Ashwin L. deSouza

Total Mesorectal Excision for Rectal Cancer: The Potential Advantage of Robotic Assistance

PURPOSE: The purpose of this study was to analyze the safety, feasibility, and efficacy of the da Vinci S HD robotic system in mesorectal excision for rectal adenocarcinoma, with the aim to identify areas of potential advantage for the robot in this procedure. METHODS: This study was conducted as a retrospective review of a prospectively maintained database of 44 consecutive cases of robot-assisted mesorectal excision for rectal adenocarcinoma performed between August 2005 and February 2010. Patient demographics, perioperative outcomes, and complications were evaluated and compared with similar published reports and relevant literature. RESULTS: There were 28 (63.6%) men and 16 (36.4%) women, with a mean age of 63 years. The majority of patients were either overweight or obese and 88.7% of lesions were in the mid or low rectum. We performed 36 low anterior resections (6 intersphincteric) and 8 abdominoperineal resections with a median blood loss of 150 mL (range, 50–1000), a median operative time of 347 minutes (range, 155–510), and a median length of stay of 5 days (range, 3–36). The median lymph node yield was 14 (range, 5–45) and the circumferential resection margin was negative in all patients. We had 1 distal margin positivity (2.7%), 2 anastomotic leaks (5.6%), 1 death (2.7%), and 2 conversions (4.5%) to the open approach. No robot-associated morbidity occurred in this series. CONCLUSIONS: This series compares favorably with similar published reports with regard to the safety and feasibility of robotic assistance in total mesorectal excision for rectal cancer. The lower conversion rates reported for robotic rectal resection compared with laparoscopy require validation in large randomized trials.

A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma.

PURPOSE: This retrospective study was designed to compare open with robot-assisted total mesorectal excision for rectal adenocarcinoma. METHODS: With use of predefined exclusion criteria, all consecutive laparoscopic-assisted (51 patients) and robot-assisted (36 patients) rectal resections for adenocarcinoma from August 2005 to November 2009 at a single institution were considered. Hand-assisted laparoscopy was used for splenic flexure mobilization in all cases. Patients were assigned into robotic and open groups on the basis of the technique used for total mesorectal excision. All 36 robot-assisted resections had the total mesorectal excision performed with robotic assistance and were included in the robotic group. Forty-six of the 51 patients who received a laparoscopic-assisted procedure had the total mesorectal excision performed through the hand port using open surgical technique and were included in the open group. Both groups were compared with respect to patient demographics, perioperative outcomes, and pathology. RESULTS: The robotic and open groups were comparable in age, sex, body mass index, history of prior abdominal surgery, ASA class, number of patients receiving neoadjuvant chemoradiation, and tumor stage. There were more abdominoperineal resections (P = .019) and more low and mid rectal tumors (P = .007) in the robotic group. Total procedure time was longer in the robotic group (P = .003), but blood loss was less (P = .036). Lymph node yield, intraoperative and postoperative complications, and length of stay were all comparable. There were 3 positive circumferential margins in the open group vs none in the robotic group, but this did not reach statistical significance. CONCLUSIONS: Robotic total mesorectal excision is feasible and safe, and is comparable to open total mesorectal excision in terms of perioperative and pathological outcomes. The longer operative time associated with robotic total mesorectal excision could decrease as experience with this relatively new technique increases. Large randomized trials are necessary to validate the potential benefits of less blood loss and lower margin positivity rates observed in this study.

Robotic cylindrical abdominoperineal resection with transabdominal levator transection.

PURPOSE: The extralevator approach to abdominoperineal resection is an emerging surgical option for patients with low rectal cancer. This technique involves a wide excision of the levator muscles that could reduce the high incidence of circumferential margin positivity associated with conventional abdominoperineal resections. We present our technique of robotic cylindrical abdominoperineal resection where the daVinci robot is used to perform a controlled transection of the levator muscles transabdominally under direct visualization. METHODS: Five patients with rectal adenocarcinoma within 5 cm of the anal verge underwent robot-assisted cylindrical abdominoperineal resection. Safety, feasibility, immediate postoperative outcomes, and pathological adequacy of the specimen were assessed. RESULTS: The procedure was successfully completed in all 5 patients without any intraoperative complications, robot-associated morbidity, or conversion to the open approach. The mean operative time and length of hospital stay were 343 minutes and 5.8 days. An intact mesorectal envelope and negative circumferential margin was achieved in all cases. All specimens had a cylindrical shape. CONCLUSIONS: Robotic assistance enables the transabdominal transection of the levator muscles in cylindrical abdominoperineal resection, with acceptable perioperative and pathological outcomes. Further studies are essential to objectively define the safety, efficacy, and long-term results of this new technique.

Robotic Pursestring Technique in Low Anterior Resection

PURPOSE: Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system. METHODS: Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed. RESULTS: The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day. CONCLUSIONS: The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.

Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Minimally Invasive Rectal Dissection: Time to Dock the Robot

T he fact that minimally invasive colorectal surgery offers numerous advantages over conventional open surgery is now universally accepted. It is more than 15 years since Jacobs et al reported the first laparoscopic colectomy, and yet laparoscopy is still not widely used for colorectal resections in the United States. In an analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, Kemp and Finlayson reported a 3% to 6.5% increase in the proportion of colorectal resections performed laparoscopically from 2000 to 2004. Moreover, this report also revealed that laparoscopy was adopted mainly in teaching institutions and in urban hospitals. With consistent evidence to support less pain, a faster return of bowel function, and a shorter hospital stay with a laparoscopic approach, why has laparoscopic colorectal surgery not gained a fraction of the popularity enjoyed by laparoscopic cholecystectomy and fundoplication, a decade after it was first introduced? This has been largely due to the steep learning curve associated with this technique, which can be as high as 25 to 60 cases – 6 and can even continue beyond 120 cases for laparoscopic proctectomy. The 2-dimensional vision, fulcrum effect of elongated instruments, and, most importantly, the loss of the 7 degrees of freedom provided by the surgeon’s hand have restricted this approach to the exceptionally skilled surgeon, the dedicated surgical team, the uncomplicated case, and the thin patient. A new minimally invasive approach was clearly the need of the hour. Necessity is indeed the mother of invention and the drawbacks of an existing system serve as its greatest inspiration! With great expectation that the limitations of laparoscopy might be overcome, the da Vinci robot was introduced and gained Food and Drug Administration approval in 2000. Here was a system that offered 3-dimensional imaging, tremor filtration, motion scaling, a surgeon-controlled camera platform, and, most importantly, endowristed instruments with 7 degrees of freedom. With robot-assisted prostatectomy taking the lead, almost every surgical specialty has reported the use of the da Vinci robot in one procedure or another. However, the total loss of haptic feedback, the limited range of movement of the robotic arms, the longer operating time, and the significant cost remain important drawbacks of this technique. The introduction of any new technology in medicine is usually met with a certain degree of healthy skepticism. Initial reports on the safety and feasibility of robotic assistance in colorectal surgery began appearing in the medical literature in 2002 and immediately issues of cost-effectiveness, the lack of any objective advantage for the robot, and the longer operating time were raised at nearly every scientific meeting featuring presentations on robotic colorectal surgery. Opponents stressed the fact that just because we can do robotic surgery does not mean that we should. Fortunately for the proponents the corollary is also true. If we do not use the robot for colorectal surgery, how are we to know that we should not! Although the mere presence of a new technology does not support its widespread utilization, paradoxically, it is only through the widespread utilization of the technology that data to either support or reject it can be obtained. Data from prospective randomized controlled trials remain the undisputed evidence on which treatment recommendations should be based. However, it is virtually impossible for a single surgeon to attain the numbers sufficient to support any valid statistical analysis within a reasonable time frame. It is for this reason that multicenter trials have evolved and have been successfully and consistently used to compare laparoscopic with open colorectal surgery. –10 When evaluating a new technology, the very concept of a multicenter trial takes for granted that there should be multiple centers with significant experience with the new technique. It is indeed ironic that we have to extensively use robotic assistance in colorectal surgery to know whether we should continue doing so! Be that as it may, a Financial Disclosures: Dr Prasad has received an honorarium from Intuitive Surgical, honoraria and fellowships from Ethicon and Covidien. Dr deSouza received a salary (Fellowship in Laparoscopic and Minimally Invasive Colon and Rectal Surgery, University of Illinois at Chicago) from Ethicon.

Endoscopic-assisted closure of a chronic colocutaneous fistula.

In the absence of such factors as distal obstruction, a complete rosette of mucosa at the external opening, foreign body, malignancy, inflammatory bowel disease, or epithelialization of the tract, conservative management should allow healing of a postoperative, anastomotic, enterocutaneous fistula. Chronic or high-output fistulae usually require surgical correction. We describe the combined use of endoscopic clips and fibrin glue in the closure of a chronic colocutaneous fistula.