Reply to: doi: 10.1007/s00464-011-1808-9: Robotic versus laparoscopic total mesorectal excision for rectal cancer: comparative analysis of oncologic safety and short-term outcomes

Abstract

The technical advantages of using a robot in minimally invasive surgery of the pelvis are evident. Less clear is whether robotic surgery has clinical advantages over conventional laparoscopy. In our retrospective analysis, we did not find any significant differences in short-term outcomes between laparoscopic total mesorectal excision (TME) and robotic TME, but the clear perception of the surgeon is that the great maneuverability of wrist robotic instruments, the availability of a third arm, and the three-dimensional view with the possibility of moving the optic on one’s own make it easier to perform a challenging operation as minimally invasive TME [1]. This is confirmed by the absence of conversions from robotic to open surgery in this study, as reported also in other series [2, 3]. Whether these advantages will determine better clinical or oncologic outcomes is to be demonstrated, and the robotic versus laparoscopic resection for rectal cancer (ROLARR) trial, which started in January in the United Kingdom should answer this question. Professor Hottenrott’s comment gets to the heart of the matter regarding the introduction of robotic technology in a hospital institution: the problem of high costs. Cost-effectiveness analysis is indeed relevant, but it is not different from other business plans daily performed by clinical and research institutions. At the European Institute of Oncology (IEO, Milan, Italy), a program was started to introduce robotic surgery into every surgical oncologic specialty. A business plan was drafted after evaluation of the feasibility and sustainability of the project. A multidisciplinary team including general surgeons, urologists, gynecologists, and thoracic and head-and-neck surgeons was created and trained. In 2006, 25 procedures were performed, and in 2009, 547 procedures were performed. In the same year, a second robot was bought, and a school of robotic surgery was created. The driving forces of this robotic ‘‘explosion’’ were certainly urologists and gynecologists, but other specialists also had the opportunity to access robotic technology, creating savings by maximizing robot use. In this specific experience, general surgeons without laparoscopic experience were enabled to perform such advanced minimally invasive procedures as colorectal resections with a short learning curve, no conversions to open surgery, and short-term outcomes at least equivalent to those of laparoscopic surgery [4]. Therefore, I think we should change our mind-sets. Rather than compare the two operations, which are equivalent as minimally invasive TME, whether robotically or laparoscopically performed, we should evaluate whether the technical advantages proposed by the new technology can improve the diffusion of advanced oncologic minimally invasive surgery. If the robotic technology allows a larger number of surgeons to perform an adequate minimally invasive TME with a shorter learning curve period, less surgeon fatigue, and fewer conversions to open surgery, then the better quality-of-life outcomes of advanced oncologic laparoscopic surgery, still confined to few centers, will be accessible to more patients.