperative recovery.
This report describes the successful management of stage IV recto-sigmoid carcinoma with synchronous liver metastasis using a minimally invasive combined approach.
Case Presentation
Patient Profile
A 64-year-old male presented with complaints suggestive of colorectal malignancy and was referred for further evaluation.
Reason for Admission:
Carcinoma rectum with hepatic metastasis
Diagnosis:
Carcinoma Recto- sigmoid colon
Drug Allergy:
None
Clinical Examination
- Blood Pressure: 120/70 mmHg
- Pulse: 78/min
- SpO₂: 98% on room air
- CVS: S1 S2 +
- CNS: Conscious, oriented
- Respiratory System: AEBE
- Abdomen: Soft, non-tender
Preoperative Evaluation
Endoscopic Biopsy
- Transverse colon polyp: Inflammatory polyp
- Ascending colon polyp: Hyperplastic polyp with low-grade dysplasia
- Sigmoid lesion: Moderately differentiated adenocarcinoma
PET-CT Findings
- Hypermetabolic lesion in recto-sigmoid region (SUVmax 22.4)
- Solitary hepatic lesion in segment V (SUVmax 16.6)
- No distant nodal or visceral metastases
Impression
Malignant recto-sigmoid lesion with solitary liver metastasis.
Surgical Procedure
Procedure Performed
Robotic-Assisted Anterior Resection with Laparoscopic Hepatic Metastasectomy under GA + Epidural
(Date: 12/12/2025)
Operative Technique
After informed consent and anesthesia clearance, the patient was positioned in modified lithotomy with Trendelenburg tilt.
Pneumoperitoneum was established, and ports were placed under vision.
Hepatic Resection
- Liver mobilized
- Metastatic lesion identified
- Parenchymal transection performed using laparoscopic CUSA (cavitron ultrasonic surgical aspirator)
- Hemostasis ensured
- Peritoneal nodules excised
Colorectal Resection
- Inferior mesenteric vessels ligated
- Sigmoid and rectum mobilized
- Splenic flexure mobilization done for tension free anastomosis
- Distal rectal division with Endo – GIA- linear stapler
- Proximal colon divided with adequate margins
- Intracorporeal coloanal anastomosis using circular stapler
- Anastomosis assessed for perfusion and integrity
Peritoneal lavage was performed, and ports were closed in layers.
Intraoperative Findings
- Distal sigmoid/recto-sigmoid tumor
- No mesorectal/mesocolic lymph nodes
- Solitary liver metastasis
- No ascites
- No other visceral metastases
- No peritoneal nodules
Operative Details
- Blood Loss: Minimal
- Complications: None
- Drain: Nil
Histopathological Examination
Primary Tumor
- Site: Recto-sigmoid
- Histology: Adenocarcinoma
- Grade: Moderately differentiated (G2)
- Size: 3 × 1.5 cm
- Invasion: Muscularis propria (pT2)
- Lymphovascular invasion: Present
- Perineural invasion: Absent
Margins
- All margins: Negative
- Circumferential margin: 1.3 cm
- Distal margin: 5 cm
Lymph Nodes
- Examined: 8
- Positive: 0
Liver Lesion
- Metastatic adenocarcinoma (1.5 cm)
- Resection margins free
Final Pathological Stage (AJCC 8th Edition)
pT2N0M1a (Stage IV A)
Adjuvant Therapy
The patient received adjuvant chemotherapy with CAPEOX regimen:
- Oxaliplatin 260 mg IV
- Capecitabine 500 mg (2-0-2 for 14 days)
He tolerated chemotherapy well without major complications.
Follow-Up
- Regular follow-up with CBC, RFT, LFT, and imaging
- Patient asymptomatic at last review
- No evidence of recurrence
Discussion
Management of colorectal carcinoma with synchronous liver metastasis requires multidisciplinary planning.
Simultaneous resection offers advantages:
- Reduced overall hospital stay
- Avoidance of second surgery
- Faster initiation of chemotherapy
- Improved patient compliance
Robotic surgery enhances pelvic visualization and precision, particularly in low anterior resections. Laparoscopic hepatic metastasectomy is well established for small peripheral lesions.
Our case demonstrates that combined minimally invasive surgery is safe and effective in selected patients with limited metastatic disease.
Histopathological clearance, negative margins, and absence of nodal involvement predict favorable prognosis.
Conclusion
Simultaneous robotic-assisted anterior resection and laparoscopic hepatic metastasectomy is a feasible and oncologically sound approach in selected patients with stage IV colorectal cancer and solitary liver metastasis. This strategy offers optimal disease control with reduced morbidity and faster recovery.
