Sofoklis Panteleimonitis

Robotic versus laparoscopic rectal surgery in high-risk patients

Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate despite progress in equipment design and consistent practice. The robotic system has shown an advantage over the laparoscopic approach due to stable three‐dimensional views, improved dexterity and better ergonomics. These factors make the robotic approach more favourable for rectal surgery. The aim of this study was to compare the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high‐risk patients.

Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

AIM To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery. METHODS A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors. RESULTS Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions. CONCLUSION There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

Prior experience in laparoscopic rectal surgery can minimise the learning curve for robotic rectal resections: a cumulative sum analysis.

BackgroundThe learning curve for robotic colorectal surgery is ill-defined. This study aimed to investigate the learning curve of experienced laparoscopic rectal surgeons when starting with robotic total mesorectal excision (TME) using cumulative sum (CUSUM) charts.MethodsThis retrospective case series analysed patients who underwent curative and elective laparoscopic or robotic TMEs for rectal cancer performed by two surgeons. The first consecutive robotic TME cases of each surgeon were 1:1 propensity score matched to their laparoscopic TME cases using age, body mass index, American Society of Anesthesiologists grade, T stage (AJCC) and tumour location height. The matched laparoscopic cases defined individual standards for the quality indicators: operating time, R stage, lymph node harvest, length of hospital stay and major complications (Clavien–Dindo grade 3–5). Deviation of more than a quarter of a standard deviation from the mean for the continuous indicators, or exceeding the observed risk for the binary indicators was defined as off-target with an upward inflection in the CUSUM curve.ResultsFrom 2006 to 2015, 384 (294 laparoscopic; 90 robotic) TMEs met the inclusion criteria. Surgeon A performed 206 (70.1%) of the laparoscopic and 43 (47.8%) of the robotic cases. Surgeon B performed 88 (29.9%) of the laparoscopic and 47 (52.2%) of the robotic cases. After matching, no covariate exhibited an absolute standardised mean difference >0.25. For surgeon A, the CUSUM curves showed no apparent learning process compared to his laparoscopic standards. For surgeon B, a learning process for operation time, lymph node harvest and major complications was demonstrated by an initial upward inflection of the CUSUM curves; after 15 cases, all quality indicators were generally on target.ConclusionsFor experienced laparoscopic colorectal surgeons, the formal learning process for robotic TME may be short to reach a similar performance level as obtained in conventional laparoscopy.

Tailored robotic abdominoperineal resection with the da Vinci Xi for a re-growth of rectal tumour after complete clinical response - a video vignette.

Controversy persists as to the optimal surgical technique for abdominoperineal excision of the rectum (APER).(1–3). Extra-levator dissection has been advocated by certain groups who claim to have better R0 resection rates and a reduced incidence of perforation (4–6). However, such a radical approach may result in poorer wound healing, prolonged hospital stay and increased wound morbidity (7). In this operative video we present an abdominoperineal resection using the da Vinci Xi on a 34-year-old lady who had a low rectal adenocarcinoma. This article is protected by copyright. All rights reserved.

Modular approach for single docking robotic colorectal surgery

We have read the article by Priatno and Kim with great interest (1). The article and attached video describe the single docking technique for rectal resection using the da Vinci ® Si system. Robotic rectal surgery has shown steady increase during recent times. With challenging ergonomics of heavy mechanical arm of the robotic Si system, arm collision was often quoted as the main reason for limited adoption. With this in mind, surgeons have tried various other techniques such as hybrid, laparoscopic assisted or double docking as possible solution to this problem (2-4).

Robotic vascular ligation, medial to lateral dissection and splenic flexure mobilization for rectal cancer - a video vignette

a pursestring suture and replaced in the abdomen. A stapled coloanal anastomosis was achieved with a CDH 29 circular stapler. A covering ileostomy was made. The robotic console time was 120 min with an estimated blood loss of 50 ml. The patient was discharged on postoperative day 5 without any significant morbidity. Sphincter-saving procedures for low rectal cancers, although technically challenging, are possible with the advanced robotic systems. The da Vinci Xi system makes multiquadrant surgery possible in the same docking position, which facilitates complete splenic flexure mobilization for better colonic length, necessary for a tension-free anastomosis. Further, well-designed trials need to be conducted to evaluate the long-term functional and oncological outcomes of Robotic ISR.

Port placement for laparoscopic colonic resections - a video vignette

Laparoscopic colonic resections often require manipulation and surgical action in all abdominal quadrants. Port placement, a fundamental part of a successful procedure, often varies widely among surgeons and is currently dictated by individual experience and preference. This variability may be suboptimal for the operation at hand, can be confusing for trainees and many times provide inadequate working posture for the surgeons, resulting in discomfort due to muscular fatigue in the hands, arms, shoulders and cervical spine. This article is protected by copyright. All rights reserved.

Tailor-made robotic anterior resection and hysterectomy - a video vignette

In this video we describe a standardized approach to a technically difficult procedure (Low anterior resection and en - bloc hysterectomy) using the Da Vinci Xi. Along with the video there is a detailed commentary of the steps, the possible pitfalls and advice for the most effective approach to this operation. The patient is a 55-years- old lady with Adenocarcinoma. This article is protected by copyright. All rights reserved.

Laparoscopic en bloc total mesorectal excision post chemoradiotherapy - a video vignette.

The role of laparoscopy in rectal surgery is recognised as an important development in recent years with large multicentre trials demonstrating the safety and feasibility of this approach (1–3). However, total mesorectal excision (TME) surgery in locally advanced rectal cancers remains challenging, often resulting in the adoption of an open approach by the surgical community in such patients. In this operative video we demonstrate a laparoscopic TME on a 72-year-old male patient with body mass index (BMI) 30, with locally advanced low rectal cancer (T4b anterior rectal cancer) who received long course neoadjuvant chemoradiotherapy. Surgery was performed at 12 weeks post treatment. The tumour was involving the left seminal vesicle, therefore an en bloc resection of the seminal vesicle was performed to achieve R0 resection. A standardised approach as previously described for laparoscopic TME was employed during this procedure (4). This article is protected by copyright. All rights reserved.

Robotic TME for a T4 rectal cancer after radiotherapy - a video vignette

Neoadjuvant treatment plays an important role in the downstaging of rectal cancer. Some patients who are treated in this way will develop a complete clinical response (1). The adoption of a “watch and wait” policy for patients who have undergone complete clinical response is now accepted in many centres (2,3). An intensive follow-up protocol, including clinical, endoscopic and magnetic resonance imaging (MRI) assessment every four months for the first 2 years is recommended (3). Studies have shown that despite some excellent responses to the initial treatment, up to 30% of patients will develop a regrowth requiring surgical resection (1–3). This article is protected by copyright. All rights reserved.