Robotic total mesorectal excision: operative technique and review of the literature

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

Robotics Total Mesorectal Excision Up To the Minute

Surgical techniques have evolved over the past few decades, and minimally invasive surgery has been rapidly adapted to become a preferred operative approach for treating colorectal diseases. However, many of the procedures remain a technical challenge for surgeons to perform laparoscopically, which has prompted the development of robotic platforms. Robotic surgery has been introduced as the latest advance in minimally invasive surgery. The present article provides an overview of robotic rectal surgery and describes many advances that have been made in the field over the past two decades. More specifically, the introduction of the robotic platform and its benefits, and the limitations of current robotic technology, are discussed. Although the main advantages of robotic surgery over conventional laparoscopy appear to be lower conversion rates and better surgical specimen quality, oncological and functional outcomes appear to be similar to those of other alternatives. Other potential benefits include earlier recovery of voiding and sexual function after robotic total mesorectal excision. Nevertheless, the costs and lack of haptic feedback remain the primary limitations to the widespread use of robotic technology in the field.

Developing a robotic colorectal cancer surgery program: understanding institutional and individual learning curves

IMPORTANCE

Robotic colorectal resection continues to gain in popularity. However, limited data are available regarding how surgeons gain competency and institutions develop programs.

OBJECTIVE

To determine the number of cases required for establishing a robotic colorectal cancer surgery program.

DESIGN

Retrospective review.

SETTING

Cancer center.

PATIENTS

We reviewed 418 robotic-assisted resections for colorectal adenocarcinoma from January 1, 2009, to December 31, 2014, by surgeons at a single institution. The individual surgeon's and institutional learning curve were examined. The earliest adopter, Surgeon 1, had the highest volume. Surgeons 2-4 were later adopters. Surgeon 5 joined the group with robotic experience.

INTERVENTIONS

A cumulative summation technique (CUSUM) was used to construct learning curves and define the number of cases required for the initial learning phase. Perioperative variables were analyzed across learning phases.

MAIN OUTCOME MEASURE

Case numbers for each stage of the learning curve.

RESULTS

The earliest adopter, Surgeon 1, performed 203 cases. CUSUM analysis of surgeons' experience defined three learning phases, the first requiring 74 cases. Later adopters required 23-30 cases for their initial learning phase. For Surgeon 1, operative time decreased from 250 to 213.6 min from phase 1-3 (P = 0.008), with no significant changes in intraoperative complication or leak rate. For Surgeons 2-4, operative time decreased from 418 to 361.9 min across the two phases (P = 0.004). Their intraoperative complication rate decreased from 7.8 to 0 % (P = 0.03); the leak rate was not significantly different (9.1 vs. 1.5 %, P = 0.07), though it may be underpowered given the small number of events.

CONCLUSIONS

Our data suggest that establishing a robotic colorectal cancer surgery program requires approximately 75 cases. Once a program is well established, the learning curve is shorter and surgeons require fewer cases (25-30) to reach proficiency. These data suggest that the institutional learning curve extends beyond a single surgeon's learning experience.

Robotic-laparoscopic rectal cancer excision versus traditional laparoscopy

BACKGROUND AND OBJECTIVES

Robotic surgery has been advocated for the radical excision of rectal cancer. Most data supporting its use have been reported from European and Asian centers, with a paucity of data from the United States documenting clear advantages of the robotic technique. This study compares the short-term outcome of robotic versus laparoscopic surgery.

METHODS

Consecutive patients who underwent laparoscopic (group 1) or robotic (group 2) rectal cancer excision at a single institution over a 2-year period were retrospectively reviewed. The main outcome measures were operative time, blood loss, conversion rates, number of lymph nodes, margin positivity, length of hospital stay, complications, and readmission rates.

RESULTS

Forty-two patients were analyzed. The median operative time was shorter in group 1 than that in group 2 (240 minutes vs 260 minutes, P=.04). No difference was noted in blood loss, transfusion rates, intraoperative complications, or conversion rates. There was no difference in circumferential or distal margin positivity. The median length of stay was shorter in group 1 (5 days vs 6 days, P=.05). The 90-day complication rate was similar in both groups (33% vs 43%, P=.75), but there was a trend toward more anastomotic leaks in group 1 (14% vs 0%, P=.23). Similarly, a non-statistically significant trend toward a higher readmission rate was noted in group 1 (24% vs 5%, P=.18).

CONCLUSION

Robotic rectal cancer excision yielded a longer operative time and hospital length of stay, although immediate oncologic results were comparable. The need for randomized data is critical to determine whether the added resource utilization in robotic surgery is justifiable.

Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors’ centre.

Single stage robotic total mesorectal excision-a stepwise approach

Background

The totally robotic procedure was traditionally described as a two-stage technique or a three-stage technique. The number of stages corresponds to the number of movements of the robotic cart. In this video article, we develop a stepwise approach video of robotic total mesorectal excision (TME) for mid rectal cancer (the surgery was performed by SHK) using a da Vinci^® Si HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) at Korea University Anam Hospital, Seoul.

Methods

After the induction of general anesthesia, the patient is placed in a modified lithotomy position. Six ports are used, including one 12-mm camera port, four 8-mm robotic working ports, and one 5-mm port for the assistant. The patient is tilted to the right side and placed in the Trendelenburg position. The small-bowel loops retracted out from the pelvic cavity to the right upper quadrant (RUQ) to expose the inferior mesenteric artery (IMA). The surgery is divided into three phases: (I) abdominal phase: vascular ligation, and sigmoid colon to splenic flexure mobilization; (II) pelvic dissection phase; and (III) rectal reconstruction phase. Mesorectal clearing was done at the level of rectal transection line (1-2 cm from distal tumor margin), then the rectum was transected with robotic stapler. Once this step is finished, the robotic arms are undocked and the cart is moved away from the patient. The remaining steps are performed in a conventional laparoscopic method.

Results

Robotic TME was performed in a 56-year-old man with an endoscopically define rectal mass. The lesion was moderately differentiated adenocarcinoma, 8 cm from the anal verge (AV). The rectal mass was managed with single stage robotic TME. The operative time was 160 minutes and the patient was discharge on post operative day 10. Final pathology revealed moderately differentiated adenocarcinoma.

Conclusions

Single stage robotic TME was efficient and feasible technique for mid rectal cancer resection.

Longterm -ostomy as a quality marker: Comparison of outcomes from a six year series of laparoscopic surgery in MRI defined low rectal cancer

AIM

We propose long-term -ostomy rate following laparoscopic rectal cancer resection must be included as an overall quality indicator of treatment in conjunction with frequently reported and readily available end points.

METHOD

A database was collated prospectively of consecutive rectal cancer resections over a 6-year period. Recorded data included pre-operative MRI (tumour stage and height from the anal-verge), as well as demographics, treatment, local recurrence rate, survival and -ostomy rate as the primary outcome measure.

RESULTS

65 patients were identified and classified as low-rectal cancer if the tumour on MRI was < 6 cm from the anal verge or middle/upper-rectal cancer if between 6 and 15 cm from the anal-verge and below the peritoneal reflection. Permanent stoma rates including colostomies and non-reversed ileostomies were 31.7% for middle/upper rectal cancer; 62.5% for low-rectal cancer and an overall rate of 42.1% for all rectal cancers. For upper-rectal cancer the rates of local recurrence, predicted mortality, R0 resection and conversion were: 0%, 1.9%, 97.6% and 0% respectively. Corresponding figures for low-rectal cancer were: 4.2%, 2.7%, 95.8% and 0%. There were no significant differences for age, sex, predicted morbidity/mortality, survival, recurrence or leak rates between the groups.

CONCLUSION

Laparoscopic rectal cancer surgery has a comparable permanent -ostomy rate to open rectal cancer surgery. We benchmark 31.7% as the permanent -ostomy rate for upper-rectal cancer and 62.5% for low-rectal cancer following laparoscopic resection, in the context of 96.9% R0 resection and 0% conversion rate in a consecutive series of patients.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Outcome of tumor-specific mesorectal excision for rectal cancer: the impact of laparoscopic resection

OBJECTIVE

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center.

METHODS

We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival.

RESULTS

A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis.

CONCLUSION

We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.

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

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

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

BACKGROUND:

Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes.

MATERIALS AND METHODS:

A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points.

RESULTS:

Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time.

CONCLUSIONS:

The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

Current status of robotic surgery for rectal cancer: A bird's eye view

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors' own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included.

Laparoscopic approach to gastrointestinal malignancies: Toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.