Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer

Patient quality of life and short-term surgical outcomes between robotic and laparoscopic anterior resection for adenocarcinoma of the rectum

PURPOSE

To compare patient quality of life (QoL) and short-term surgical outcomes between robotic anterior resection (r-AR) and laparoscopic (l-AR) approach.

METHODS

Consecutive patients having undergone either robotic or laparoscopic AR for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by post-operative histology and short-term complications. QoL was prospectively assessed using the EORTC QLC-CR30 and QLC-CR29 questionnaires.

RESULTS

In total, 36 patients (18 r-AR) with a median follow-up of 12 months following surgery (9-month robotic and 20-month laparoscopic) were studied. The two groups were similarly matched for age and gender. Laparoscopic patients had a lower ASA grade (p = 0.02). There was no significant difference in surgical outcomes between groups. r-AR patients reported lower pain scales (2 ± 6 vs. 11 ± 13) (p = 0.04), lower levels of insomnia 0 vs. 8 ± 15 (p = 0.04) and a lower abdominal pain scale (2 ± 9 vs. 17 ± 27) (p = 0.04). Male impotence scores were higher in l-AR 33 ± 35 compared to r-AR 7 ± 21 (p = 0.03).

CONCLUSION

Despite its recent introduction to our centre, the quality of oncological resection using the robotic surgery is comparable to laparoscopy. Lower impotence and QoL scores in patients after robotic procedure may be explained on the basis of better visualisation and precise tissue handling.

Robotic Rectal Resection With a Single-docking Technique Thanks to the Rotation of the R3 Arm

BACKGROUND

Robotic surgery for rectal resection presents some advantages compared with the traditional technique; however, it also presents some limitations, especially due to the multiple changes of surgical fields. We describe a new technique to perform low-anterior resection using single docking with the rotation of the third arm and our perioperative results.

MATERIALS AND METHODS

A total of 31 patients who underwent low-anterior rectal robotic resection with single-docking technique using robotic daVinci SI (Surgical Intuitive System) were included in the study.

RESULTS

The mean operative time was 338 minutes. The conversion rate was 3%. The mean time of refeeding was 1.4 days and the mean time of hospital stay was 6 days.

CONCLUSIONS

Our technique allowed to use the robot for all surgical steps with a single docking, thereby reducing the cost of the hybrid technique and facilitating the operative team in the management of the robotic cart.

Robotic Resection is a Good Prognostic Factor in Rectal Cancer Compared with Laparoscopic Resection: Long-term Survival Analysis Using Propensity Score Matching

BACKGROUND

Robotic total mesorectal excision for rectal cancer has rapidly increased and has shown short-term outcomes comparable to conventional laparoscopic total mesorectal excision. However, data for long-term oncologic outcomes are limited.

OBJECTIVE

The aim of this study is to evaluate long-term oncologic outcomes of robotic total mesorectal excision compared with laparoscopic total mesorectal excision.

DESIGN

This was a retrospective study.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

A total of 732 patients who underwent totally robotic (n = 272) and laparoscopic (n = 460) total mesorectal excision for rectal cancer were included in this study.

MAIN OUTCOME MEASURES

We compared clinicopathologic outcomes of patients. In addition, short- and long-term outcomes and prognostic factors for survival were evaluated in the matched robotic and laparoscopic total mesorectal excision groups (224 matched pairs by propensity score).

RESULTS

Before case matching, patients in the robotic group were younger, more likely to have undergone preoperative chemoradiation, and had a lower tumor location than those in the laparoscopic group. After case matching most clinicopathologic outcomes were similar between the groups, but operative time was longer and postoperative ileus was more frequent in the robotic group. In the matched patients excluding stage IV, the overall survival, cancer-specific survival, and disease-free survival were better in the robotic group, but did not reach statistical significance. The 5-year survival rates for robotic and laparoscopic total mesorectal excision were 90.5% and 78.0% for overall survival, 90.5% and 79.5% for cancer-specific survival, and 72.6% and 68.0% for disease-free survival. In multivariate analysis, robotic surgery was a significant prognostic factor for overall survival and cancer-specific survival (p = 0.0040, HR = 0.333; p = 0.0161, HR = 0.367).

LIMITATIONS

This study has the potential for selection bias and limited generalizability.

CONCLUSIONS

Robotic total mesorectal excision for rectal cancer showed long-term survival comparable to laparoscopic total mesorectal excision in this study. Robotic surgery was a good prognostic factor for overall survival and cancer-specific survival, suggesting potential oncologic benefits.

Robotics in Colorectal Surgery

Over the past few decades, robotic surgery has developed from a futuristic dream to a real, widely used technology. Today, robotic platforms are used for a range of procedures and have added a new facet to the development and implementation of minimally invasive surgeries. The potential advantages are enormous, but the current progress is impeded by high costs and limited technology. However, recent advances in haptic feedback systems and single-port surgical techniques demonstrate a clear role for robotics and are likely to improve surgical outcomes. Although robotic surgeries have become the gold standard for a number of procedures, the research in colorectal surgery is not definitive and more work needs to be done to prove its safety and efficacy to both surgeons and patients.

Efficacy of the Da Vinci surgical system in colorectal surgery comparing with traditional laparoscopic surgery or open surgery

In order to compare the curative effect of the Da Vinci surgical system (DVSS) with laparoscopic surgery (LS) or open surgery for colorectal resection, literature search was conducted in PubMed, Excerpt Medica Database (Embase), and Cochrane library up to January 15, 2016. Odds ratio (OR) and weighted mean difference with their corresponding 95% confidence intervals were used as effect size for evaluation of different outcomes. In total, 10 studies consisting of 2767 patients were included for the meta-analysis. As a result, there were no significant differences between DVSS and LS/open surgery in the long-term oncologic outcomes ( p > 0.05). However, DVSS achieved a significantly lower length of hospital stay and estimated blood loss (EBL), but a longer operation time. Moreover, DVSS showed a significantly reduced conversion to open surgery than LS (OR = 0.19, 95% confidence interval: 0.08–0.48). Subgroup analysis indicated that DVSS had different results in rectal adenocarcinoma and colon cancer subgroups on outcomes of conversion to open surgery and operation time. DVSS is superior to LS/open surgery in length of hospital stay and EBL, but needs longer operation time. Long-term outcomes of DVSS are comparable with the other approaches. From long-term perspective, DVSS has an equivalent effect to the other two techniques.

Robot-assisted versus laparoscopic-assisted surgery for colorectal cancer: a meta-analysis

BACKGROUND AND OBJECTIVES

Robotic surgery is positioned at the cutting edge of minimally invasive management of colorectal cancer. We performed a meta-analysis of data from randomized controlled trials (RCTs) and non-RCTs (NRCTs) that compared the clinicopathological outcomes of robotic-assisted colorectal surgery (RACS) with those of laparoscopic-assisted colorectal surgery (LACS). Inferences on the feasibility and the relative safety and efficacy have been drawn.

METHODS

A literature search for relevant studies was performed on MEDLINE, Ovid, Embase, Cochrane Library, and Web of Science databases. Inter-group differences in the standardized mean differences and relative risk were assessed. Operation times, conversion rates to open surgery, estimated blood loss (EBL), early postoperative morbidity, and length of hospital stay (LHS) were compared. Oncologic outcomes assessed were number of lymph nodes harvested and lengths of proximal and distal resection margins.

RESULTS

Twenty-four studies (2 RCTs and 22 NRCTs [5 prospective plus 17 retrospective]) with a total of 3318 patients were included. Of these, 1466 (44.18 %) patients underwent RACS and 1852 (55.82 %) underwent LACS. Conversion rates, EBL and LHS were significantly lower, while the operation times and total costs were similar between RACS and LACS. Complication rates and oncological accuracy of resection showed no significant difference.

CONCLUSION

Based on this meta-analysis, RACS appears to be a promising surgical approach with its safety and efficacy comparable to that of LACS in patients undergoing colorectal surgery. Further studies are required to evaluate the long-term cost-efficiency as well as the functional and oncologic outcomes of RACS.

Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

Current Status of Minimally Invasive Surgery for Rectal Cancer

Recent randomized controlled data have shown possible limitations to laparoscopic treatment of rectal cancer. The retrospective data, used as the basis for designing the trials, and which showed no problems with the technique, are discussed. The design of the randomized trials is discussed relative to the future meta-analysis of the recent data. The implications of the current findings on practice are discussed as surgeons try to adjust their practice to the new findings. The possible next steps for clinical and research innovations are put into perspective as new technology is considered to compensate for newly identified limitations in the laparoscopic treatment of rectal cancer.

Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.

METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.

RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups.

CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Robot-assisted approach to a retrorectal lesion in an obese female

BACKGROUND

Often detected incidentally, retrorectal tumors frequently require resection secondary to possibility of malignancy, development of infection, and localized growth with compression. The surgical approach is summarized to abdominal, posterior or a combination, depending on the location of the retrorectal mass and its relationship to the pelvic sidewall. Laparoscopic transabdominal resection of retrorectal tumors has shown safety and efficacy. Robot technology offers a stable platform with superb optics, and endo-wristed instruments that can facilitate dissection in the narrow pelvis. We present the emerging new technique of robot-assisted minimally invasive approach to a retrorectal mass in an obese female.

METHODS

An obese 35-year-old female, body mass index (BMI) 41 kg/m², with an incidental 2 cm cystic retrorectal lesion involving the pelvic sidewall was taken to the operating room for a robot-assisted minimally invasive resection of the mass.

RESULTS

Total operative time was 2 hours and 30 minutes, and total robotic dissection at 70 minutes. The patient was discharged on postoperative day 2. Final pathology revealed a benign Mullerian type cyst, 2.2 cm in greatest dimension.

CONCLUSIONS

Robot-assisted minimally invasive resection of a retrorectal mass is safe and feasible. This method can be particularly useful in the narrow pelvis and with obese patients.

Robot-assisted versus standard laparoscopic colorectal surgery

BACKGROUND AND OBJECTIVES

Over the years, there has been a continual shift toward more minimally invasive surgical techniques, such as the use of laparoscopy in colorectal surgery. Recently, there has been increasing adoption of robotic technology. Our study aims to compare and contrast robot-assisted and laparoscopic approaches to colorectal operations.

METHODS

Forty patients undergoing laparoscopic or robotic colorectal surgery performed by 2 surgeons at an academic center, regardless of indication, were included in this retrospective review. Patients undergoing open approaches were excluded. Study outcomes included operative time, estimated blood loss, length of stay, complications, and conversion rate to an open procedure.

RESULTS

Twenty-five laparoscopic and fifteen robot-assisted colorectal surgeries were performed. The mean patient age was 61.1 ± 10.7 years in the laparoscopic group compared with 61.1 ± 8.5 years in the robotic group (P = .997). Patients had a similar body mass index and history of abdominal surgery. Mean blood loss was 163.3 ± 249.2 mL and 96.8 ± 157.7 mL, respectively (P = .385). Operative times were similar, with 190.8 ± 84.3 minutes in the laparoscopic group versus 258.4 ± 170.8 minutes in the robotic group (P = .183), as were lengths of hospital stay: 9.6 ± 7.3 and 6.5 ± 3.8 days, respectively (P = .091). In addition, there was no difference in the number of lymph nodes harvested between the laparoscopic group (14.0 ± 6.5) and robotic group (12.3 ± 4.2, P = .683).

CONCLUSIONS

In our early experience, the robotic approach to colorectal surgery can be considered both safe and efficacious. Furthermore, it also preserves oncologically sufficient outcomes when performed for cancer operations.

Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes

PURPOSE

Sexual and urinary dysfunctions are complications in radical treatment of deep infiltrating endometriosis (DIE) with colorectal involvement. The aim of this article is to report the preliminary results of our single-institution experience with robotic treatment of DIE, evaluating intraoperative and postoperative surgical outcomes and focusing on the impact of this surgical approach on autonomic functions such as urogenital preservation and sexual well-being.

METHODS

From January 2011 through December 2013, a case series of 10 patients underwent robotic radical treatment of DIE with colorectal resection using the da Vinci System. Surgical data were evaluated, together with perioperative urinary and sexual function as assessed by means of self-administered validated questionnaires.

RESULTS

None of the patients reported significant postoperative complications. Questionnaires concerning sexual well-being, urinary function, and impact of symptoms on quality of life demonstrated a slight worsening of all parameters 1 month after surgery, while data were comparable to the preoperative period 1 year after surgery. Dyspareunia was the only exception, as it was significantly improved 12 months after surgery.

CONCLUSIONS

Robot-assisted surgery seems to be advantageous in highly complicated procedures where extensive dissection and proper anatomy re-establishment is required, as in DIE with colorectal involvement. Our preliminary results show that robot-assisted surgery could be associated with a low risk of complications and provide good preservation of urinary function and sexual well-being.

Robotic versus laparoscopic low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

The objective of this meta-analysis was to compare the clinical and oncologic outcomes of robotic low anterior resection (R-LAR) with conventional laparoscopic low anterior resection (L-LAR).

METHODS

A search in the MEDLINE, Embase, and Ovid databases was performed for studies published before July 2014 that compared the clinical and oncologic outcomes of R-LAR and L-LAR. The methodological quality of the selected studies was assessed. Depending on statistical heterogeneity, a fixed or random effects model was used for the meta-analysis. The clinical and oncologic outcomes evaluated included operative time, estimated blood loss, length of hospital stay, rate of conversion to open surgery, post-operative complications, circumferential margin status, and number of lymph nodes collected.

RESULTS

Eight studies, including 324 R-LAR cases and 268 conventional L-LAR cases, were analyzed. The meta-analysis showed that R-LAR was associated with a shorter hospital stay (mean difference (MD) = -1.03; 95% confidence interval (CI) = -1.78, -0.28; P = 0.007), lower conversion rate (odds ratio (OR) = 0.08; 95% CI = 0.02, 0.31; P = 0.0002), lower rate of circumferential margin involvement (OR = 0.5; 95% CI = 0.25, 1.01; P = 0.05), and lower overall complication rate (MD = 0.65; 95% CI = 0.43, 0.99; P = 0.04) compared with L-LAR. There was no difference in operative time (MD = 28.4; 95% CI = -3.48, 60.27; P = 0.08), the number of lymph nodes removed (MD = -0.63; 95% CI = -0.78, 2.05; P = 0.38), and days to return of bowel function (MD = -0.15; 95% CI = -0.37, 0.06; P = 0.17).

CONCLUSIONS

R-LAR was shown to be associated with a shorter hospital stay, lower conversion rate, lower rate of circumferential margin involvement, and lower overall complication rate compared with L-LAR. There were no differences in operative time, the number of lymph nodes removed, and days to return of bowel function.

Robotic versus laparoscopic colorectal surgery

BACKGROUND

Robotic approaches have become increasingly used for colorectal surgery. The aim of this study is to examine the safety and efficacy of robotic colorectal procedures in an adult population.

STUDY DESIGN

A systematic review of articles in both PubMed and Embase comparing laparoscopic and robotic colorectal procedures was performed. Clinical trials and observational studies in an adult population were included. Approaches were evaluated in terms of operative time, length of stay, estimated blood loss, number of lymph nodes harvested, and perioperative complications. Mean net differences and odds ratios were calculated to examine treatment effect of each group.

RESULTS

Two hundred eighteen articles were identified, and 17 met the inclusion criteria, representing 4,342 patients: 920 robotic and 3,422 in the laparoscopic group. Operative time for the robotic approach was 38.849 minutes longer (95% confidence interval: 17.944 to 59.755). The robotic group had lower estimated blood loss (14.17 mL; 95% confidence interval: -27.63 to -1.60), and patients were 1.78 times more likely to be converted to an open procedure (95% confidence interval: 1.24 to 2.55). There was no difference between groups with respect to number of lymph nodes harvested, length of stay, readmission rate, or perioperative complication rate.

CONCLUSIONS

The robotic approach to colorectal surgery is as safe and efficacious as conventional laparoscopic surgery. However, it is associated with longer operative time and an increased rate of conversion to laparotomy. Further prospective randomized controlled trials are warranted to examine the cost-effectiveness of robotic colorectal surgery before it can be adopted as the new standard of care.

Robotic Low Anterior Resection for Rectal Cancer: A National Perspective on Short-term Oncologic Outcomes

OBJECTIVE

This study examines short-term outcomes and pathologic surrogates of oncologic results among patients undergoing robotic versus laparoscopic low anterior resection for rectal cancer. A total of 6403 patients met inclusion criteria. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches.

BACKGROUND

Although laparoscopic low anterior resection (LLAR) has gained popularity as an acceptable approach, the robotic low anterior resection (RLAR) remains largely unproven. We compared short-term oncologic outcomes between rectal cancer patients undergoing either RLAR or LLAR.

STUDY DESIGN

All patients with rectal cancer in the National Cancer Data Base undergoing RLAR or LLAR from 2010 to 2011 were included. Predictors of RLAR were modeled with multivariable logistic regression. Groups were matched on propensity to undergo RLAR. Primary endpoints included lymph node retrieval and margin status, whereas secondary 30-day outcomes were mortality, hospital length of stay (LOS), and unplanned readmission rates.

RESULTS

A total of 6403 patients met inclusion criteria, of which 956 (14.9%) underwent RLAR. RLAR patients were more likely to be treated at academic centers, receive neoadjuvant therapy, and have higher T-stage and longer time to surgery (all P < 0.001). Neoadjuvant therapy and treatment at an academic/research center remained the only significant predictors of robotic use after multivariable adjustment. After propensity matching, RLAR was associated with lower conversion (9.5 vs 16.4%, P < 0.001). There were no significant differences in lymph node retrieval, margin status, 30-day mortality, readmission, or hospital LOS.

CONCLUSIONS

In this largest series to date, we demonstrated equivalent perioperative safety and patient outcomes for robotic compared to LLAR in the setting of rectal cancer. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches, suggesting that a robotic approach may be a suitable alternative. Further studies comparing long-term cancer recurrence and survival should be performed.

Does robotics improve minimally invasive rectal surgery? Functional and oncological implications

OBJECTIVE

Robot-assisted surgery has been reported to be a safe and effective alternative to conventional laparoscopy for the treatment of rectal cancer in a minimally invasive manner. Nevertheless, substantial data concerning functional outcomes and long-term oncological adequacy is still lacking. We aimed to assess the current role of robotics in rectal surgery focusing on patients' functional and oncological outcomes.

METHODS

A comprehensive review was conducted to search articles published in English up to 11 September 2015 concerning functional and/or oncological outcomes of patients who received robot-assisted rectal surgery. All relevant papers were evaluated on functional implications such as postoperative sexual and urinary dysfunction and oncological outcomes.

RESULTS

Robotics showed a general trend towards lower rates of sexual and urinary postoperative dysfunction and earlier recovery compared with laparoscopy. The rates of 3-year local recurrence, disease-free survival and overall survival of robotic-assisted rectal surgery compared favourably with those of laparoscopy.

CONCLUSIONS

This study fails to provide solid evidence to draw definitive conclusions on whether robotic systems could be useful in ameliorating the outcomes of minimally invasive surgery for rectal cancer. However, the available data suggest potential advantages over conventional laparoscopy with reference to functional outcomes.

Robotic Rectal Cancer Surgery

There are an estimated 39,000 new cases of rectal cancer in the United States per year which makes it the third most prevalent cancer when paired with colon cancer. Given its complexity, there are now multiple modalities available for its successful treatment. This includes innovative chemotherapy, radiation, transanal resection techniques, and minimally invasive surgery. Robotic surgery for the treatment of rectal cancer represents the current pinnacle of minimally invasive technology for this disease process.

A Review of the Long-Term Oncologic Outcomes of Robotic Surgery Versus Laparoscopic Surgery for Colorectal Cancer

The goal of this review was to compare long-term oncologic outcomes of robotic versus laparoscopic resection of colorectal cancer. A literature search was performed using PubMed, EMBASE, Cochrane, and Medline (2002-2014). Search terms: laparoscopic, robotic, rectal, colon, surgery, oncologic, and outcomes. Studies comparing overall and disease free survival of robotic versus laparoscopic surgery for colorectal cancer were included. Meta-analysis was performed using OpenMeta[Analyst] for Windows 8. Five studies were identified reporting on overall survival, disease free survival, lymph node extraction, and distal and circumferential resection margin. Three hundred and seventeen patients underwent robotic resection and 368 underwent laparoscopic resection, with similar demographics. Operative times were longer with robotic resections, with no difference in estimated blood loss (EBL) or length of stay. The disease stage was distributed similarly in both groups. Similar numbers underwent neo-adjuvant therapy. Laparoscopic resection was associated with 3.2 mm larger distal resection margins (p = 0.04) and 2.2 more lymph nodes removed (p = 0.001), but with equivalent circumferential resection margin status. Disease-free and overall survival was equivalent. Robotic and laparoscopic surgery for colorectal cancer offer comparable overall and disease free survival. Laparoscopic surgery offered a slight advantage in operative time, distal margin, and lymph node yield. Larger, prospective trials are needed to confirm the equivalence of these approaches.

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

The Role of Robotic Surgery for Rectal Cancer: Overcoming Technical Challenges in Laparoscopic Surgery by Advanced Techniques

The conventional laparoscopic approach to rectal surgery has several limitations, and therefore many colorectal surgeons have great expectations for the robotic surgical system as an alternative modality in overcoming challenges of laparoscopic surgery and thus enhancing oncologic and functional outcomes. This review explores the possibility of robotic surgery as an alternative approach in laparoscopic surgery for rectal cancer. The da Vinci® Surgical System was developed specifically to compensate for the technical limitations of laparoscopic instruments in rectal surgery. The robotic rectal surgery is associated with comparable or better oncologic and pathologic outcomes, as well as low morbidity and mortality. The robotic surgery is generally easier to learn than laparoscopic surgery, improving the probability of autonomic nerve preservation and genitourinary function recovery. Furthermore, in very complex procedures such as intersphincteric dissections and transabdominal transections of the levator muscle, the robotic approach is associated with increased performance and safety compared to laparoscopic surgery. The robotic surgery for rectal cancer is an advanced technique that may resolve the issues associated with laparoscopic surgery. However, high cost of robotic surgery must be addressed before it can become the new standard treatment.

Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy

INTRODUCTION

Total mesorectal excision (TME) for rectal cancer can be challenging to perform in the presence of difficult pelvic anatomy. In our previous studies based on open and laparoscopic TME, we found that pelvic MRI-based pelvimetry could well reflect anatomical difficulty of the pelvis and operative time increased in direct proportion to the difficulty. We explored different outcomes of robotic surgery for TME based on classifications of difficult pelvic anatomies to determine whether this method can overcome these challenges.

METHODS

We reviewed data from 182 patients who underwent robotic surgery for rectal cancer between January 2008 and August 2010. Patient demographics, pathologic outcomes, pelvimetric results, and operative and postoperative outcomes were assessed. The data were compared between easy, moderate, and difficult groups classified by MRI-based pelvimetry.

RESULTS

Comparing the three groups, there was no difference between the groups in terms of operative and pathologic outcomes, including operation time. High BMI, history of preoperative chemoradiotherapy, and lower tumor levels were significantly associated with longer operation time (p < 0.001, p < 0.001, p = 0.009), but the pelvimetric parameter was not.

CONCLUSION

There was no difference between the easy, moderate, and difficult groups in terms of surgical outcomes, such as operation time, for robotic rectal surgery. The robot system can provide more comfort during surgery for the surgeon, and may overcome challenges associated with difficult pelvic anatomy.

Long-term oncologic outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic surgery

OBJECTIVE

The aim of this study is to evaluate long-term oncologic outcomes of robotic surgery for rectal cancer compared with laparoscopic surgery at a single institution.

BACKGROUND

Robotic surgery is regarded as a new modality to surpass the technical limitations of conventional surgery. Short-term outcomes of robotic surgery for rectal cancer were acceptable in previous reports. However, evidence of long-term feasibility and oncologic safety is required.

METHODS

Between April 2006 and August 2011, 217 patients who underwent minimally invasive surgery for rectal cancer with stage I-III disease were enrolled prospectively (robot, n = 133; laparoscopy, n = 84). Median follow-up period was 58 months (range, 4-80 months). Perioperative clinicopathologic outcomes, morbidities, 5-year survival rates, prognostic factors, and cost were evaluated.

RESULTS

Perioperative clinicopathologic outcomes demonstrated no significant differences except for the conversion rate and length of hospital stay. The 5-year overall survival rate was 92.8% in robotic, and 93.5% in laparoscopic surgical procedures (P = 0.829). The 5-year disease-free survival rate was 81.9% and 78.7%, respectively (P = 0.547). Local recurrence was similar: 2.3% and 1.2% (P = 0.649). According to the univariate analysis, this type of surgical approach was not a prognostic factor for long-term survival. The patient's mean payment for robotic surgery was approximately 2.34 times higher than laparoscopic surgery.

CONCLUSIONS

No significant differences were found in the 5-year overall, disease-free survival and local recurrence rates between robotic and laparoscopic surgical procedures. We concluded that robotic surgery for rectal cancer failed to offer any oncologic or clinical benefits as compared with laparoscopy despite an increased cost.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME).

METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups.

CONCLUSIONS

RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.

Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study

The true benefits of robotic surgery are controversial, and whether robotic total mesorectal excision (R-TME) can be justified as a standard treatment for rectal cancer patients needs to be clarified. This case-matched study aimed to compare the postoperative complications and short- and long-term outcomes of R-TME and laparoscopic TME (L-TME) for rectal cancer.Among 1029 patients, we identified 278 rectal cancer patients who underwent R-TME. Propensity score matching was used to match this group with 278 patients who underwent L-TME.The mean follow-up period was similar between both groups (L-TME vs R-TME: 52.5 ± 17.1 vs 51.0 ± 13.1 months, P = 0.253), as were patient characteristics. The operation time was significantly longer in the R-TME group than in the L-TME group (361.6 ± 91.9 vs 272.4 ± 83.8 min; P < 0.001), whereas the conversion rate, length of hospital stay, and recovery of pain and bowel motility were similar between both groups. The rates of circumferential resection margin involvement and early complications were similar between both groups (L-TME vs R-TME: 4.7% vs 5.0%, P = 1.000; and 23.7% vs 25.9%, P = 0.624, respectively), as were the 5-year overall survival, disease-free survival, and local recurrence rates (93.1% vs 92.2%, P = 0.422; 79.6% vs 81.8%, P = 0.538; 3.9% vs 5.9%, P = 0.313, respectively).The oncologic quality, short- and long-term outcomes, and postoperative morbidity in the R-TME group were comparable with those in the L-TME group.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.

Comparative effectiveness in colon and rectal cancer

Treatment of colorectal cancer is becoming more uniform, with wider acceptance of standardized guidelines. However, areas of controversy exist where the appropriate treatment is not clear, including: should a segmental colectomy or a more extensive resection be performed in hereditary nonpolyposis colorectal cancer? should an asymptomatic primary cancer be resected in the presence of unresectable metastatic disease? what is the role of extended lymph node resection in colon and rectal cancer? are there clinically significant benefits for a robotic approach to colorectal resection versus a laparoscopic approach? This chapter will examine these issues and discuss how they may be resolved.

Total mesorectal excision: open, laparoscopic or robotic

Goals Total mesorectal excision (TME) is the gold standard technique for the surgical treatment of rectal cancer. Despite the benefits of minimally invasive surgery, laparoscopic TME (LTME) is a technically challenging procedure with a long learning curve. Robotic TME (RTME) has been advocated as an alternative to conventional LTME, but large studies supporting the efficacy or RTME are scarce. This work will review the current literature on minimally invasive surgery for rectal cancer and discuss future directions in the field. Methods A review of recent large single and multicenter studies on minimally invasive surgery for rectal cancer was conducted. Results Based on two large randomized clinical studies (CLASICC (Green et al. 2013) and COLOR II (van der Pas et al. 2013)). LTME is safe and feasible for the treatment of rectal cancer. Compared to open surgery, LTME has been shown to result in superior postoperative outcomes and similar oncologic results. However, the conversion rate of LTME is around 17 %. The literature supporting RTME is more limited. Robotic rectal resection appears to have similar postoperative and oncologic outcomes compared to LTME. RTME results in higher costs and possibly lower conversion rates. A large randomized clinical trial (ROLARR) comparing robotic to laparoscopic surgery for rectal cancer is underway. Conclusions Despite the technical challenges, current data supports the use of minimally invasive technique for rectal cancer surgery with superior short-term outcomes compared to an open approach. The use of robotic surgery is promising, but still limited and awaiting the conclusion of randomized clinical trials.

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Robotics in general surgery: an evidence-based review

Since its introduction, robotic surgery has been rapidly adopted to the extent that it has already assumed an important position in the field of general surgery. This rapid progress is quantitative as well as qualitative. In this review, we focus on the relatively common procedures to which robotic surgery has been applied in several fields of general surgery, including gastric, colorectal, hepato-biliary-pancreatic, and endocrine surgery, and we discuss the results to date and future possibilities. In addition, the advantages and limitations of the current robotic system are reviewed, and the advanced technologies and instruments to be applied in the near future are introduced. Such progress is expected to facilitate the widespread introduction of robotic surgery in additional fields and to solve existing problems.

Robotics: The next step?

Robotic systems were introduced 15 years ago to support complex endoscopic procedures. The technology is increasingly used in gastro-intestinal surgery. In this article, literature on experimental- and clinical research is reviewed and ergonomic issues are discussed.

METHODS

literature review was based on Medline search using a large variety of search terms, including e.g. robot(ic), randomized, rectal, oesophageal, ergonomics. Review articles on relevant topics are discussed with preference.

RESULTS

There is abundant evidence of supremacy in performing complex endoscopic surgery tasks when using the robot in an experimental setting. There is little high-level evidence so far on translation of these merits to clinical practice.

DISCUSSION

Robotic systems may appear helpful in complex gastro-intestinal surgery. Moreover, dedicated computer based technology integrated in telepresence systems opens the way to integration of planning, diagnostics and therapy. The first high tech add-ons such as near infrared technology are under clinical evaluation.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME.

MATERIALS AND METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME.

CONCLUSIONS

RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.