Minimally Invasive Rectal Procedures for Ulcerative Colitis, Rectal Prolapse, and Rectal Cancer
One great advantage is decreased surgeon fatigue with greater surgeon control. The surgeon sits comfortably at the console and has control of three graspers and the camera. The surgeon no longer has to rely on assistants for retraction or camera positioning. Operating at the console lessens fatigue and provides greater comfort for the surgeon; however, the assistant often has to work at awkward angles. The three arms of the robot are all equipped with articulated instruments that allow for easier, more ergonomic dissection of structures such as blood vessels and may help facilitate exposure with better retraction. While no published data are available, these benefits seem to be more pronounced in obese patients. Visualization is superb with a high-definition camera that provides excellent optics and a 3D view when working at the monitor.
Because laparoscopic colorectal procedures require working in two to three quadrants of the abdomen, and docking and undocking the robot takes a significant period of time, the colorectal procedures currently best suited for robotic assistance are those in the pelvis. Although proctectomy still requires the surgeon to work in three separate quadrants of the abdomen, the adaptation of a hybrid technique utilizing traditional laparoscopic techniques for working in the left upper and lower quadrants and the robot for the pelvis minimizes the amount of time needed for docking the robot. Port placement has not been standardized for any robotic colorectal procedure and is dependent on the surgeon. When working in the pelvis, the ports for the lateral robotic arms must be placed as far apart as possible to avoid having the robotic arms interfere with each other; generally they are best placed in a straight line horizontally above the umbilicus. Separate ports may be placed to facilitate the laparoscopic dissection of the colon. Initially, colonic mobilization, including mobilization of the splenic flexure and high ligation of mesenteric vessels, is performed through a strict laparoscopic approach. The robot is then docked with the patient in a steep Trendelenburg position. The rectal dissection and mobilization is performed with the assistance of the robot. The increased dexterity and strength of the robotic graspers and the additional retraction afforded by the robotic graspers may provide some benefit for the rectal dissections. This is seen particularly in an obese patient with a narrow pelvis where the extra torque generated by the robotic arms can open up tissue planes.
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Hellan et al. reported on their short-term outcomes on performing robotic-assisted total mesorectal excision for rectal cancer. Over three years they performed 39 procedures for low- and mid-rectal cancers excluding T4 lesions. The morbidity was 12.8% with an anastamotic leak rate of 12.1%; there were no mortalities. Median operating room time was 285 minutes with a 2.6% conversion rate. Patients had a median time to resumption of diet of 1.5 days and a median length of stay of four days. All circumferential margins were negative with a median of 13 lymph nodes removed per patient. Short-term follow-up (median 13 months) revealed no local recurrences.21
Although the authors do not compare
robotic- with laparoscopic-assisted proctectomy, their operating times, post-operative gastrointestinal recovery, and length of stay were comparable with other published prospective trials on laparoscopic- assisted total mesorectal excision (TME) for rectal cancer. Luca et al. reported similar results on 55 patients operated on for left-sided or rectal cancer.22
The mean operative time was 290 minutes with no conversions. A median of 18 lymph nodes were harvested with clear circumferential margins in all specimens. The anastomotic leak rate was 12.7%, first time to flatus averaged two days, and length of stay was seven days.
Currently, robotic-assisted colorectal surgery is in its infancy. No clear-cut benefit is seen at this point in time with respect to cost and recovery when compared with strict laparoscopic procedures. Further studies are required comparing traditional minimally invasive techniques with robotic-assisted proctectomy to determine whether the increased cost and time of the procedure translate into long-term benefit for the patient.
Conclusions and Future Directions
Minimally invasive colorectal surgery is continuing to evolve. Single- incision laparoscopic surgery (SILS) procedures are leading to development of new instrumentation that angulates and may make retraction and exposure of the mesorectum easier. Most literature to date has documented that minimally invasive procedures are safe and effective for both benign and malignant conditions. The results of the CLASICC 2 trial and the ACOSOG trial will provide further data on short- and long-term outcomes of minimally invasive rectal cancer resections. As costs decrease and proficieny increases, utilization may become more widespead. n
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