Robotic Colorectal Surgery Research Articles

Robotic Colorectal Surgery

Surgical innovation is constant, most recently is the introduction of robotic surgery. While the incorporation of minimally invasive surgery in the field of colorectal surgery is generally rapid, robotic surgery is yet to gain momentum in the field. Laparoscopic colorectal surgery is now widely practiced, yet it has its own limitations, specifically in rectal surgery and operating in the pelvis. The advent of robotic surgery comes with hopes to address these limitations at no cost of compromising oncological outcomes. There are abundant reports in the literature on early experiences with the robotic technique with early results demonstrating safety and feasibility of the technique. However, as with any new technology, it comes with its own limitations. Benefits, limitations, outcomes, and future directions of this new technology as it applies to colorectal surgery are discussed.

Setup and positioning in robotic colorectal surgery

Preparation for robotic colorectal surgery is more complicated than open and laparoscopy approaches. The colorectal surgeon interested in robotic training should be familiar with and well prepared for robotic draping, positioning of the operating table, the patient cart, the vision cart, the surgeon console, and other operating equipment. Port placement requires more strategy than for the laparoscopic platform and differs depending on the type of robotic system utilized. Anesthesia personnel should be prepared for potential airway issues related to operating table and patient positioning. Robotic technology is complex and, though the system checks itself at an enormously rapid rate, there is a low incidence of robotic malfunction. All operating room personnel should be familiar with these malfunctions and how to resolve them.

The future of robotic instruments in colon and rectal surgery

Robotic surgery began approximately 30 years ago, growing steadily, and has now become one of the mainstream topics within the surgical literature across multiple surgical disciplines. More recently, robotic use has expanded to colorectal surgery, demonstrating increased usage in the more difficult operations involved. As competition in the marketplace and technology increase and improve, the size and cost of these systems may progressively decrease, and their presence will likely grow. With that, innovative and novel concepts are being introduced at a rapid pace. The enhanced performance gained by the surgeon with these devices will hopefully enable the difficult operations to become more feasible and potentially even safer. We present a brief history of the instruments related to robotic colorectal surgery and discuss some of the robotic instruments that may be seen in a future robotic-enabled operating room.

Robotic colorectal surgery: Evolution and future

The introduction of laparoscopic cholecystectomy changed the approach to abdominal surgery revealing the patient-specific advantages of minimally invasive approaches to gastrointestinal diseases. Unfortunately, inherent limitations of laparoscopy impeded widespread utilization of laparoscopic surgery in advanced procedures such as laparoscopic colectomy. Even as prospective and randomized trials demonstrated outcomes advantages for the patient, few surgeons introduced laparoscopic colectomy into their practice. Robotic surgery has offered solutions to these inherent limitations of laparoscopic surgery. Yulan Wang and Computer Motion introduced the first FDA approved robotic surgery assistant, AESOP. This robot responded to foot controls and subsequently oral commands providing tremor free reliable video-laparoscopic camera control. As video-laparoscopic colorectal surgery evolved, Colorectal Surgeons were plagued with the intrinsic limitations of laparoscopic surgery, such as motion reversal and motion amplification of the surgical instruments caused by the fulcrum effect of the abdominal wall trocar. Using Department of Defense grants and venture capital funding, two surgical technology companies, Computer Motion and Intuitive Surgery developed robotic surgical systems to overcome these limitations, Zeus and da Vinci, respectively. Although these robotic surgical systems were intended to perform remote battle-field surgery with the surgeon stationed on an aircraft carrier or remote MASH Hospital, state licensing issues and malpractice concerns prompted both companies to focus on surgery with the patient, surgeon and robot in the same operating room. Zeus gained FDA approval first and Da Vinci followed shortly after. Eventually patent conundrums proved only solvable by Intuitive buying out Computer Motion leading to a consolidation of the technology from both companies into the subsequent generations of Da Vinci. More recently, as Intuitive׳s patents begin to expire, new robotic surgery companies are entering the market with surgical robots targeting specific niches in the future robotic surgery market. In particular, MedRobotics, for example, will soon introduce a surgical robot given FDA approval for transanal resections of neoplastic lesions. Similarly, Titan will enter the market with a surgical robot at a substantially lower price-point that the da Vinci. Clearly, surgical robotic options for colorectal patients will continue to expand in the near future. The long-term use of these technologies, of course, will require a long period of prospective and randomized clinical trials.

Single incision robotic colorectal surgery: History, indications, and techniques for success with single incision colectomy

Colorectal surgery has made significant strides in the past decade progressing from laparoscopy to robotics and from multiple to single-port implementations. In selected demographics, single incision robotic colectomy (SIRC) can be an effective tool in providing an oncologic resection with excellent cosmesis. We reviewed the current state of single incision robotic colorectal surgery incorporating our institutions retrospective database for single incision robotic surgery from 2010 to 2014 to assess the viability of SIRC. Our analysis indicates that SIRC is appropriate for right, left, and sigmoid colon resections in individuals with BMI <30 regardless of age and ASA. However, we do not believe that single incision robotic surgery is mature enough for low anterior rectal surgery given the efficacy and excellent safety profile of multi-port robotic low anterior resections.

Comparative assessment of the short-term outcomes of robotassisted and laparoscopic surgery for colorectal cancer

Aim of the study. a comparative assessment of perioperative parameters and short-term outcomes of robotic and laparoscopic surgery for colorectal cancer (CRC). Material and methods. The results of surgical treatment of 101 patients with colorectal cancer underwent robotic (I group, n = 30) and laparoscopic (II group, n = 71) radical operations were analyzed. Results. Surgery duration in I group ranged from 140 to 420 minutes (on average 260,9 ± 80,1 min.), in II group - 120-465 minutes (on average - 243,3 ± 72,9 min.; P = 0,314). Blood loss in I group averaged on 100 ± 29,4 ml (50,0-150,0 ml) compared to 141,7 ± 76 ml in II group (the difference is statistically significant, P = 0,006). Conversion rate, complications, duration of the postoperative period did not have a statistically significant difference between the groups. The study of circular resection margins after robotic surgeries confirmed the radical intervention (R0-resection) in all cases. Differences in the number of lymph nodes (12-22) between the groups were not observed. Conclusion. Safety and efficacy of robotic colorectal surgery is comparable to laparoscopic surgery. Long-term results require further study.

Application of enhanced recovery after surgery in minimally invasive colorectal surgery

ERAS combines modern anesthesia, pain control, and nutritional support technologies, and contains a series of evidence-based perioperative optimization measures, including preoperative preparation, intraoperative anesthesia and postoperative care, to reduce surgical stress and enhance recovery. Several clinical studies and meta-analysis have demonstrated that ERAS can accelerate postoperative rehabilitation in colorectal patients. In addition, minimally invasive colorectal surgery has the advantages of less trauma, less bleeding, and faster postoperative recovery, compared with open surgery. It has become the standard operation for colon resection. Recently 3D laparoscopic and robotic colorectal surgery, which overcomes limitations of conventional laparoscopic surgery, is increasingly used. Therefore, whether ERAS combined with minimally invasive colorectal surgery causes a cumulative advantage receives much concern. A number of studies and meta-analysis have demonstrated that ERAS combined with laparoscopic colorectal cancer surgery can shorten the length of hospital stay and reduce the incidence of complications, as the best perioperative plan for elective colorectal surgery.

Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database

Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery. Risk factors associated with conversion from robotic to open colectomy and comparisons of the risk factors between robotic and laparoscopic approaches have not been previously reported. Patients who underwent elective laparoscopic and robotic colorectal surgeries between July 1, 2012 and April 28, 2015, were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified, and hierarchical logistic regression models were used to identify risk factors for conversion. There were 4796 cases that met study inclusion criteria. Conversion was required in 18.2 % of laparoscopic and 7.7 % of robotic cases (p < 0.0001). Risk factors for conversion in the laparoscopic group included the following: moderate/severe adhesions, obesity, colorectal cancer, hypertension, rectal operations, urgent priority, and tobacco use. Risk factors for conversion in the robotic group included the following: severe adhesions, bleeding disorder, presence of cancer, cirrhosis, and use of statins. Higher surgeon volume was protective in both groups. Conversion rates are lower for robotic than for laparoscopic colorectal surgery with fewer predictors of conversion. Recognition of factors predicting conversion may allow surgeons to choose an operative approach that optimizes the benefits of the available technologies.

Structured training and competence assessment in colorectal robotic surgery. Results of a consensus experts round table.

A structured training is a key element for the learning of techniques with a high level of complexity, such as robotic colorectal surgery. This study reports the results of an expert consensus round table held during the 6th Clinical Robotic Surgery Association (CRSA) congress, focusing on recommendations in robotic colorectal surgery. Three sequential steps are proposed for training: a basic module, to learn basic robotic skills and general competencies; an advanced module, to acquire skills to safely perform a colorectal resection, and tutored clinical practice providing procedures of increasing complexity. Each specific skill of the basic module and performance of each surgical step of a colorectal procedure was evaluated and rated from 1 to 3. Defining requirements to begin robotic colorectal activity, delineation of structured training programs and objectification of the acquired competences are key elements for a safe and efficient learning of robotic colorectal surgery. Copyright © 2016 John Wiley & Sons, Ltd.

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.

Overview of robotic colorectal surgery: Current and future practical developments.

Minimal access surgery has revolutionised colorectal surgery by offering reduced morbidity and mortality over open surgery, while maintaining oncological and functional outcomes with the disadvantage of additional practical challenges. Robotic surgery aids the surgeon in overcoming these challenges. Uptake of robotic assistance has been relatively slow, mainly because of the high initial and ongoing costs of equipment but also because of limited evidence of improved patient outcomes. Advances in robotic colorectal surgery will aim to widen the scope of minimal access surgery to allow larger and more complex surgery through smaller access and natural orifices and also to make the technology more economical, allowing wider dispersal and uptake of robotic technology. Advances in robotic endoscopy will yield self-advancing endoscopes and a widening role for capsule endoscopy including the development of motile and steerable capsules able to deliver localised drug therapy and insufflation as well as being recharged from an extracorporeal power source to allow great longevity. Ultimately robotic technology may advance to the point where many conventional surgical interventions are no longer required. With respect to nanotechnology, surgery may eventually become obsolete.

Post-operative outcomes in robotic and laparoscopic colorectal surgery

Post-operative outcomes in robotic and laparoscopic colorectal surgery

Trocar Site Hernia after Use of an 8-mm Bladeless Trocar in Robotic Colorectal Surgery

Port site hernias are a rare complication after laparoscopic and robotic surgery. The current case is an 8-㎜ port site hernia which occurred after robot-assisted colorectal surgery. A 70-year-old female with a BMI (body mass index) of 25.7 was diagnosed as rectosigmoid colon cancer. She underwent a robot-assisted low anterior resection with double-stapled anastomosis for AJCC (American Joint Committee on Cancer) stage IIIB. After the main procedure, fascial defects in the supra-pubic and the supra-umbilical site were closed with a routine procedure (12 ㎜). Thirty two months after surgery, she developed an incisional hernia in the left mid abdomen (8-㎜ port). Recognition of the potential for a port site hernia using an 8-mm bladeless trocar port as well as a 12-㎜ port is essential in robotic surgery. Patients with risk factors for a port site hernia may require complete port site closure.

Incisional and port-site hernias following robotic colorectal surgery.

The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8%) with a mean follow-up of 16.5months. The overall incisional hernia rate was 5.8%. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68%, p<0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Emerging and Evolving Technology in Colon and Rectal Surgery.

Minimally invasive surgery has changed the way we manage many colon and rectal pathologies. Multiple techniques, from straight laparoscopic procedures, to hand-assisted and single-port techniques are available, requiring surgeons to go through various learning curves. Robotic surgery is a relatively novel technique in general surgery which appears to hold most promise for rectal resection. Laparoscopic rectal procedures are difficult, and even in experienced hands, conversion rates are around 17%. Robotic surgery may be a point of difference in these cases, despite a long learning curve and higher costs. This article will describe the role of robotics in colorectal surgery. Room set up, port placement, and docking strategies will be described for common procedures, with emphasis on a hybrid robotic low anterior resection.

Case-matched Comparison of Robotic Versus Laparoscopic Colorectal Surgery

Robotic colorectal surgery is an emerging technique. In this study, we aimed to compare outcomes of robotic colorectal operations to laparoscopy. Patients undergoing robotic colorectal surgery between November 2010 and July 2013 were case matched to laparoscopic counterparts based on diagnosis and operation type. Perioperative and short-term postoperative outcomes were compared. There were 57 patients who underwent robotic colorectal surgery. American Society of Anaesthesiologists score was higher in patients who underwent robotic surgery (2 vs. 3, P=0.01). Blood loss (200 vs. 300 mL, P=0.27) and conversion rate to open surgery (6 vs. 5, P=0.75) were similar between the groups. Operating time was longer in robotic surgery (172 vs. 267 min, P<0.0001). Time to first bowel movement (3 vs. 3 d, P=0.38), hospital stay (5 vs. 6 d, P=0.22), and postoperative complications were comparable between the groups. In the early learning curve period, robotic colorectal surgery shows similar short-term outcomes with longer operating time compared with conventional laparoscopy.

Value of robotic colorectal surgery.

No patient benefit yet

Spin Is Common in Studies Assessing Robotic Colorectal Surgery: An Assessment of Reporting and Interpretation of Study Results.

Spin has been defined previously as "specific reporting that could distort the interpretation of results and mislead readers." The purpose of this study was to determine the frequency and extent of misrepresentation of results in robotic colorectal surgery. Publications referenced in MEDLINE or EMBASE between 1992 and 2014 were included in this study. Studies comparing robotic colorectal surgery with other techniques with a nonsignificant difference in the primary outcome(s) were included. Interventions included robotic versus alternative techniques. Frequency, strategy, and extent of spin, as previously defined, were the main outcome measures : A total of 38 studies (including 24,303 patients) were identified for inclusion in this study. Evidence of spin was found in 82% of studies. The most common form of spin was concluding equivalence between surgical techniques based on nonsignificant differences (76% of abstracts and 71% of conclusions). Claiming improved benefits, despite nonsignificance, was also commonly observed (26% of abstracts and 45% of conclusions). Because of the small sample size, we did not find evidence of an association between spin and study design, type of funding, publication year, or study size. Acknowledging the equivocal nature of the study happened rarely (47% of abstracts and 34% of conclusions). The absence of spin predicted whether authors acknowledged equivocal results (p = 0.02). A total of 50% of studies did not disclose whether they received funding, whereas 39% of studies failed to state whether a conflict of interest existed. A limited number of randomized controlled trials were available. Spin occurred in >80% of included studies. Many studies concluded that robotic surgery was as safe as more traditional techniques, despite small sample sizes and limited follow-up. Authors often failed to recognize the difference between nonsignificance and equivalence. Failure to disclose financial relationships, which could represent potential conflict(s) of interest, is concerning. Readers of these articles need to be critical of author conclusions, and publishers should ensure that conclusions correspond with the study methods and results.

The influence of body mass index on clinical short-term outcomes in robotic colorectal surgery.

Robotic surgery has been developed to address the technical limitations of laparoscopic surgery and might result in similar outcomes for patients with low and high body mass index (BMI). Demographic, peri-operative data and surrogate oncologic markers for colorectal cancer of patients that underwent robotic colorectal procedures were collected in a prospective database and analyzed. 103 consecutive patients (36 normal-weight, 33 overweight, 34 obese) underwent robotic colorectal surgery from 11/2011 to 05/2012. While operating room (OR) time was longer for the obese patients (123.4 vs 137.9 and 154.7 min), results for estimated blood loss (104.2 vs 153 and 155.9 mL), conversions (2.8 vs 6.1 and 5.9%), complications (19.4 vs 21.2 and 32.4%), re-admissions (11.1 vs 112.1 and 20.6) and mortality (0% for all) were comparable. BMI did not affect the surrogate markers in patients with malignancies. Data demonstrates that patient BMI does not have a significant impact on short-term clinical outcomes during robotic colorectal surgery. Copyright © 2015 John Wiley & Sons, Ltd.

The 114th Annual Scientific Meeting of the American Society of Colon and Rectal Surgeons.

The 114th Annual Scientific Meeting of the American Society of Colon and Rectal Surgeons (ASCRS) took place in Boston, Massachusetts, from May 30 to June 3, 2015. Of the 3029 participants, there were 2080 physicians and healthcare providers including 759 attendees representing 75 countries outside of the USA. In addition to many workshops, symposia, hands-on laboratories and 98 podium/video presentations, there were 413 e-poster presentations (of 954 total abstracts received a record high). The meeting included workshops on how to write examination questions, transanal endoscopic surgery, anal intraepithelial neoplasia and high-resolution anoscopy, laparoscopic colectomy, optimal management of fecal incontinence and robotic colorectal surgery: tips, tricks and simulation. Symposia included laparoscopic and robotic surgery, advanced endoscopy and endoluminal surgery, managing complex surgical patients/complications, the genetics of colorectal cancer and an update on inflammatory bowel disease. There was a special emphasis on rectal cancer, including symposia addressing ‘‘Controversies in rectal cancer management’’ and ‘‘Optimizing outcomes through techniques.’’ Of the named lectureships, the ‘‘Masters in Colorectal Surgery Lectureship’’ (each year, a different senior surgeon who has made a considerable contribution to the specialty and ASCRS is honored) titled ‘‘The value of mentorship’’ was delivered by ASCRS President-Elect Patricia L. Roberts, MD, to honor ASCRS Past-President David J. Schoetz, Jr., MD (both of Lahey Hospital and Medical Center, Burlington, MA). Previous honorees include ASCRS Past-Presidents Eugene P. Salvati, MD (2014), Victor W. Fazio, MD (2013), Herand Abcarian, MD (2012), Philip H. Gordon, MD (2011), and the first recipient Stanley M. Goldberg, MD (2010). Another named lectureship, the Norman D. Nigro, MD Research Lectureship, was delivered by Professor Antonio Lacy, MD, PhD (Barcelona, Spain), on ‘‘The evolution of minimally invasive surgery for colorectal cancer: Past, Present, and Future.’’ A memorial lectureship honoring Fig. 1 Terry C. Hicks, MD (Oschner Clinic, New Orleans, LA), on the right (immediate Past-President ASCRS, 2014–2015) handing over the Presidential Medallion to Charles E. Littlejohn, MD (Stamford, Connecticut), on the left (current ASCRS President, 2015–2016) at the ASCRS Annual Business Meeting on June 3, 2015, in Boston, MA