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

Feasibility of hybrid robotic rectal surgery

PURPOSE

To investigate the feasibility of combined robotic rectal surgery and transanal total mesorectal excision (hybrid robotic surgery).

METHODS

Among 143 robotic rectal surgeries performed from 2017 to 2022, 85 were hybrid robotic surgeries and were analyzed in this study. The cohort comprised 59 males and 26 females with a mean age of 65.8 years old and a mean body mass index of 22.6 kg/m2. The cStage was I in 20 cases, II in 21, III in 36, IV in 4, and other in 4. The operation types were low anterior resection in 21 cases, intersphincteric resection in 27, abdominoperineal resection in 32, total pelvic exenteration in 2, and other in 3. Twelve patients (14.1%) received neoadjuvant chemotherapy or chemoradiotherapy, and 39 (45.9%) underwent lateral lymph node dissection.

RESULTS

The mean operation time for total mesorectal excision was 302.7 min, and the median blood loss was 71.5 ml. No cases required conversion to laparotomy. The median length of postoperative hospital stay was 15.9 days. Complications of Clavien-Dindo grade ≥ 3 occurred in 3 cases (4.2%). Urinary dysfunction occurred in 6 cases (8.3%). Three (4.2%) patients were diagnosed with positive circumferential resection margins.

CONCLUSION

Hybrid robotic surgery is safe and oncologically feasible.

Comparative study of robotic-assisted vs. laparoscopic surgery for colorectal cancer: a single-center experience

Background

Colorectal cancer (CRC) surgeries are commonly performed using either robotic-assisted colorectal surgery (RACS) or laparoscopic colorectal surgery (LCS). This study aimed to compare clinical and surgical outcomes between RACS and LCS for CRC patients.

Methods

We included 225 patients from Tianjin Medical University Cancer Institute & Hospital (TJMUCH) between January 2021 and June 2024, divided into RACS (n=82) and LCS (n=143) groups. Data on demographics, clinicopathological variables, surgical parameters, and perioperative outcomes were analyzed. Statistical significance was set at p < 0.05.

Results

RACS was associated with longer surgery durations (median: 218.5 vs. 165 minutes) and greater blood loss (median: 100 vs. 50 mL) compared to LCS (p < 0.001 for both). Additionally, the median hospitalization cost was notably higher for RACS at 117,822 RMB compared to 78,174 RMB for LCS (p < 0.0001). RACS was used more frequently for proctectomy (87.80% vs. 72.48%). No significant differences were found in lymph node dissection (LND), postoperative hospital stay, conversion to open surgery, or postoperative complications between the groups (p > 0.05). Anastomotic leakage was the most common complication in both groups (RACS: 3.66%, LCS: 4.20%), with no significant difference in incidence (p = 0.876). To reduce bias due to surgical site, cases of rectal and sigmoid colon cancer were singled out. Hierarchical analysis showed significant differences still remained in surgical duration, blood loss, and surgical site distribution for proctectomy and sigmoid colon resection (p < 0.001). RACS did not show a clear advantage in surgical field exposure or tissue retraction.

Conclusion

RACS, despite superior visualization, involved longer operative times and more blood loss than LCS. Both techniques had similar clinical outcomes, with LCS offering specific technical advantages.

Outcome of Colorectal Robotic Surgery in Newly Established Robotic Surgery Center: A Case Series

INTRODUCTION

The robotic platform compared to laparoscopy has proven to have similar postoperative outcomes, however its adoption in the Middle East has been slow and there is limited data regarding outcomes with its use in small newly established robotic colorectal programs. Our aim was to report our experience and outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare them to larger, more experienced centers.

METHODS

This is retrospective review of data collected between November 2021 and March 2023 from a tertiary health care referral center. The series included 51 patients who had elective or urgent robotic colorectal surgery. Patients who had emergency surgery were excluded. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and quality of oncological specimen.

RESULTS

The overall morbidity was 31.4% (n = 16 patients). Only 9.8% (n = 5) had serious morbidity of which three required interventions under general anesthesia. The median length of hospital stay was 6 days (IQR = 4), and there was no mortality. Of 17 rectal cancer resections, 88% had complete mesorectal excision, 15 of them were R0 resections, median lymph node harvested was 14 (IQR = 7) and two cases were converted to open. All the colon cancer resections had R0 resection, median lymph nodes harvested was 21 (IQR = 4) and none were converted to open.

CONCLUSIONS

The implementation and integration of robotic colorectal surgery at a newly established center in a small country, when led by fellowship trained robotic colorectal surgeons, is safe and effective in terms of morbidity, mortality, conversion to open and specimen pathological quality.

Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

The deconstructed procedural description in robotic colorectal surgery

Increasing robotic surgical utilisation in colorectal surgery internationally has strengthened the need for standardised training. Deconstructed procedural descriptions identify components of an operation that can be integrated into proficiency-based progression training. This approach allows both access to skill level appropriate training opportunities and objective and comparable assessment. Robotic colorectal surgery has graded difficulty of operative procedures lending itself ideally to component training. Developing deconstructed procedural descriptions may assist in the structure and progression components in robotic colorectal surgical training. There is no currently published guide to procedural descriptions in robotic colorectal surgical or assessment of their training utility. This scoping review was conducted in June 2022 following the PRISMA-ScR guidelines to identify which robotic colorectal surgical procedures have available component-based procedural descriptions. Secondary aims were identifying the method of development of these descriptions and how they have been adapted in a training context. 20 published procedural descriptions were identified covering 8 robotic colorectal surgical procedures with anterior resection the most frequently described procedure. Five publications included descriptions of how the procedural description has been utilised for education and training. From these publications terminology relating to using deconstructed procedural descriptions in robotic colorectal surgical training is proposed. Development of deconstructed robotic colorectal procedural descriptions (DPDs) in an international context may assist in the development of a global curriculum of component operating competencies supported by objective metrics. This will allow for standardisation of robotic colorectal surgical training and supports a proficiency-based training approach.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery

BACKGROUND/OBJECTIVE

The reduced-port approach can overcome the limitations of single-incision laparoscopic surgery while maintaining its advantages. Here, we compared the effects of robotic reduced-port surgery and conventional laparoscopic approaches for left-sided colorectal cancer.

METHODS

Between January 2015 and December 2016, the clinicopathological characteristics and treatment outcomes of 17 patients undergoing robotic reduced-port surgery and 49 patients undergoing laparoscopic surgery for left-sided colorectal cancer were compared.

RESULTS

The two groups were comparable in almost all outcome measures except for the distal resection margin, which was significantly longer in the laparoscopic group (P < 0.001). The between-group differences in reoperation, incisional hernia development, and overall and progression-free survival were nonsignificant; however, the total hospital cost was significantly higher in the robotic group than in the laparoscopic group (US$13779.6 ± US$3114.8 vs. US$8556.3 ± US$2056.7, P < 0.001).

CONCLUSION

Robotic reduced-port surgery for left-sided colorectal cancer is safe and effective but more expensive with no additional benefit compared with the conventional laparoscopic approach. This observation warrants further evaluation.

Robotic colorectal surgery in elderly patients: A single‐centre experience

Introduction

The purpose of this study was to evaluate outcomes in elderly patients (age ≥ 65 years) undergoing robotic colorectal surgery (RCRS) in comparison with non‐elderly patients.

Materials and Methods

Data was collected on elderly and non‐elderly patients who underwent RCRS from a prospectively maintained database.

Results

A total of 89 elderly and 73 non‐elderly patients were identified. No statistically significant differences in postoperative complication, reoperation, wound infection, anastomotic leak or mortality were observed. The median length of stay was 1 day longer in elderly patients (p = 0.007). Subgroup analysis of octogenarians demonstrated outcomes that compared favourably with younger patients.

Conclusion

RCRS in elderly patients is safe and effective, with outcomes that do not differ significantly with younger patients. Older age should not be considered to be a specific exclusion criteria for RCRS. To our knowledge, this study represents the largest in the literature to examine outcomes specifically in elderly patients undergoing RCRS.

Is Robotic Assisted Colorectal Cancer Surgery Equivalent Compared to Laparoscopic Procedures during the Introduction of a Robotic Program? A Propensity-Score Matched Analysis

Simple Summary

The introduction of a robotic program is challenging and requires extensive experience in minimally invasive surgery. Short-term outcomes and oncological quality should not differ between robotic and laparoscopic surgery. To our knowledge, no data on the quality of surgery at the time of introduction of the robotic platform are available. The aim of this study was to compare short-term outcomes and oncological findings of robotic-assisted colorectal resections with those of conventional laparoscopic surgery within the first three years after the introduction of the robotic platform.

Abstract

Background: Robotic surgery represents a novel approach for the treatment of colorectal cancers and has been established as an important and effective method over the last years. The aim of this work was to evaluate the effect of a robotic program on oncological findings compared to conventional laparoscopic surgery within the first three years after the introduction. Methods: All colorectal cancer patients from two centers that either received robotic-assisted or conventional laparoscopic surgery were included in a comparative study. A propensity-score-matched analysis was used to reduce confounding differences. Results: A laparoscopic resection (LR Group) was performed in 82 cases, and 93 patients were treated robotic-assisted surgery (RR Group). Patients’ characteristics did not differ between groups. In right-sided resections, an intracorporeal anastomosis was significantly more often performed in the RR Group (LR Group: 5 (26.31%) vs. RR Group: 10 (76.92%), p = 0.008). Operative time was shown to be significantly shorter in the LR Group (LR Group: 200 min (150–243) vs. 204 min (174–278), p = 0.045). Conversions to open surgery did occur more often in the LR Group (LR Group: 16 (19.51%) vs. RR Group: 5 (5.38%), p = 0.004). Postoperative morbidity, the number of harvested lymph nodes, quality of resection and postoperative tumor stage did not differ between groups. Conclusion: In this study, we could clearly demonstrate robotic-assisted colorectal cancer surgery as effective, feasible and safe regarding postoperative morbidity and oncological findings compared to conventional laparoscopy during the introduction of a robotic system.

The impact of body mass index on outcomes in robotic colorectal surgery: a single-centre experience

Obesity is an independent risk factor for postoperative morbidity and mortality in laparoscopic colorectal surgery (LCRS). The technological advantages of robotic colorectal surgery (RCRS) may allow surgeons to overcome the limitations of LCRS in obese patients, but it is largely unknown if this translates to superior outcomes. The aim of this study was to compare perioperative, postoperative and short-term oncological outcomes in obese (BMI ≥ 30.0 kg/m²) and non-obese (BMI < 30 kg/m²) patients undergoing RCRS in a university teaching hospital. Demographic, perioperative and postoperative data along with short-term oncological outcomes of obese and non-obese patients that underwent RCRS for both benign and malignant colorectal disease were identified from a prospectively maintained database. A total of 107 patients (34 obese, 73 non-obese) underwent RCRS over a 4-year period. No statistically significant differences in the incidence of complications, 30-day reoperation, 30-day mortality, conversion to open surgery, anastomotic leak or length of inpatient stay were demonstrated. Obese patients had a significantly higher rate of surgical site infection (SSI) (p < 0.0001). Short-term oncological outcomes in both groups were favourable. There was no statistically significant difference in median duration of surgery between the two cohorts. The results demonstrate that obese patients undergoing RCRS in this institution experience similar outcomes to non-obese patients. These results suggest that RCRS is safe and feasible in obese patients and may be superior to LCRS in this cohort, where the literature suggests a higher complication rate compared to non-obese patients. The inherent advantages of robotic surgical platforms, such as improved visualisation, dexterity and ergonomics likely contribute to the improved outcomes in this challenging patient population.

Advantages of robotic surgery in the treatment of complex pelvic organs prolapse

Robot-assisted surgery is safe and effective to treat the complex pelvic organs prolapse (C-POP). The present study analyzes all the robotic procedures and their advantages in the treatment of C-POP performed in a Proctologic and Pelvic Floor Clinical Centre. All the patients affected by C-POP who had robot-assisted surgery were retrospective analyzed. The anatomical and functional outcomes were respectively evaluated through POP-Q grading system and Wexner score about constipation and incontinence. The satisfaction rate was investigated using a five-point scale. From September 2014 to December 2018, 229 women underwent robotic surgery. The follow-up was 12 months. There were no robot-related complications. One hematoma (4.5%) of the recto-vaginal space occurred after Robotic Ventral Rectopexy with Folded Mesh (R-VRP-FM). In the robotic assisted lateral suspension (R-ALS) group there was one case of anterior vaginal wall mesh exposure (0.9%). After the robotic ventral rectopexy (R-VRP) the recurrence rate of external rectal prolapse, internal rectal prolapse, rectocele and enterocele was respectively 6.6, 9.5, 7.4 and 9.5%. After R-VRP-FM only one cystocele (14%) and one partial rectal prolapse (25%) recurred. Vaginal bulge symptoms resolution rate was 95.4%. The mean Wexner constipation score significantly decreased after R-VRP and R-VRP-FM. Vaginal bulge symptoms improved in 98.3% of cases with any apical prolapse recurrence after robotic abdominal colposacropexy. Success rate after R-ALS was 99.1% and 96.4% for apical and anterior prolapse respectively. Robotic assistance makes some surgical steps easier and more precise and this may result in less morbidity and better results.

Short-term clinical outcomes of a European training programme for robotic colorectal surgery

BACKGROUND

Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery-EARCS).

METHODS

Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors.

RESULTS

Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups.

CONCLUSIONS

Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.

Men With Inflammatory Bowel Disease: Sexual Function, Fertility, Medication Safety, and Prostate Cancer

Half of patients with inflammatory bowel disease (IBD) are men, yet less attention has been focused on their sexual issues despite higher rates of sexual dysfunction and infertility than the general population. Depression and IBD disease activity are the most consistently reported risk factor for sexual dysfunction among men with IBD. Methotrexate and sulfasalazine have been rarely associated with impotence. Sulfasalazine reversibly reduces male fertility. No other medications used in IBD significantly affect fertility in humans. There is no increase in adverse fetal outcomes among offspring of fathers with IBD. Patients with IBD seem to be at a higher risk for prostate cancer; therefore, screening as recommended for high-risk patients should be considered.

Comparison of outcome and cost between the open, laparoscopic, and robotic surgical treatments for colon cancer: a propensity score-matched analysis using nationwide hospital record database

BACKGROUND

There are limited studies that compare the cost and outcome of robotic-assisted surgery to open and laparoscopic surgery for colon cancer treatment. We aimed to compare the three surgical modalities for colon cancer treatment.

METHODS

We performed a cohort study using the population-based Nationwide Inpatient Sample database. Patients with a primary diagnosis of colon cancer who underwent robotic, laparoscopic, or open surgeries between 2008 and 2014 were eligible for enrollment. We compared in-hospital mortality, complications, length of hospital stay, and cost for patients undergoing one of these three procedures using a multivariate adjusted logistic regression analysis and propensity score matching.

RESULTS

Of the 531,536 patients undergoing surgical treatment for colon cancer during the study period, 348,645 (65.6%) patients underwent open surgeries, 174,748 (32.9%) underwent laparoscopic surgeries, and 8143 (1.5%) underwent robotic surgeries. In-hospital mortality, length of hospital stay, wound complications, general medical complications, general surgical complications, and costs of the three surgical treatment modalities. Compared to those undergoing laparoscopic surgery, patients undergoing open surgery had a higher mortality rate (OR 2.98, 95% CI 2.61-3.40), more general medical complications (OR 1.77, 95% CI 1.67-1.87), a longer length of hospital stay (6.60 vs. 4.36 days), and higher total cost ($18,541 vs. $14,487) in the propensity score matched cohort. Mortality rate and general medical complications were equivalent in the laparoscopic and robotic surgery groups, but the median cost was lower in the laparoscopic group ($14641 vs. $16,628 USD).

CONCLUSIONS

Laparoscopic colon cancer surgery was associated with a favourable short-term outcome and lower cost compared with open surgery. Robot-assisted surgery had comparable outcomes but higher cost as compared to laparoscopic surgery.

Hybrid abdominal robotic approach with conventional transanal total mesorectal excision (TaTME) for rectal cancer: feasibility and outcomes from a single institution

Total mesorectal excision (TME) is currently recognised as the standard of care for patients with rectal cancer. Complete TME is known to be associated with lower rates of recurrence. Robotic and endoscopic TaTME approaches are reported to offer excellent proximal and distal rectal dissection into the TME plane, however, combining both approaches in a hybrid procedure could potentially optimise visualisation of the dissection plane and confer improved circumferential and distal margin rates. The aim of this study was to analyse the feasibility of a hybrid robotic abdominal approach with conventional TaTME for rectal cancer. Furthermore, pathological and patient outcomes were assessed. A review of prospectively maintained databases was undertaken to assess all patients undergoing robotic TME surgery for rectal tumours from August 2016 to October 2017. Patient demographics, tumour characteristics and outcomes were collated from patient charts and hospital databases. All patients underwent a modified Cecil approach after multidisciplinary team discussion. Eight patients (7 male, 1 female) underwent a combined hybrid approach with a median age of 60 years (range 47-73) and BMI of 29.5 (range 20-39.1) kg/m². Median distance from the anorectal junction (ARJ) was 7.5 (range 4-13) cm. Six patients underwent neoadjuvant treatment with chemoradiotherapy. Patients had a median length of stay (LOS) of 9 (range 4-33) days. There were no intra-operative complications encountered and no patients required a conversion to an open procedure. Complications included one anastomotic leak and one presacral collection. All patients had a complete TME with RO resection with a median number of lymph nodes harvested was 22 (range 6-37) lymph nodes. This hybrid technique is a feasible, practical and operatively favourable approach to rectal cancer surgery with initial pathological outcomes and complication profile equivalent to other approaches.

Cost-effectiveness of current approaches in rectal surgery

Colorectal cancer is ranked as the fourth malignant cause of mortality. With the tremendous revolution in the modern medical techniques, minimally invasive approaches have been incorporated into rectal surgery. The effectiveness of surgical procedures is usually measured by a combination of qualitative (quality of life) and quantitative (years of life) measures, while the costs should reflect the use of different resources that were involved in delivering the medical care and they are affected by several factors, including length of hospital stay. In this review, we provide an insight into the cost-effectiveness of the different types of rectal surgeries in order to present a systematic approach for future preferences. A comprehensive literature review using Medline (via PUBMED), Embase and Cochrane Central Register of clinical trials (via clinical trial.org) was performed. Minimally invasive rectal surgeries have considerable cost-effective properties that outweigh those of the open techniques in terms of earlier return to bowel function, lower morbidity rates, reduced pain, shorter length of hospital stay and the overall patients’ quality of life although there was no difference in long-term oncological and survival outcomes. The paucity of currently available long-term oncologic, quality of life, and economic outcomes may limit an adequate comparison of robotic surgeries to other surgical techniques. It is therefore recommended to conduct focused studies to help balance the cost/benefit factors along with other technical considerations aimed at reducing the cost of robotic systems with subsequent improvement of their cost-effectiveness.

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Colorectal cancer is the fourth cause of mortality. Minimally invasive surgery is now considered the standard of care.

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Cost of minimally invasive surgery is offset by the better outcomes due to less complications and shorter hospital stay.

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TaTME requires two working teams and two sets of instruments which increases the total cost.

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Robotic surgery in obese patients demonstrated superior results when it comes to hospital stay and overall complications.

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Well conducted clinical trials looking at cost effectiveness of new technologies in colorectal surgery are needed.

Monopolar Electrosurgical Scissors Versus Harmonic Scalpel in Robotic Anterior Resection of Rectal Cancer: A Retrospective Cohort Study

Background: Robot-assisted surgical techniques have been introduced in recent years as an alternative minimally invasive approach for colorectal surgery. In practice, we found that the monopolar electrosurgical scissors had its unique advantages in preservation of the pelvic autonomic nerves. We performed a retrospective review of short-term results between using monopolar electrosurgical scissors and harmonic scalpel in robotic anterior resection (using the da Vinci^® Surgical System) in rectal cancer patients. Method: Forty-six patients who underwent robotic anterior resection of rectal cancer from June 2016 to January 2018 were retrospectively analyzed and compared. Twenty-two cases underwent resection using monopolar electrosurgical scissors and 24 cases underwent resection using the harmonic scalpel. Patient characteristics, perioperative clinical results, complications, and pathological results were compared between two groups. Results: There were not significantly different patient characteristics between the two groups. The mean operative time was lesser in the monopolar electrosurgical scissors group than in the inharmonic scalpel group [95.59 ± 21.44 minutes versus 81.45 ± 13.89 minutes, P < .01]. The mean estimated blood loss was lesser in the monopolar electrosurgical scissors group than in the inharmonic scalpel group [48.64 ± 19.35 mL versus 61.82 ± 24.23 mL, P = .03]. The complication rate was 18.2% in the monopolar electrosurgical scissors group and 16.7% in the harmonic scalpel group (P = .89). The mean time of postoperational urinary catheter was lesser in the monopolar electrosurgical scissors group [3.73 ± 1.16 days versus 4.59 ± 1.71 days, P = .02]. The day to first passing flatus [3.45 ± 0.80 days versus 3.59 ± 1.14 days, P = .67], feeding time [4.50 ± 1.00 days versus 4.05 ± 1.87 days, P = .35], hospital stay [8.18 ± 3.74 days versus 8.68 ± 3.44 days, P = .52], and the mean number of harvested lymph nodes of detection [13.59 ± 1.71 versus 13.77 ± 1.41, P = .67] were comparable between procedures. Conclusion: Monopolar electrosurgical scissors were used safely and effectively in robotic anterior resection of rectal cancer (using the da Vinci Surgical System). The use of monopolar electrosurgical scissors has benefits in performing blunt and sharp separation in narrow pelvic and cheaper hospitalization expenses.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Comparison of Short-Term Outcomes Between Robotic-Assisted and Laparoscopic Surgery in Colorectal Cancer

Aim. The robotic technique has been established as an alternative approach to laparoscopy in colorectal surgery. The aim of this study was to compare short-term outcomes of robot-assisted and laparoscopic surgery in colorectal cancer. Methods. The cases of robot-assisted or laparoscopic colorectal resection were collected retrospectively between July 2015 and October 2017. We evaluated patient demographics, perioperative characteristics, and pathologic examination. A multivariable linear regression model was used to assess short-term outcomes between robot-assisted and laparoscopic surgery. Short-term outcomes included time to passage of flatus and postoperative hospital stay. Results. A total of 284 patients were included in the study. There were 104 patients in the robotic colorectal surgery (RCS) group and 180 in the laparoscopic colorectal surgery (LCS) group. The mean age was 60.5 ± 10.8 years, and 62.0% of the patients were male. We controlled for confounding factors, and then the multiple linear model regression indicated that the time to passage of flatus in the RCS group was 3.45 days shorter than the LCS group (coefficient = −3.45, 95% confidence interval [CI] = −5.19 to −1.71; P < .001). Additionally, the drainage of tube duration (coefficient = 0.59, 95% CI = 0.3 to 0.87; P < .001) and transfers to the intensive care unit (coefficient = 7.34, 95% CI = 3.17 to 11.5; P = .001) influenced the postoperative hospital stay. The total costs increased by 15501.48 CNY in the RCS group compared with the LCS group ( P = .008). Conclusions. The present study suggests that colorectal cancer robotic surgery was more beneficial to patients because of shorter postoperative recovery time of bowel function and shorter hospital stays.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PURPOSE

Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.

METHODS

All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.

RESULTS

A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).

CONCLUSIONS

In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

Short-term surgical outcomes and patient quality of life between robotic and laparoscopic extralevator abdominoperineal excision for adenocarcinoma of the rectum

Introduction Some studies advocate a laparoscopic extralevator abdominoperineal excision (l-ELAPE) approach for low rectal cancer. The da Vinci™ robot (r-ELAPE) technique has potential to overcome some limitations of l-ELAPE, such as reduction of the learning curve and more precise tissue handling. It is unknown whether this approach results in improved surgical or quality of life outcomes compared with l-ELAPE. This study aimed to address this issue. Methods Consecutive patients having undergone either robotic or laparoscopic ELAPE for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by postoperative histology and short-term complications. Quality of life was prospectively assessed using the European Organisation for Research and Treatment of Cancer QLC-CR30 and QLC-CR29 questionnaires. Results A total of 22 patients (11 r-ELAPE) with a median follow-up of 13 months (8 months robotic; 22 months laparoscopic) were studied. The groups were similarly matched for age, gender, American Society of Anesthesiologists status, preoperative chemoradiotherapy and tumour height. All had R0 resection. There was no significant difference in short-term surgical outcomes between groups. There was no significant difference in mean global health scores between the two groups (74 ± 14 r-ELAPE vs. 73 ± 10 l-ELAPE). The r-ELAPE group had a lower mean impotence score compared with the I-ELAPE group (55.5 ± 40 vs. 72.2 ± 44), although this was not statistically significant. Conclusions The newly introduced r-ELAPE was non-inferior to l-ELAPE in either patient quality of life or surgical outcomes. Robotic surgery could be particularly beneficial in the technically challenging area of low rectal cancer surgery with a shorter learning curve than laparoscopy.

Outcomes of robotic versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiation therapy and the effect of learning curve

Randomized controlled trials have demonstrated that laparoscopic surgery for rectal cancer is safe and can accelerate recovery without compromising oncological outcomes. However, such a surgery is technically demanding, limiting its application in nonspecialized centers. The operational features of a robotic system may facilitate overcoming this limitation. Studies have reported the potential advantages of robotic surgery. However, only a few of them have featured the application of this surgery in patients with advanced rectal cancer undergoing neoadjuvant chemoradiation therapy (nCRT).From January 2012 to April 2015, after undergoing nCRT, 40 patients with mid or low rectal cancer were operated using the robotic approach at our institution. Another 38 patients who were operated using the conventional laparoscopic approach were matched to patients in the robotic group by sex, age, the body mass index, and procedure. All operations were performed by a single surgical team. The clinicopathological characteristics and short-term outcomes of these patients were compared. To assess the effect of the learning curve on the outcomes, patients in the robotic group were further subdivided into 2 groups according to the sequential order of their procedures, with an equal number of patients in each group. Their outcome measures were compared.The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, rectal resection type, and pathological examination result. After undergoing nCRT, more patients in the robotic group exhibited clinically advanced diseases. The complication rate was similar between the 2 groups. The operation time and the time to the resumption of a soft diet were significantly prolonged in the robotic group. Further analysis revealed that the difference was mainly observed in the first robotic group. No significant difference was observed between the second robotic and laparoscopic groups.Although the robotic approach may offer potential advantages for rectal surgery, comparable short-term outcomes may be achieved when laparoscopic surgery is performed by experienced surgeons. However, our results suggested a shorter learning curve for robotic surgery for rectal cancer, even in patients who exhibited more advanced disease after undergoing nCRT.

Precision in robotic rectal surgery using the da Vinci Xi system and integrated table motion, a technical note

Robotic rectal surgery is becoming increasingly more popular among colorectal surgeons. However, time spent on robotic platform docking, arm clashing and undocking of the platform during the procedure are factors that surgeons often find cumbersome and time consuming. The newest surgical platform, the da Vinci Xi, coupled with integrated table motion can help to overcome these problems. This technical note aims to describe a standardised operative technique of single docking robotic rectal surgery using the da Vinci Xi system and integrated table motion. A stepwise approach of the da Vinci docking process and surgical technique is described accompanied by an intra-operative video that demonstrates this technique. We also present data collected from a prospectively maintained database. 33 consecutive rectal cancer patients (24 male, 9 female) received robotic rectal surgery with the da Vinci Xi during the preparation of this technical note. 29 (88%) patients had anterior resections, and four (12%) had abdominoperineal excisions. There were no conversions, no anastomotic leaks and no mortality. Median operation time was 331 (249–372) min, blood loss 20 (20–45) mls and length of stay 6.5 (4–8) days. 30-day readmission rate and re-operation rates were 3% (n = 1). This standardised technique of single docking robotic rectal surgery with the da Vinci Xi is safe, feasible and reproducible. The technological advances of the new robotic system facilitate the totally robotic single docking approach.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy

OBJECTIVE

The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic.

BACKGROUND

The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes.

METHODS

Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes.

RESULTS

A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group.

CONCLUSIONS

The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

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.

Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study

PURPOSE

Urological and sexual dysfunction are recognised risks of rectal cancer surgery; however, there is limited evidence regarding urogenital function comparing robotic to laparoscopic techniques. The aim of this study was to assess the urogenital functional outcomes of patients undergoing laparoscopic and robotic rectal cancer surgery.

METHODS

Urological and sexual functions were assessed using gender-specific validated standardised questionnaires. Questionnaires were sent a minimum of 6 months after surgery, and patients were asked to report their urogenital function pre- and post-operatively, allowing changes in urogenital function to be identified. Questionnaires were sent to 158 patients (89 laparoscopy, 69 robotic) of whom 126 (80 %) responded. Seventy-eight (49 male, 29 female) of the responders underwent laparoscopic and 48 (35 male, 13 female) robotic surgery.

RESULTS

Male patients in the robotic group deteriorated less across all components of sexual function and in five components of urological function. Composite male urological and sexual function score changes from baseline were better in the robotic cohort (p < 0.001). In females, there was no difference between the two groups in any of the components of urological or sexual function. However, composite female urological function score change from baseline was better in the robotic group (p = 0.003).

CONCLUSION

Robotic rectal cancer surgery might offer better post-operative urological and sexual outcomes compared to laparoscopic surgery in male patients and better urological outcomes in females. Larger scale, prospective randomised control studies including urodynamic assessment of urogenital function are required to validate these results.

Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

AIM

To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery.

METHODS

A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors.

RESULTS

Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions.

CONCLUSION

There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients.

Robotic Surgery for Colon and Rectal Cancer

Robotic surgery, used generally for colorectal cancer, has the advantages of a three-dimensional surgical view, steadiness, and seven degrees of robotic arms. However, there are disadvantages, such as a decreased sense of touch, extra time needed to dock the robotic cart, and high cost. Robotic surgery is performed using various techniques, with or without laparoscopic surgery. Because the results of this approach are reported to be similar to or less favorable than those of laparoscopic surgery, the learning curve for robotic colorectal surgery remains controversial. However, according to short- and long-term oncologic outcomes, robotic colorectal surgery is feasible and safe compared with conventional surgery. Advanced technologies in robotic surgery have resulted in favorable intraoperative and perioperative clinical outcomes as well as functional outcomes. As the technical advances in robotic surgery improve surgical performance as well as outcomes, it increasingly is being regarded as a treatment option for colorectal surgery. However, a multicenter, randomized clinical trial is needed to validate this approach.

The Learning Curve of Robotic-Assisted Low Rectal Resection of a Novice Rectal Surgeon

BACKGROUND

With the increasing availability of the surgical robotic system, the young generation colorectal surgeons may learn robotic-assisted rectal surgery upfront. There are currently very limited studies evaluating the learning curve of novice rectal surgeons.

OBJECTIVE

This study aimed to evaluate the learning curve of a surgeon who had limited experience in open and laparoscopic rectal surgery.

METHODS

Thirty-nine consecutive robotic-assisted total mesorectal excisions were performed from March 2013 to October 2014. All cases were performed by a single surgeon whose prior experience in open or laparoscopic low rectal cancer resections was <5 cases. The learning curve was analyzed using the cumulative sum method.

RESULTS

Thirty-four low anterior resections, four abdomino-perineal resections, and one Hartmann's operation were performed. The mean total operating time was 397.2 ± 184.3 min. There was no conversion. The major complication rate was 10.3 %. When total operating time was analyzed with the CUSUM method, three phases could be identified. They are the initial eight cases, middle 17 cases, and the final 14 cases. The first phase consisted of more proximal tumors (86.3 ± 20.7 vs. 58.0 ± 34.9 mm from anal verge, p = 0.04) and was associated with a shorter total operating time (243.5 ± 38.0 vs. 540.9 ± 133.4 min, p = 0.000) and less estimated blood loss (81.3 ± 25.9 vs. 168.8 ± 99.5 ml, p = 0.02) compared to the second phase. When the third phase is compared with the first and second phase, it has shorter total operating time (310.6 ± 164.5 vs. 44 5.7 ± 179.8 min, p = 0.03). Complications rate were 12.5, 17.6, and 0 % for phase one, two, and three respectively.

CONCLUSIONS

In this study, the learning curve for a novice rectal surgeon was 25 cases. This is comparable to those who have already mastered the technique with laparoscopic or open approach. Surgical robotic system may have a role in shortening the learning curve for low rectal resection.

Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades

The advent of total mesorectal excision (TME) together with minimally invasive techniques such as laparoscopic colorectal surgery and robotic surgery has improved surgical results. However, the incidence of bladder and sexual dysfunction remains high. This may be particularly distressing for the patient and troublesome to manage for the surgeon when it does occur. The increased use of neoadjuvant and adjuvant radiotherapy is also associated with poorer functional outcomes. In this review, we evaluate current understanding of the anatomy of pelvic nerves which are divided into the areas of the inferior mesenteric artery pedicle, the lateral pelvic wall and dissection around the urogenital organs. Surgical techniques in these areas are discussed. We also discuss the results in functional outcomes of the various techniques including open, laparoscopic and robotic over the last 30 years.

Novel technique of robotic extralevator abdominoperineal resection with gracilis flap closure

BACKGROUND

The purpose of this paper is to introduce a robotic assisted approach to extralevator abdominoperineal excision in the modified Lloyd-Davis position with reconstruction of the perineum using pedicled gracilis flaps, and to discuss outcomes in a cohort of six patients.

METHODS

Data was collected by chart review on six patients who underwent extralevator excision with gracilis flap reconstruction from 10/2013 to 06/2015. Technical details, operative data, oncologic outcomes, and wound healing complications were evaluated.

RESULTS

There were no instances of intraoperative perforation or positive circumferential resection margin, and one case of locoregional recurrence. Two patients experienced flap venous congestion and one patient developed a perineal abscess. All patients went on to complete healing.

CONCLUSIONS

The combination of a minimally invasive robotic assisted extralevator abdominoperineal excision performed in the modified Lloyd-Davis position with reconstruction of the perineum with pedicled gracilis flaps has excellent oncologic outcomes and acceptable wound healing complications. Copyright © 2016 John Wiley & Sons, Ltd. StartCopTextCopyright © 2016 John Wiley & Sons, Ltd.

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.

Combining all forces: abdominoperineal resection in an obese male

BACKGROUND

In patients with rectal cancer, pelvic dissection is challenging. A complete total mesorectal excision (TME) is particularly difficult in a narrow and long pelvis often encountered in males. This difficulty is compounded in the obese. In addition to the open approach being morbid, laparoscopy has often proven difficult secondary to rigid instruments along with a steep learning curve. Robot assistance offers an advantage, however limitations are observed in abdominal colon dissection outside of the pelvis. As these individual modalities have their disadvantages, they each can contribute unique aspects in a combined or a hybrid approach to rectal tumors. Therefore, a multi-modal, combined approach, involving hand assist, laparoscopic, and robotic assistance, to a 5-cm tumor at the anal verge was applied to an abdominoperineal resection in an obese, male patient.

METHODS

An obese 58-year-old male, BMI of 36 kg/m², with a 5-cm anal canal squamous cell carcinoma which recurred after Nigro protocol treatment, underwent a multi-modal abdominoperineal resection.

RESULTS

The approach to recurrent anal cancer is as that for rectal cancer. Hence, a hand port was placed to assist in colon mobilization, visceral mesenteric dissection, and to facilitate the laparoscopic division of the inferior mesenteric artery (IMA) at its origin. The robot was used for deep pelvic dissection and TME. The levators were divided in the perineal phase. A complete mesorectal excision was achieved and a cylindrical specimen was extracted.

CONCLUSIONS

An abdominoperineal resection with a multi-modal approach (hand assist, laparoscopic, and robotic) is safe and effective in resection of low rectal cancers especially in the narrow, obese, and male pelvis.

Clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer: initial results in a center for minimally invasive surgery

PURPOSE

A robotic system was mainly designed to allow precise dissection in deep and narrow spaces. We report the clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer.

METHODS

Between July 2009 and January 2012, 60 consecutive patients undergoing robotic surgery for rectal cancer at the Eulji University Hospital were included.

RESULTS

The mean total operation time, docking time, and surgeon console time were 466.8 ± 115.6, 7.5 ± 6.7, and 261 ± 87.5 min, respectively. Oral intake of diet was started at 3.3 ± 0.9 days and the mean hospital stay was 8.6 ± 2.4 days. All 60 procedures were technically successful without the need for conversion to open or laparoscopic surgery. Complications included anastomotic leakage, anastomotic stricture, postoperative bleeding, ileus, and perineal wound infection in 3 (5 %), 1 (1.7 %), 2 (3.3 %), 2 (3.3 %), and 1 (1.7 %) patient, respectively. The mean distal resection margin and total number of lymph nodes harvested was 3.1 ± 1.7 cm and 20.1 ± 11.5, respectively. During the mean follow-up period of 48.5 months (range, 7-75), the 4-year overall and disease-free survival rates were 87.7 and 72.8 %, respectively.

CONCLUSIONS

A totally robotic approach for rectal cancer operations was a time-consuming procedure, although we already had a lot experience in laparoscopic colorectal surgery. However, the dexterity of the robotic surgery could enable the surgeon to expand the choice of surgical methods according to the condition of the rectal cancer without the need for conversion.

Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.

Laparoscopy Versus Robotic Surgery for Colorectal Cancer: A Single-Center Initial Experience

Background Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.