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.     

La chirurgie robotique dans le cancer du rectum

Laparoscopic surgery is now the standard therapy for rectal cancer. It remains technically challenging which limits its application. Robotic surgery is a new technology that enables a surgeon to perform minimally invasive operations with more facilities. This review of current literature shows feasibility and oncological safety of robotic rectal cancer surgery. Robotic rectal surgery is associated with comparable postoperative and oncological results when compared with laparoscopic rectal surgery. It appears to be an effective alternative with a lower conversion rate to open surgery, and better recovery in voiding and sexual function. These potential benefits of robotic surgery could justify its costs.     

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.     

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology may make it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer has been claimed to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also potential advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robotic systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.     

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.     

Oncologic outcomes of laparoscopic surgery for rectal cancer: A systematic review and meta-analysis of the literature

Aim

To review and compare the oncologic outcomes in patients with rectal cancer undergoing laparoscopic vs. open rectal surgery.

Methods

An electronic literature search was performed for trials reporting oncologic outcomes for laparoscopic rectal resections. Variables of interest were survival, recurrence rates, margin status and nodal retrieval. Trials were excluded if variables were not specifically analysed for rectal resections. A meta-analysis was performed to assess the difference in oncologic outcomes between the two treatment approaches.

Results

Data on a total of 1403 laparoscopic (LG) and 1755 open (OG) rectal resections were gathered from 24 publications. Overall survival at 3 years (LG = 76%, OG = 69%) was not statistically different between the two treatment groups. The mean local recurrence rates were 7% for laparoscopic and 8% for open procedures (NS). There was no difference in radial margin positivity, 5% of patients undergoing laparoscopic surgery compared to 8% for open surgery. Laparoscopic procedures harvested a mean of 10 nodes as compared to 12 for open procedures, p = 0.001.

Conclusions

Data gathered in this meta-analysis indicate that there are no oncologic differences between laparoscopic and open resections for treatment of primary rectal cancer.     

Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

Background

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.

Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

Background and aimsThe role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.MethodsMedline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.ResultsSeven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78–1.06, p = 0.241) and 0.86 (95% CI:0.73–1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54–0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55–0.99, p = 0.041).ConclusionsThis meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.     

Advances in Laparoscopic and Robotic Gastrectomy for Gastric Cancer

Robot-assisted gastrectomy has been reported to be a safe alternative to both conventional laparoscopy and the open approach for treating early gastric carcinoma. Currently, there are a limited number of published reports on this technique in the literature. We assessed the current status of robotic and laparoscopic surgery in the treatment of gastric cancer and compared the operative outcomes, learning curves, and oncological outcome of the two approaches. Robotic gastrectomy offers benefits that include increased ease of performing D2 lymph node dissection and reduced blood loss compared with laparoscopic gastrectomy. However, the operative time is longer, and robotic gastrectomy is more costly for the patients. Regarding to the operative and oncological outcomes, there appears to be no significant differences between laparoscopic and robotic gastrectomies after the surgeon overcomes the associated learning curves. Sharing the available knowledge regarding laparoscopic and robotic gastrectomies could shorten these learning curves. For elder patients, minimally invasive surgery that decreases the postoperative recovery time should be considered the preferred treatment. Prospective randomized studies are required to compare the surgical and oncological outcomes among laparoscopic, robotic, and open surgeries for both early and advanced gastric cancer.     

Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results

Introduction  Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy. Objective  To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. Methods  One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered. Results  In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo-anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in “long-course” neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3±38.3 min and mean blood loss was 215±180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1±1.4 days and hospital stay 10.4±4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3±2.2 cm. Nodal sampling of 12.4±4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method). Conclusions  Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe.     

Robotic Versus Laparoscopic Surgery for Colorectal Cancer: a Case-control Study

BackgroundRobotic resections represent a novel approach to treatment of colorectal cancer. The aim of our study was to critically assess the implementation of robotic colorectal surgical program at our institution and to compare it to the established laparoscopically assisted surgery.Patients and methodsA retrospective case-control study was designed to compare outcomes of consecutively operated patients who underwent elective laparoscopic or robotic colorectal resections at a tertiary academic centre from 2019 to 2020. The associations between patient characteristics, type of operation, operation duration, conversions, duration of hospitalization, complications and number of harvested lymph nodes were assessed by using univariate logistic regression analysis.ResultsA total of 83 operations met inclusion criteria, 46 robotic and 37 laparoscopic resections, respectively. The groups were comparable regarding the patient and operative characteristics. The operative time was longer in the robotic group (p < 0.001), with fewer conversions to open surgery (p = 0.004), with less patients in need of transfusions (p = 0.004) and lower reoperation rate (p = 0.026). There was no significant difference between the length of stay (p = 0.17), the number of harvested lymph nodes (p = 0.24) and the overall complications (p = 0.58).ConclusionsThe short-term results of robotic colorectal resections were comparable to the laparoscopically assisted operations with fewer conversions to open surgery, fewer blood transfusions and lower reoperation rate in the robotic group.Key words: robotic surgery, laparoscopic surgery, minimally invasive surgery, colorectal cancer     

Robotic Surgery for Colon and Rectal Cancer: Current Status,Recent Advances,and Future Directions

Purpose of Review

The minimally invasive approach to colorectal cancers has been validated as providing oncologic outcomes comparable to open surgery. Current laparoscopic instrumentation, however, has its limitations especially in the performance of rectal cancer resections. Robotic surgery for colorectal cancers is an important addition to the technologies available to the surgeon. We review the literature and draw on our own experience to examine the advantages and disadvantages of robot-assisted surgery for the treatment of colorectal cancers and the evidence for the superior outcomes frequently cited and to identify subsets that may benefit the most.

Recent Findings

Most of the evidence for robotic surgery emanates from nonrandomized studies. These studies show acceptable perioperative and oncologic outcomes, with lower conversion rates and circumferential margin positivity than with laparoscopy. The only randomized trial, the ROLARR, did not show any significant difference between the two modalities regarding conversion rates or pathologic outcomes.

Summary

Current evidence does not conclusively support robotic surgery over laparoscopy or vice versa. Robotics is an emerging field and innovations including the current da Vinci Xi system, single port, and TAMIS platforms may all enable more complex surgeries going forward. Robotic surgery has a short learning curve. Patients undergoing surgery for low rectal cancers, who have any combination of male gender, obesity, and T3 cancers, as well as the need for complete mesocolic excision in right colon cancers, may be considered for the robotic approach with appreciable benefits and no detriment.

     

达芬奇机器人手术系统结直肠癌根治术的现状和展望

达芬奇机器人手术系统的出现是微创外科的重大变革。创新性机器人技术克服了传统腹腔镜的许多技术缺点。目前达芬奇机器人系统结直肠手术是安全可行的，术后短期效果与传统腹腔镜手术相似。但是，显著增加的手术费用未产生与之相应的肿瘤学优势。开发新技术克服现有机器人系统缺陷的同时，需开展多中心前瞻性随机对照临床试验评估达芬奇机器人手术系统结直肠癌根治术的长期疗效和潜在优势。本文旨在阐述机器人结直肠外科的发展现状，并展望新一代机器人平台的应用前景。      

A systematic review on robotic pancreaticoduodenectomy

BackgroundRobotic surgery might have several advantages in respect of the laparoscopic approach since might make more feasible the execution of a complex procedure such as pancreaticoduodenectomy (PD). The aim of the present systematic review is to evaluate the current state of the literature on robotic PD.MethodsA systematic literature search was performed, from January 1st 2003 to July 31st 2012, for studies which reported PDs performed for neoplasm and in which at least one surgical reconstructive or resective step was robotically performed.ResultsThirteen studies, representing 207 patients, met the inclusion criteria. The definition of the robotic approach was heterogeneous since the technique was defined as robotic, robotic-assisted, robot-assisted laparoscopic and robotic hybrid. Resection and reconstruction steps of robotic PD were also heterogeneous combining sequentially different approaches: totally robotic technique, laparoscopic–robotic resection and robotic reconstruction, laparoscopic resection and robotic reconstruction, hand port-assisted laparoscopic resection and robotic reconstruction, laparoscopic–robotic resection and reconstruction through mini-laparotomy. As regard the type of PD 66% were classic Whipple operations and 34% pylorus-preserving pancreatoduodenectomies. The management of pancreatic stump was a pancreaticogastrostomy in 23%, end-to-side pancreaticojejunostomy in 67%, and fibrin glue occlusion of the main pancreatic duct in 10% of cases. The overall procedure failure (rates of conversion to open surgery) was 14%. The overall morbidity rate was 58% and the reoperation rate was 7.3%.ConclusionsThere have been an increasing number of recent case series suggesting increased utilization of robotic PD over the past decade. The technical approach is heterogenous. For highly selected patient, robotic PD is feasible with similar morbidity and mortality compared to open or purely laparoscopic approaches. Data on cost analysis are lacking and further studies are needed to evaluate also the cost-effectiveness of the robotic approach for PD in comparison to open or laparoscopic techniques. The current state of the art analysis on robotic DP can be also useful in planning future trials.     

Comparison of transanal total mesorectal excision (TaTME) versus laparoscopic TME for rectal cancer: A case matched study

BackgroundTransanal total mesorectal excision (TaTME) has been developed to improve the quality of laparoscopic TME for patients with rectal cancer. Recently, international concern on TaTME was raised by a national cohort study showing an increased rate of local recurrences. This study aimed to compare clinicopathological and mid-term oncological outcomes of TaTME versus laparoscopic TME (LaTME) for mid and low rectal cancer of a high volume center.MethodsFrom August 2014 to October 2019, patients with mid or low rectal cancer who received TaTME procedure were identified. The cases were matched with patients treated with LaTME. Data were retrospectively collected including operative details, postoperative morbidity, pathologic results, and oncologic outcomes. Primary endpoint was the local recurrence (LR) rate.ResultsPropensity score matching yielded 70 patients in each of the groups. There were no statistically significant differences between the 2 groups in terms of postoperative complications, conversion rate to open surgery and circumferential resection margin. Local recurrence occurred in 2 patients (2.9%) in the transanal group, whereas 1 patient developed a local recurrence in the laparoscopic group (1.4%)(p = 0.559). Kaplan–Meier survival analysis showed a 2 year Local recurrence rate 1.5% VS 1.6%(p = 0.934), DFS 88.0% VS 87.7%, OS 94.0% vs 100% for transanal and laparoscopic group, respectively.ConclusionsIn a high volume center the transanal total mesorectal procedure is feasible, and appears to be safe alternative to laparoscopic surgery. Oncological outcomes were acceptable and no increased multi or unifocal local recurrence rate was found.     

Robotic curative para-aortic lymph node dissection via INfra-mesocolon for gastric cancer: Robotic CAVING approach

BackgroundTwo major surgical complications in D2 plus para-aortic nodal dissection (PAND) for gastric cancer (GC) have been pancreatic fistula and abdominal abscess [1]. The increase in these complications is due to the excessive mobilization of the pancreas. We previously reported a laparoscopic Curative PAND Via INfra-mesocolon for GC (CAVING), which minimizes mobilization of the pancreas [2]. Robotic surgery may be more comfortable than laparoscopic surgery for the surgeon performing this CAVING approach because robotic surgery has ergonomic benefits and advantages, such as native wrist-like motion and three-dimensional vision. We initially report successful robotic CAVING approach on a 72-year-old male with GC with para-aortic nodal metastases (clinical stage IV) [3].MethodsWe apply PAND after chemotherapy to patients with resectable gastric cancer who are suspected of having metastases to the lymph nodes around the para-aorta. CAVING approach minimizes mobilization of the pancreas and maximizes the view from the caudal side, which has been likened to cave exploration, a specialty of robotic surgery. The caudal side of the root of the superior mesenteric artery (SMA) can be dissected via the infra-pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach.ResultsAfter neoadjuvant chemotherapy using trastuzumab plus S-1 and oxaliplatin, robotic subtotal gastrectomy plus D2 with PAND was performed. The operation took 491 min (105 min for PAND) with no intraoperative complications, and blood loss of 92 ml. Final pathological examination showed complete response, yp stage 0 [3]. The patient was discharged uneventfully on postoperative day 17.ConclusionsRobotic CAVING approach is feasible and safe in advanced GC with para-aortic nodal metastases, but its oncological value has yet to be determined.     

Partial nephrectomy: a contemporary review regarding outcomes and different techniques

Open partial nephrectomy is evolving as the standard of care for treatment of all amendable renal masses with laparoscopic and robotic assisted surgery being reported with increasing frequency. We reviewed the literature to assess the current state of knowledge regarding various outcomes with open, laparoscopic, and robotically assisted partial nephrectomy. Many studies report excellent long-term functional and oncological outcomes when evaluating open partial nephrectomy for both imperative and elective reasons. Preservation of renal function as compared with radical nephrectomy seems to be major benefit. With limited data and follow-up, laparoscopic partial nephrectomy is an evolving technique with oncological outcomes, in experienced hands, similar to those seen in large open partial nephrectomy series. However, laparoscopic partial nephrectomy seems to be associated with longer ischemia times, increased reoperative rates, and complication rates. Robotic nephrectomy is technically feasible but the overall virtues of such an approach remain to be determined. Concerns over preservation of renal function with any approach are paramount with continued efforts to limit warm ischemia without compromising oncological efficacy.     

Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis

BackgroundRobotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent.MethodA systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model.ResultThis review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates.ConclusionRPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.     

Minimally Invasive Liver Surgery for Hepatic Colorectal Metastases

Minimally invasive surgery has been cautiously introduced in surgical oncology over the last two decades due to a concern of compromised oncological outcomes. Recently, it has been adopted in liver surgery for colorectal metastases. Colorectal cancer is a major cause of cancer-related death in the USA. In addition, liver metastasis is the most common site of distant disease and its resection improves survival. While open resection was the standard of care, laparoscopic liver surgery has become the standard of care for minor liver resections. Laparoscopic liver surgery provides equivalent oncological outcomes with better perioperative results compared to open liver surgery. Robotic liver surgery has been introduced as it is believed to overcome some of the limitations of laparoscopy. Finally, laparoscopic radio-frequency ablation and microwave coagulation can be used as adjuncts in minimally invasive surgery to complement or replace surgical resection when not possible.