Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients

New developments in colorectal surgery

PURPOSE OF REVIEW

New developments in colorectal surgery have been driven primarily by technical innovations, which in turn are responsible for changes in practice. This review examines recent publications that describe and have contributed to these changes.

RECENT FINDINGS

We identified and reviewed recent publications in the areas of fecal incontinence, constipation, single incision and robotic surgical techniques, complex anal fistulas, diverticulitis, local excision techniques for rectal neoplasms, surgical care improvement, use of mechanical bowel preparation, and magnetic resonance imaging after neoadjuvant chemoradiotherapy for rectal cancer.

SUMMARY

New technologies and practice innovations will enhance patient outcomes and quality of life. Multiinstitutional studies, randomized when practical, will be necessary to further define the safety and efficacy of these new surgical techniques and to further define best practices in colon and rectal surgery.

A new application of the four-arm standard da Vinci® surgical system: totally robotic-assisted left-sided colon or rectal resection

BACKGROUND

The key to successful rectal cancer resection is to perform complete total mesorectal excision (TME). Laparoscopic TME can be challenging, especially in the narrow confines of the pelvis. Robotic-assisted surgery can overcome these limitations through superior three-dimensional (3-D) visualization and the increased range of movements provided by the endowrist function. To date, all totally robotic resections of the rectum have been described using da Vinci® S or Si systems. Due to the limitations of the standard system, only hybrid procedures have been described so far.

AIM

To evaluate the feasibility and short-term outcomes of performing totally robotic-assisted laparoscopic colorectal resections using the standard da Vinci® system with a fourth arm extension.

METHODS

The standard system was docked from the patient's left hip. Four 8-mm robotic trocars were inserted. Upon completion of phase 1 (pedicle ligation, colonic mobilization, splenic flexure takedown), the two left-sided arms are repositioned to allow phase 2 (pelvic dissection), enabling the entire procedure except for the distal transection and anastomosis to be performed robotically.

RESULTS

Twenty-one robotic procedures were performed from August 2008 to September 2009. The mean age of the patients was 61 years (13 males). The procedures performed included seven anterior resections, seven low anterior resections, five ultralow anterior resections, one abdominoperineal resection, and one resection rectopexy. The majority of the cases were performed in patients with colon or rectal cancer. Operative time ranged from 232 to 444 (mean 316) min. Postoperative morbidity occurred in three patients (14.3%) with no mortalities or conversions. Average hospital stay was 6.4 days. Mean lymph node yield for the cases with cancer was 17.8.

CONCLUSIONS

The standard da Vinci® system with four arms can be used to perform totally robotic-assisted colorectal procedures for the left colon and rectum with short-term outcomes similar to those of conventional laparoscopic techniques.

Optimal Total Mesorectal Excision for Rectal Cancer: the Role of Robotic Surgery from an Expert's View

Total mesorectal excision (TME) has gained worldwide acceptance as a standard surgical technique in the treatment of rectal cancer. Ever since laparoscopic surgery was first applied to TME for rectal cancer, with increasing penetration rates, especially in Asia, an unstable camera platform, the limited mobility of straight laparoscopic instruments, the two-dimensional imaging, and a poor ergonomic position for surgeons have been regarded as limitations. Robotic technology was developed in an attempt to reduce the limitations of laparoscopic surgery. The robotic system has many advantages, including a more ergonomic position, stable camera platform and stereoscopic view, as well as elimination of tremor and subsequent improved dexterity. Current comparison data between robotic and laparoscopic rectal cancer surgery show similar intraoperative results and morbidity, postoperative recovery, and short-term oncologic outcomes. Potential benefits of a robotic system include reduction of surgeon's fatigue during surgery, improved performance and safety for intracorporeal suture, reduction of postoperative complications, sharper and more meticulous dissection, and completion of autonomic nerve preservation techniques. However, the higher cost for a robotic system still remains an obstacle to wide application, and many socioeconomic issues remain to be solved in the future. In addition, we need more concrete evidence regarding the merits for both patients and surgeons, as well as the merits compared to conventional laparoscopic techniques. Therefore, we need large-scale prospective randomized clinical trials to prove the potential benefits of robot TME for the treatment of rectal cancer.

Total mesorectal excision for rectal cancer: the potential advantage of robotic assistance

PURPOSE

The purpose of this study was to analyze the safety, feasibility, and efficacy of the da Vinci S HD robotic system in mesorectal excision for rectal adenocarcinoma, with the aim to identify areas of potential advantage for the robot in this procedure.

METHODS

This study was conducted as a retrospective review of a prospectively maintained database of 44 consecutive cases of robot-assisted mesorectal excision for rectal adenocarcinoma performed between August 2005 and February 2010. Patient demographics, perioperative outcomes, and complications were evaluated and compared with similar published reports and relevant literature.

RESULTS

There were 28 (63.6%) men and 16 (36.4%) women, with a mean age of 63 years. The majority of patients were either overweight or obese and 88.7% of lesions were in the mid or low rectum. We performed 36 low anterior resections (6 intersphincteric) and 8 abdominoperineal resections with a median blood loss of 150 mL (range, 50-1000), a median operative time of 347 minutes (range, 155-510), and a median length of stay of 5 days (range, 3-36). The median lymph node yield was 14 (range, 5-45) and the circumferential resection margin was negative in all patients. We had 1 distal margin positivity (2.7%), 2 anastomotic leaks (5.6%), 1 death (2.7%), and 2 conversions (4.5%) to the open approach. No robot-associated morbidity occurred in this series.

CONCLUSIONS

This series compares favorably with similar published reports with regard to the safety and feasibility of robotic assistance in total mesorectal excision for rectal cancer. The lower conversion rates reported for robotic rectal resection compared with laparoscopy require validation in large randomized trials.