Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial

Laparoscopy for rectal cancer

Several large case series and single-institution trials have shown that laparoscopy is feasible for rectal cancer. Pending the results of the UK CLASICC, COLOR II, Japanese JCOG 0404, and ACOSOG Z6051 trials, the oncologic and long-term safety of laparoscopic rectal cancer surgery is unclear and the technique is best used at centers that can effectively collect and analyze outcomes data. Robotic and endoluminal techniques may change our approach to the treatment of rectal cancer in the future. Training, credentialing, and quality control are important considerations as new and innovative surgical treatments for rectal cancer are developed.

Laparoscopy for colon cancer: state of the art

As a result of several years of trials and investigations, laparoscopic colectomy for colon cancer is now considered an acceptable and safe alternative to traditional open techniques. Four large randomized trials (Barcelona, COST, COLOR, CLASSIC) have shown the noninferiority of laparoscopic colectomy in overall survival, disease-free survival, and overall and local recurrences. Laparoscopic surgery is associated with better short-term outcomes, such as shorter hospital stay, shorter duration of ileus, less narcotic usefulness and postoperative pain, and a faster postoperative recovery. The procedures are also safe and feasible in elderly patients. Hand-assisted laparoscopic colectomy is a recent hybrid technique that could reduce learning time, and its role has been established in more challenging procedures. Future prospects include robotic and natural-orifice surgery.

Operative blood loss and use of blood products after full robotic and conventional low anterior resection with total mesorectal excision for treatment of rectal cancer

To date, no studies have investigated the estimated blood loss (EBL) after full robotic low anterior resection (R-LAR) in a case-matched model, comparing it with the conventional open approach (O-LAR). Forty-nine patients in the R-LAR and 105 in the O-LAR group were matched for age, gender, BMI (body mass index), ASA (American Society of Anesthesiology) class, tumor-node-metastasis (TNM) classification and UICC (Union for International Cancer Control) stage, distance of the lower edge of the tumor from the anal verge, presence of comorbidities, and preoperative hemoglobin (Hb). EBL was significantly higher in the O-LAR group (P < 0.001); twelve units of packed red blood cells were globally transfused in the O-LAR group, compared to one unit only in the R-LAR (P = 0.051). A significantly higher postoperative Hb drop (3.0 vs. 2.4 g/dL, P = 0.015) was registered in the O-LAR patients. The length of hospital stay was much lower for the R-LAR group (8.4 vs. 12.4 days, P < 0.001). The number of harvested lymph nodes (17.4 vs. 13.5, P = 0.006) and extent of distal margin (2.9 vs. 1.9 cm, P < 0.001) were significantly higher in the R-LAR group. Open surgery was confirmed as the sole variable significantly associated (P < 0.001) with blood loss (odds ratio = 4.41, 95% CI 2.06-9.43). It was a confirmed prognosticator of blood loss (P = 0.006) when a preoperative clinical predictive model was built, using multivariate analysis (odds ratio = 3.95, 95% CI 1.47-10.6). In conclusion, R-LAR produced less operative blood loss and less drop in postoperative hemoglobin when compared to O-LAR. Other clinically relevant outcomes were similar or superior to O-LAR.

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.

Robotic colon and rectal surgery: a series of 131 cases

BACKGROUND

Laparoscopic colorectal surgery has become a mainstay in the treatment of benign and malignant colorectal diseases. There are inherent limitations to conventional laparoscopy which can be overcome by the robot. Here we present our experience with 131 cases of robotic and robot-assisted colon and rectal resections.

METHODS

This is a retrospective review of a prospectively maintained database. From August 2005 through June 2009, we performed a total of 131 totally robotic and robot-assisted colorectal resections. These included 42 right colectomies (RC), 16 anterior resections (AR) for benign disease, 8 AR with rectopexy for prolapse, 7 total proctocolectomies (TPC), 47 low and ultralow anterior resections (LAR) for rectal cancer, and 11 abdominal perineal resections (APR). All LARs were done as a hybrid procedure (laparoscopic splenic flexure mobilization followed by robotic rectal dissection), and all APR specimens were extracted through the perineal incision. All coloanal anastomoses were diverted with a loop ileostomy.

RESULTS

There were no intraoperative complications in this series. Postoperative complications included 10 patients with ileus or small bowel obstruction (SBO), 2 patients with anastomotic leaks, 1 patient with an abscess, and 3 patients with temporary peripheral neuropathy that resolved spontaneously. Five patients required reoperation and there were a total of 4 conversions (3.7%) across all case types.

CONCLUSIONS

Robotic colon and rectal resections are safe and feasible options for the treatment of both benign and malignant disease processes. Further studies comparing oncologic and perioperative outcomes of robotic, laparoscopic, and open techniques are needed to determine the utility and efficacy of this technology in the field of colorectal surgery.

Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery

AIM

Robotic colorectal surgery is an emerging field and may offer a solution to some of the difficulties inherent to conventional laparoscopic surgery. The aim of this review is to provide a comprehensive and critical analysis of the available literature on the use of robotic technology in colorectal surgery.

METHOD

Studies reporting outcomes of robotic colorectal surgery were identified by systematic searches of electronic databases. Outcomes examined included operating time, length of stay, blood loss, complications, cost, oncological outcome, and conversion rates.

RESULTS

Seventeen Studies (nine case series, seven comparative studies, one randomized controlled trial) describing 288 procedures were identified and reviewed. Study heterogeneity precluded a meta-analysis of the data. Robotic procedures tend to take longer and cost more, but may reduce the length of stay, blood loss, and conversion rates. Complication profiles and short-term oncological outcomes are similar to laparoscopic surgery.

CONCLUSION

Robotic colorectal surgery is a promising field and may provide a powerful additional tool for optimal management of more challenging pathology, including rectal cancer. Further studies are required to better define its role.

Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis

AIM

The main aim of this review was to compare the safety and efficacy of the Da Vinci Surgical System (DVSS) and conventional laparoscopic surgery (CLS) in different types of abdominal intervention.

SUMMARY OF BACKGROUND DATA

DVSS is an emerging laparoscopic technology. The surgeon directs the robotic arms of the system through a console by means of hand controls and pedals, making use of a stereoscopic viewing system. DVSS is currently being used in general, urological, gynecologic, and cardiothoracic surgery.

METHODS

This systematic review analyses the best scientific evidence available regarding the safety and efficacy of DVSS in abdominal surgery. The results found were subjected to meta-analysis whenever possible.

RESULTS

Thirty-one studies, 6 of them randomized control trials, involving 2166 patients that compared DVSS and CLS were examined. The procedures undertaken were fundoplication (9 studies, one also examining cholecystectomy), Heller myotomy (3 studies), gastric bypass (4), gastrectomy (2), bariatric surgery (1), cholecystectomy (4), splenectomy (1), colorectal resection (7), and rectopexy (1). DVSS was found to be associated with fewer Heller myotomy-related perforations, a more rapid intestinal recovery time after gastrectomy-and therefore a shorter hospital stay, a shorter hospital stay following cholecystectomy (although the duration of surgery was longer), longer colorectal resection surgery times, and a larger number of conversions to open surgery during gastric bypass.

CONCLUSIONS

The publications reviewed revealed DVSS to offer certain advantages with respect to Heller myotomy, gastrectomy, and cholecystectomy. However, these results should be interpreted with caution until randomized clinical trials are performed and, with respect to oncologic indications, studies include variables such as survival.

Safety and learning curve in robotic colorectal surgery

Robotic surgery has recently started to be used for minimally invasive colorectal surgery. Because of limited access and high cost, very few colorectal units are available in the US. We describe our experience with benign and malignant disease since September 2008 in a dedicated colorectal practice. A prospective collected robotic database was queried for colon and rectal procedures. Anonymized demographic, intraoperative, and postoperative data, and pathology information, were collected and analyzed. A total of 48 robotic procedures for colorectal maladies were performed in the study period. There were 35 females and 13 males. The average age was 57 years. Twenty-two cases were performed for diverticulitis, 13 for malignancy (10 distal rectum (<8 cm anal verge), two rectosigmoid, and one ascending colon cancer), 10 for rectal prolapse, two for rectovaginal fistula, and one for incidental appendiceal mucocele found during a gynecologic resection. The average operating room time (OR) was 162 min and there were no conversions to open procedures. Blood loss averaged 104 mL. Mean length of hospital stay (LOS) was 5.4 days. Patient readmission occurred in 27.3% of cases. The anastamotic leak rate was 2.1% (one patient). No mortalities were reported. When the analysis was performed for colorectal malignancies (13 procedures), there were nine females and four males. Average age was 59 years. The mean OR time was 191.1 min. Mean intraoperative blood loss was 123 mL and there were no conversions to open surgery. Average LOS was 7.0 days. There was one anastamotic leak (7.7%). The length of stay was increased for the patient with anastamotic leak (18 days) and for a patient with high stoma output and postoperative ileus (17 days). Readmission rate was 30.1%. The total number of lymph nodes retrieved averaged 19.5, with a mean distal margin of 3.0 cm and in all cases negative radial margins. Robotic colorectal surgery for benign and malignant disease is safe, and short-term outcomes are comparable with those of traditional and laparoscopic surgery. Oncologic resections were adequate with excellent lymph node sampling and radial and distal margins.

Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study

BACKGROUND

Robotic total mesorectal excision (RTME), a novel approach for the treatment of rectal cancer, has been shown in previous studies to be safe and effective. However, the results of this approach compared with laparoscopic total mesorectal excision (LTME) have not been reported in terms of clinical outcome and oncologic data. This study compared early outcomes for rectal cancer between two groups.

METHODS

Between April 2003 and March 2009, 82 patients from a prospectively maintained database were enrolled in a case-matched study. The patients were matched for gender, age, body mass index (BMI), and type of operative procedure.

RESULTS

Neoadjuvant chemoradiotherapy was performed for 33 RTME patients (80.5%) and 18 LTME patients (43.9%) (p=0.001). The mean operative time was 296 min for RTME and 315 min for LTME (p=0.357). The number of conversions were 3 (7.3%) for RTME and 9 (22%) for LTME (p=0.12). The anastomotic leak rate after surgery did not differ between RTME (n=3, 8.6%) and LTME (n=1, 2.9%) (p=0.62). The mean number of harvested lymph nodes was 13.1 with RTME and 16.2 with LTME (p=0.07), and negative distal resection margins (DRMs) were noted in all surgical specimens. Positive circumferential resections (CRMs) were identified in 2.4% of the RTME cases and 4.9% of the LTME cases. No difference was noted in lengths of the DRMs, times until a liquid diet, or postoperative hospital stays. The total hospitalization costs were higher in the RTME group, although the difference did not reach statistical significance. There was no operative mortality or port-site recurrence in either group.

CONCLUSION

For rectal cancer, RTME may be as feasible and safe as LTME in terms of technical and oncologic issues. Further prospective randomized trials are necessary for conclusions to be drawn concerning definite oncologic outcomes of robotic procedures for rectal cancer.

Robotic assistance in right hemicolectomy: is there a role?

PURPOSE

The purpose of this study was to evaluate the results, postoperative outcomes, and cost of robotic assistance in right hemicolectomy and determine its safety, feasibility, and efficacy as compared with the conventional laparoscopic approach.

METHODS

From August 2005 to February 2009, 40 robot-assisted right hemicolectomies were performed by the authors at a single institution. These were compared with 135 laparoscopic right hemicolectomies performed by the authors, at the same hospital and during the same time period. Cost data from July 2006 until the end of the study period were compared between the 2 groups.

RESULTS

Both groups were comparable with respect to age, sex, body mass index, American Society of Anesthesiologists' class, history of prior abdominal surgery, and diagnosis. There was no significant difference in the lymph node harvest, estimated blood loss, conversion rate, length of stay, or incidence of complications and wound infection between the 2 groups. A robotic procedure was associated with a longer operative time (P < .001) and a higher cost (P = .003).

CONCLUSION

Robotic assistance in right hemicolectomy is safe and feasible but is associated with a longer operative time and, at present, with a higher cost compared with laparoscopy. However, right hemicolectomy serves as an ideal procedure to begin the learning curve in robotic colorectal surgery, which can subsequently progress to robotic rectal resections where the robot has the greatest potential for benefit.

Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes

PURPOSE

The aim of this study is to compare short-term outcomes and surgical quality of robot-assisted (RAP) and laparoscopic (LAP) total mesorectal excision (TME) in patients with low rectal cancer.

METHODS

From December 2007 to June 2009, 41 consecutive patients with low rectal cancer underwent TME by robot-assisted procedures. The lowest tumor margins were below peritoneal reflection and 1.0-8.0 cm above the anal verge. These patients were matched 1:2 by age, gender, body mass index, date of surgery, American Society of Anesthesiologists score, and tumor stage, with 82 patients who underwent conventional LAP. Macroscopic quality of the specimens and operative and postoperative outcomes were compared.

RESULTS

Mean operation time was 168.0 ± 49.3 min for LAP group and 231.9 ± 61.4 min for RAP group (P < 0.001). Time to regular diet (RAP, 6.7 days vs. LAP, 6.6 days) and length of stay (RAP, 9.9 days vs. LAP, 9.4 days) were similar. The proportion of surgeries performed with the modified natural orifice techniques (totally intracorporeal procedures with transanal or transvaginal retrieval of specimens) was significantly higher in the RAP group (RAP, 48.8% vs. LAP, 13.4%; P < 0.001). There were no between-group differences in specimen quality, including distal resection margins, harvested lymph nodes, and circumferential margins. The overall major complication rates were similar (RAP, 9.8% vs. LAP, 7.3%; P = 0.641).

CONCLUSIONS

RAP was safe and effective for patients with low rectal cancer. Furthermore, the technical advantages of robot surgical systems may allow a novel approach using hybrid natural orifice surgery.

S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer

BACKGROUND

In recent years, robot-assisted surgery using the da Vinci System® has been proposed as an alternative to traditional open or laparoscopic procedures. The aim of this study was to compare the short-term outcomes for open, laparoscopic, and robot-assisted rectal resection for cancer.

METHODS

Two hundred sixty-three patients with rectal cancer who underwent curative resection between 2007 and 2009 were included. Patients were classified into an open surgery group (OS, n = 88), a laparoscopic surgery group (LAP, n = 123), and a robot-assisted group (RAP, n = 52). Data analyzed include operating time, length of recovery, methods of specimen extraction, quality of total mesorectal excision, and morbidity.

RESULTS

The mean operating time was 233.8 ± 59.2 min for the OS group, 158.1 ± 49.2 min for the LAP group, and 232.6 ± 52.4 min for the RAP group (p < 0.001). Patients from the LAP and RAP groups recovered significantly faster than did those from the OS group (p < 0.05). The proportion of operations performed through a natural orifice (intracorporeal anastomosis with transanal or transvaginal retrieval of specimens) was significantly higher in the RAP group (p < 0.001). The specimen quality--with a distal resection margin, harvested lymph nodes, and circumferential margin--did not differ among the three groups. The overall complication rates were 20.5, 12.2, and 19.2% in the OS, LAP, and RAP groups, respectively (p = 0.229).

CONCLUSIONS

RAP and LAP reproduce the equivalent short-term results of standard OS while providing the advantages of minimal access. For the experienced laparoscopic colorectal oncologist, use of the da Vinci robot resulted in no significant short-term clinical benefit over the conventional laparoscopic approach.

Oncologic outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer

OBJECTIVE

To evaluate local recurrence and survival after robotic-assisted total mesorectal excision (RTME) for primary rectal cancer.

SUMMARY BACKGROUND DATA

RTME is a novel approach for the treatment of rectal cancer and has been shown to be safe and effective. However, the oncologic results of this approach have not been reported in terms of local recurrence and survival rate.

METHODS

Sixty-four consecutive rectal cancer patients with stage I-III disease treated between November 2004 and June 2008 were analyzed prospectively.

RESULTS

All patients underwent RTME: 34 had colorectal anastomosis, 18 underwent coloanal anastomosis, and 12 received abdominoperineal resection. Operative mortality rate was 0%. The median operative time was 270 min and median blood loss was 200 mL. The conversion rate was 9.4%. Anastomotic leakage occurred in 4 of 52 (7.7%) patients with anastomosis. Median number of harvested lymph nodes was 14.5. Median distal margin of tumor was 3.4 cm. The circumferential resection margin was negative in all surgical specimens. No port-site recurrence occurred in any patient. Six patients developed recurrence: 2 combined local and distant, and 4 distal alone (mean follow-up of 20.2 months; range, 1.7-52.5). None of the patients developed isolated local recurrence. The mean time to local recurrence was 23 months. The 3-year overall and disease-free survival rates were 96.2% and 73.7%, respectively.

CONCLUSIONS

RTME can be carried out safely and effectively in terms of recurrence and survival rates. Further prospective randomized trials are necessary to better define the absolute benefits and limitations of robotic rectal surgery.

Robotic rectosigmoidectomy: pioneer case report in Brazil. Current scene in colorectal robotic surgery

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. Robotic surgery is an attractive mode in performing minimally-invasive surgery once it has several advantages if compared to standard laparoscopic surgery. The aim of this paper is to report the first known case of colorectal resection surgery using the robotic assisted surgical device in Brazil. A 35-year-old woman with deep infiltrating endometriosis with rectal involvement was referred for colorectal resection using da Vinci® surgical system. The authors also reviewed the most current series and discussed not only the safety and feasibility but also the real benefits of robotic colorectal surgery

Robotic pursestring technique in low anterior resection

PURPOSE

Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system.

METHODS

Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed.

RESULTS

The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day.

CONCLUSIONS

The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.

Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer

BACKGROUND

Recently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS.

METHODS

One hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher.

RESULTS

A total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283 ml, and mean operative time was 297 min. The number of harvested nodes (14.1 +/- 6.5) and margin status compared favorably with those of open series (mean distal margin 2.9 +/- 1.8 cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4 months.

CONCLUSION

RTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.

The evolution of robotic general surgery

Surgical robotics in general surgery has a relatively short but very interesting evolution. Just as minimally invasive and laparoscopic techniques have radically changed general surgery and fractionated it into subspecialization, robotic technology is likely to repeat the process of fractionation even further. Though it appears that robotics is growing more quickly in other specialties, the changes digital platforms are causing in the general surgical arena are likely to permanently alter general surgery. This review examines the evolution of robotics in minimally invasive general surgery looking forward to a time where robotics platforms will be fundamental to elective general surgery. Learning curves and adoption techniques are explored. Foregut, hepatobiliary, endocrine, colorectal, and bariatric surgery will be examined as growth areas for robotics, as well as revealing the current uses of this technology.

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

PURPOSE

To overcome the pitfalls of laparoscopy, a robotic system has been introduced in rectal cancer surgery. However, there is no standard procedure to maximize the advantages of the da Vinci S Surgical System. Therefore, we describe our technique of applying the robotic system during all of the steps of dissection in rectal cancer surgery and the short-term outcome.

METHODS

Prospectively collected data were reviewed from 50 consecutive patients who underwent single-stage, totally robotic dissection for rectal cancer resection between July 2007 and June 2008. Robotic dissection was performed following these steps: 1) ligation of the inferior mesenteric vessels and medial to lateral dissection, 2) mobilization of the sigmoid/descending/splenic flexure colon, and 3) rectal dissection. The remaining steps including rectal transection and anastomosis were performed by a conventional laparoscopic method.

RESULTS

There were 32 (64%) men and 18 (36%) women. The mean distance from the anal verge to the tumor margin was 7.3 (range, 2-13) cm. The conversion rate was 0%. The mean operative time was 304.8 (range, 190-485) minutes, and 20.6 (range, 6-48) lymph nodes were harvested. The circumferential margin was positive in one patient. The length of hospital stay after surgery was 9.2 (range, 5-24) days. Anastomotic leak rate was 8.3%, and all of the patients with leakage were managed conservatively.

CONCLUSIONS

Single-stage robotic dissection for rectal cancer surgery is feasible, and its short-term outcome is acceptable. Our technique can be a suitable procedure to maximize the advantages of the da Vinci system.

Current status of robotic assisted pelvic surgery and future developments

AIMS

The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.

RESULTS

During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.

CONCLUSIONS

Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

Laparoscopic versus open surgery for rectal cancer: long-term oncologic results

OBJECTIVE

The goal was to assess long-term oncologic outcome after laparoscopic versus open surgery for rectal cancer and to evaluate the impact of conversion.

SUMMARY BACKGROUND DATA

Laparoscopic resection of rectal cancer is technically feasible, but there are no data to evaluate the long-term outcome between laparoscopic and open approach. Moreover, the long-term impact of conversion is not known.

METHODS

Between 1994 and 2006, patients treated by open (1994-1999) and laparoscopic (2000-2006) curative resection for rectal cancer were included in a retrospective comparative study. Patients with fixed tumors or metastatic disease were excluded. Those with T3-T4 or N+ disease received long course preoperative radiotherapy. Surgical technique and follow-up were standardized. Survival were analyzed by Kaplan Meier method and compared with the Log Rank test.

RESULTS

Some 471 patients had rectal excision for invasive rectal carcinoma: 238 were treated by laparoscopy and 233 by open procedure. Postoperative mortality (0.8% vs. 2.6%; P = 0.17), morbidity (22.7% vs. 20.2%; P = 0.51), and quality of surgery (92.0% vs. 94.8% R0 resection; P = 0.22) were similar in the 2 groups. At 5 years, there was no difference of local recurrence (3.9% vs. 5.5%; P = 0.371) and cancer-free survival (82% vs. 79%; P = 0.52) between laparoscopic and open surgery. Multivariate analysis confirmed that type of surgery did not influence cancer outcome. Conversion (36/238, 15%) had no negative impact on postoperative mortality, local recurrence, and survival.

CONCLUSIONS

The efficacy of laparoscopic surgery in a team specialized in rectal excision for cancer (open and laparoscopic surgery) is suggested with similar long-term local control and cancer-free survival than open surgery. Moreover, conversion had no negative impact on survival.

Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study

BACKGROUND

The aim of this study is to compare the short-term results between robotic-assisted low anterior resection (R-LAR), using the da Vinci Surgical System, and standard laparoscopic low anterior resection (L-LAR) in rectal cancer patients.

METHODS

113 patients were assigned to receive either R-LAR (n = 56) or L-LAR (n = 57) between April 2006 and September 2007. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between the groups. Moreover, macroscopic grading of the specimen was evaluated.

RESULTS

Patient characteristics were not significantly different between the groups. The mean operation time was 190.1 +/- 45.0 min in the R-LAR group and 191.1 +/- 65.3 min in the L-LAR group (P = 0.924). The conversion rate was 0.0% in the R-LAR groups and 10.5% in the L-LAR group (P = 0.013). The serious complication rate was 5.4% in the R-LAR group and 19.3% in the L-LAR group (P = 0.025). The specimen quality was acceptable in both groups. However, the mesorectal grade was complete (n = 52) and nearly complete (n = 4) in the R-LAR group and complete (n = 43), nearly complete (n = 12), and incomplete (n = 2) in the L-LAR group (P = 0.033).

CONCLUSION

R-LAR was performed safely and effectively, using the da Vinci Surgical System. The use of the system resulted in acceptable perioperative outcomes compared to L-LAR.

Full robotic left colon and rectal cancer resection: technique and early outcome

OBJECTIVE

The technique for robotic resection of the left colon and anterior resection of the rectum with total mesorectal excision is not well defined. In this study we describe a method that standardizes robot and trocar position, and allows for a complete mobilization of the left colon and the rectum, without repositioning of the surgical cart. Outcome and pathology findings are also reported.

METHODS

From January 2007 to May 2008 a total of 55 consecutive patients affected by rectal and left colon cancer were operated on, with full robotic technique, using the Da Vinci robot. Data regarding outcome and pathology reports were prospectively collected in a dedicated database.

RESULTS

The following procedures were performed 27 left colectomies, 17 anterior resections, 4 intersphincteric resections, 7 abdominoperineal resections. There were 21 female and 34 male patients with a mean age of 63 +/- 9.9 years. Mean operative time was 290 +/- 69 minutes, ranging from 164 to 487 min., none were converted to open surgery. The median number of lymph nodes harvested was 18.5 +/- 8.3 (range 5-45), and circumferential margin was negative in all cases. Distal margin was 25.15 +/- 12.9 mm (range 6-55) for patients with rectal cancer, and 31.6 +/- 20 mm for all the patients in this series. Anastomotic leak rate was 12.7% (7/55); in all cases conservative treatment was successful.

CONCLUSIONS

Full robotic colorectal surgery is a safe and effective technique that exploits the advantages of the Da Vinci robot during the whole intervention, without the need to make use of hybrid operations. Outcome and pathology findings are comparable with those observed in open and laparoscopy procedures.

Robotic colorectal surgery

Robotic colorectal surgery has gradually been performed more with the help of the technological advantages of the da Vinci system. Advanced technological advantages of the da Vinci system compared with standard laparoscopic colorectal surgery have been reported. These are a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, despite these technological advantages, most studies did not report the clinical advantages of robotic colorectal surgery compared to standard laparoscopic colorectal surgery. Only one study recently implies the real benefits of robotic rectal cancer surgery. The purpose of this review article is to outline the early concerns of robotic colorectal surgery using the da Vinci system, to present early clinical outcomes from the most current series, and to discuss not only the safety and the feasibility but also the real benefits of robotic colorectal surgery. Moreover, this article will comment on the possible future clinical advantages and limitations of the da Vinci system in robotic colorectal surgery.