Wanda Petz

Laparoscopic and Robotic Total Mesorectal Excision in the Treatment of Rectal Cancer. Brief Review and Personal Remarks

The current standard treatment for rectal cancer is based on a multimodality approach with preoperative radiochemotherapy in advanced cases and complete surgical removal through total mesorectal excision (TME). The most frequent surgical approach is traditional open surgery, as laparoscopic TME requires high technical skill, a long learning curve, and is not widespread, still being confined to centers with great experience in minimally invasive techniques. Nevertheless, in several studies, the laparoscopic approach, when compared to open surgery, has shown some better short-term clinical outcomes and at least comparable oncologic results. Robotic surgery for the treatment of rectal cancer is an emerging technique, which could overcome some of the technical difficulties posed by standard laparoscopy, but evidence from the literature regarding its oncologic safety and clinical outcomes is still lacking. This brief review analyses the current status of minimally invasive surgery for rectal cancer therapy, focusing on oncologic safety and the new robotic approach.

The role of the robotic technique in minimally invasive surgery in rectal cancer

Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors’ centre.

Laparoscopic lymphatic roadmapping with blue dye and radioisotope in colon cancer.

Lymphatic mapping (LM) and sentinel lymph node (SLN) identification by blue dye in colon cancer is a procedure feasible during minimally invasive surgery, with good specificity, but still a low sensitivity (78% in our series). These results are in accordance with the literature and have limited more widespread diffusion of the method, both as a tool for upstaging and more controversially, as a potential roadmap to a tailored lymphadenectomy. It is possible to improve the results of LM with careful selection of patients and by the use of an intraoperative gamma camera. The preliminary results of intra‐operative lymphoscintigraphy are promising in a well‐selected small group of patients, with high levels of sensitivity and specificity. If these results are confirmed in further prospective analyses, it may be possible to undertake selected, tailored lymphadenectomy.

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.

Left Colectomy and Segmental Resections for Cancer

One of the goals of surgical oncology is to attempt to reduce the invasiveness of surgery while maintaining or further improving the outcomes of traditional open surgery. Therefore minimally invasive techniques have been applied to oncologic surgery since the end of 90s, on the basis of the good clinical results obtained by laparoscopic surgery in some benign diseases. The diffusion of laparoscopic colonic surgery has increased in recent years thanks to specific educational and training programs, but mainly in academic and high-volume hospitals [1]. The most frequently-performed procedures are the less difficult, such as sigmoidectomy for benign diseases and right colectomies with extracorporeal anastomosis [2]. Despite the improvement of technology some disadvantages of standard laparoscopy are still present, such as poor ergonomics, the difficulty to perform intracorporeal sutures and the problem of the assistant being able to hold the camera stable. Robotic surgery is an emerging technique that seems to overcome some difficulties of the standard laparoscopic approach, and its use in colorectal cancer is increasing quickly [3]. In this chapter, the technical details of robotic left colectomy and segmental colonic resections are reported.

Robotic right colectomy with complete mesocolic excision: bottom-to-up suprapubic approach - a video vignette

Complete Mesocolic Excision (CME) with central vascular ligation has been reported to potentially improve oncological results in right colectomy [1-4]. However, along with the intracorporeal anastomosis, it represents a challenging step of the laparoscopic procedure [2,3,5]. The video describes a novel bottom-to-up suprapubic approach for robotic right colectomy with CME and intracorporeal anastomosis using the DaVinci Xi Surgical System. This article is protected by copyright. All rights reserved.

Green indocyanine fluorescence in robotic abdominal surgery

Fluorescent imaging with indocyanine green (ICG) is an emerging technology that is gaining acceptance for being a valid tool in surgeons’ decision making. ICG binds to plasma lipoproteins if injected intravenously and, when excited by near-infrared light, provides anatomic information about organs vascularization and tissues perfusion. If injected in tissues, it migrates in the lymphatic system, therefore enabling the identification of lymphatic draining pathways of different organs. In this paper we address specific applications of ICG fluorescence in robotic general surgery.