World Journal of Surgery

, Volume 34, Issue 8, pp 1954–1958

Robotic Colon and Rectal Surgery: A Series of 131 Cases

Authors

    • Division of Colon and Rectal Surgery, Department of SurgeryUniversity of Illinois Medical Center at Chicago
    • Center for Robotic SurgeryAdvocate Lutheran General Hospital
  • Leela Prasad
    • Division of Colon and Rectal Surgery, Department of SurgeryUniversity of Illinois Medical Center at Chicago
    • Center for Robotic SurgeryAdvocate Lutheran General Hospital
  • Ashwin deSouza
    • Division of Colon and Rectal Surgery, Department of SurgeryUniversity of Illinois Medical Center at Chicago
    • Center for Robotic SurgeryAdvocate Lutheran General Hospital
  • Slawomir Marecik
    • Center for Robotic SurgeryAdvocate Lutheran General Hospital
  • John Park
    • Center for Robotic SurgeryAdvocate Lutheran General Hospital
  • Herand Abcarian
    • Division of Colon and Rectal Surgery, Department of SurgeryUniversity of Illinois Medical Center at Chicago
Article

DOI: 10.1007/s00268-010-0591-4

Cite this article as:
Zimmern, A., Prasad, L., deSouza, A. et al. World J Surg (2010) 34: 1954. doi:10.1007/s00268-010-0591-4

Abstract

Background

Laparoscopic colorectal surgery has become a mainstay in the treatment of benign and malignant colorectal diseases. There are inherent limitations to conventional laparoscopy which can be overcome by the robot. Here we present our experience with 131 cases of robotic and robot-assisted colon and rectal resections.

Methods

This is a retrospective review of a prospectively maintained database. From August 2005 through June 2009, we performed a total of 131 totally robotic and robot-assisted colorectal resections. These included 42 right colectomies (RC), 16 anterior resections (AR) for benign disease, 8 AR with rectopexy for prolapse, 7 total proctocolectomies (TPC), 47 low and ultralow anterior resections (LAR) for rectal cancer, and 11 abdominal perineal resections (APR). All LARs were done as a hybrid procedure (laparoscopic splenic flexure mobilization followed by robotic rectal dissection), and all APR specimens were extracted through the perineal incision. All coloanal anastomoses were diverted with a loop ileostomy.

Results

There were no intraoperative complications in this series. Postoperative complications included 10 patients with ileus or small bowel obstruction (SBO), 2 patients with anastomotic leaks, 1 patient with an abscess, and 3 patients with temporary peripheral neuropathy that resolved spontaneously. Five patients required reoperation and there were a total of 4 conversions (3.7%) across all case types.

Conclusions

Robotic colon and rectal resections are safe and feasible options for the treatment of both benign and malignant disease processes. Further studies comparing oncologic and perioperative outcomes of robotic, laparoscopic, and open techniques are needed to determine the utility and efficacy of this technology in the field of colorectal surgery.

Introduction

Laparoscopic colon and rectal surgery has become a mainstay in the treatment of benign and malignant colorectal diseases. Limitations inherent in conventional laparoscopy can be overcome by use of the robot. For this reason the robot has been employed in many urologic and gynecologic procedures with good results, and robotic surgery is no longer in its infancy in these specialties. The literature for both specialties has shown equivalent and sometimes even superior outcomes when comparing robotic surgery to conventional laparoscopy [15]. The robot provides increased dexterity of instruments, precision, 3-dimensional visuals, a steady camera, and intuitive movements that may help obtain better oncologic and overall surgical outcomes [6, 7].

The data evaluating the use of the robot in colon and rectal surgery are sparse, and the indications for its use are still evolving as more surgeons are cautiously implementing this technology and discovering its advantages and disadvantages. The advantages conferred by the robot are particularly useful for rectal dissection as the conversion rate for laparoscopic rectal dissection remains high (up to 30%) [8]. Thus far, the colorectal literature has shown that when compared to standard laparoscopy, robotic procedures have equivalent oncologic outcomes and similar return to bowel function, with the only statistically significant difference being a longer operative time [9]. With experience and a steep learning curve, this difference can be overcome, as has been shown in several smaller case series. A large series such as the one we present here has not been published thus far. Here we present 131 cases of robotic and robot-assisted colon and rectal resections.

Materials and methods

This report presents a retrospective review of a prospectively maintained database. From August 2005 through June 2009, we performed 131 totally robotic and robot-assisted colorectal resections among a total of 954 colorectal resections performed during that period (347 laparoscopic, 339 hand-assisted, 137 open). The robotic procedures included 42 right colectomies (RC), 16 anterior resections for benign disease, 8 anterior resections with rectopexy for prolapse (AR), 7 total proctocolectomies (TPC), 47 low and ultralow anterior resections (LAR) for rectal cancer (23 with and 24 without neoadjuvant therapy), and 11 abdominal perineal resections (APR). All LARs were done as a hybrid procedure (laparoscopic splenic flexure mobilization with a hand port through a Pfannenstiel incision, followed by totally robotic rectal dissection), and at all APRs the specimen was extracted through the perineal incision. In all patients who underwent an ultralow anastomosis, diversion was accomplished with a loop ileostomy. All RC and total mesorectal excisions (TME) were performed totally robotically, and therefore operative techniques for those procedures alone are described here.

Operative technique

Right hemicolectomy

The basic concept in port placement is to have the camera in the middle at the umbilicus, with one working arm superior and one inferior to the camera, just to the left of the midline. One assistant port is added to the left of the umbilicus for additional retraction. The initial dissection is done with the hook cautery in the right arm and a cadiere forceps in the left arm in either a medial-to-lateral or lateral-to-medial fashion. The vascular pedicle is taken with either the Enseal device (Ethicon Endo-Surgery, Cincinnati, OH) or the harmonic scalpel. The hepatic flexure dissection is completed with the harmonic scalpel in the right arm and the cadiere, which remains in the left arm. The specimen is brought out through an extended umbilical incision. Resection and anastomosis is performed extracorporeally.

Total mesorectal excision

The 12 mm camera port is placed just to the right of the umbilicus. Two 8 mm robotic ports are placed in the left lower quadrant, equally spaced along the line between the umbilicus and the anterior superior iliac spine; they hold the cadiere forceps and the bipolar fenestrated grasper. One 8 mm robotic port is placed in the right lower quadrant for the hook cautery. Finally, two 5 mm assistant ports are placed, one in the right upper quadrant and one in the suprapubic area. With the use of the four robotic ports and two assistant ports, only one surgical assistant is needed at the bedside. This part of the dissection is done completely robotically without any hand assistance.

To begin the dissection, the cadiere forceps is positioned at the rectosigmoid junction to provide “macroretraction” and can be advanced as necessary as the dissection progresses. Once this arm is docked in place, the camera can be zoomed into focus on the area of dissection. The bipolar fenestrated grasper is used for “microretraction” as the hook is used for dissection. The assistant supplements the retraction through the assistant ports, using both a bowel grasper and a suction/irrigator. Total mesorectal excision is then performed as it would be laparoscopically, starting in the posterior midline, then progressing around the left and the right lateral attachments, and finally dissecting the anterior aspect. For the anterior dissection, the cadiere forceps can again be used for “macroretraction” by retracting the bladder or uterus as indicated.

Distal rectal transection can be achieved using a reticulating endoscopic stapler in standard laparoscopic technique. Alternatively, this can be done through the hand port with a thoracoabdominal (TA) stapler. In low rectal lesions and in obese male patients, distal rectal transection by the above methods can be a daunting task. The advanced dexterity of the robotic system can be used to achieve a controlled right-angled rectal transection and placement of a purse string suture on the distal rectal stump. This technique avoids the intersecting staple lines in a doubled-stapled anastomosis and allows a double purse string, single stapled anastomosis to be performed a few centimeters from the pelvic floor. This technique is under evaluation and is being studied in a large series of patients to determine its safety and efficacy. An end-to-end anastomosis (EEA) stapler is then used to complete the end-to-end colorectal anastomosis. In ultralow resections, a hand-sewn coloanal anastomosis is completed from the perineal side using a Lone Star retractor (Cooper Surgical, Trumbull, CT).

Results

There were no intraoperative complications in this series. Postoperative complications included 10 patients with ileus or small bowel obstruction, 2 patients with anastomotic leaks, 1 patient with an abscess treated with percutaneous drainage, and 3 patients with temporary peripheral neuropathy that resolved spontaneously. Five patients required reoperation: one with SBO secondary to an incarcerated hernia and two with SBO requiring small bowel resections several months postoperatively; one patient with peritonitis secondary to Clostridium difficile, and one for a rectovaginal fistula. Table 1 lists all complications (medical and surgical) and their frequency. The overall average follow-up for all cases was 14.6 months. The follow-up by case type for oncologic procedures is listed in Table 2. There were a total of 4 conversions (3.7%) across all case types, including 1 RC converted to open and 1 ultralow rectal cancer case plus chemo and radiation therapy (+CRT) completed via the Pfannenstiel incision necessitated by the patient’s high body mass index, 1 benign LAR that was converted to open secondary to a large pelvic abscess, and 1 TPC where the colon was mobilized with the robot but the TME was completed through a Pfannenstiel incision because of a bulky rectal tumor. Conversion for RCs was defined as any case converted to laparoscopy or open, and for all other cases as anything completed via the Pfannenstiel incision or converted to open. Table 2 summarizes the patient demographics and intraoperative, postoperative, and oncologic outcomes for all patients by case type.
Table 1

Postoperative complications

Complication

n

Small bowel obstruction

6

Ileus

4

Cdiff

4

Peripheral neuropathy (transient)

3

Pneumonia

2

Anastomotic bleeding

2

Anastomotic leak

2

Pelvic abscess

1

CVA

1

Incarcerated incisional hernia

1

DVT from PICC

1

Retrograde ejaculation

1

Cdiff Clostridium difficile, CVA cerebrovascular accident, DVT deep vein thrombosis, PICC peripherally inserted central catheter

Table 2

Patient demographics and outcomes by case type

 

RC

AR + Pexy

AR Benign

TPC

APR

LAR/uLAR +CRT

LAR/uLAR noCRT

Total no. cases

42

8

16

7

11

23

24

Demographics

Age, years

71

45.4

55.8

41.6

69

60

62.7

BMI, average

27.3

24.1

27.8

25.6

26.2

29.3

27

Gender, % male

55

12.5

44

28

64

61

50

ASA 3 or 4, n

19

0

5

0

3

5

4

Intraoperative data

OR time, min

158.9

204.1

273.9

454.2

308.8

380.7

324.4

TME time, min

NA

NA

NA

134

123

108.3

144.3

EBL, cc

73.2

89.3

118

228.6

250

252.3

194.3

Conversions, n

1

0

1

1

0

1

0

Intraoperative complications, n

0

0

0

0

0

0

0

Oncologic data

LN harvested, n

19

NA

NA

39.8

11.8

15.1

15.3

Local recurrence, n

0

NA

NA

0

0

1

1

Distant recurrence, n

0

NA

NA

0

0

1

0

+ margins

0

NA

NA

0

0

0

0

Follow-up, months

13.2

10.3

12.9

20.7

Postoperative data

LOS, days

5.4

4.1

5.5

5.3

10.3

6.7

6.3

Complications

5

2

2

4

4

5

6

Wound infection

3

0

2

1

5

1

0

Readmission

4

0

2

5

3

4

0

Reoperation

0

0

1

0

1

1

2

RC right colectomy, AR anterior resection, TPC total proctocolectomy, APR abdominal perineal resection, LAR/uLAR low anterior resection/ultralow anterior resection, CRT chemo and radiation therapy, BMI body mass index, TME total mesorectal excision, EBL estimated blood loss, LN lymph node, LOS length of stay

Discussion

The advantages of the robot make it an appealing tool for many procedures. Potential advantages of the robot in colorectal surgery are similar to those in other fields: less operative blood loss, better oncologic technical dissection in rectal cases, and increased ease of dissection in a confined space. Several small case series have been reported thus far. Spinoglio et al. reported 50 robotic colon and rectal resections and found no significant difference from comparable laparoscopic procedures performed during the same period. The only difference was an increased operative time in the robotic group that improved with experience. They reported similar oncologic outcomes and complication rates [9]. Another case series of 55 patients reported by Luca et al. demonstrated similar clinical outcomes when compared to published data. They reported no conversions or reoperations, and comparable oncologic outcomes [6].

Robotics in colorectal surgery has specific areas where it may be advantageous—IMA dissection, and TME [10]. In our experience, the predominant indication for use of the robot in colorectal surgery has been TME, and several other authors have reported their experience with the robot in TME. Laparoscopic TME is limited both by the rigidity of the instruments and the restricted range of motion for the surgeon. The robot overcomes both of these limitations and allows for more precise oncologic dissection [10]. In a randomized pilot study, Baik et al. reported a trend toward better oncologic dissection when comparing robotic TME with laparoscopic TME. On pathologic evaluation, 17 of the 18 robotic TMEs performed were deemed macroscopically complete and the eighteenth was nearly complete. In contrast, only 13 of the 16 laparoscopic TMEs were complete, with the other 3 nearly complete [11]. Another important potential advantage is the ability to perform a better nerve-sparing TME, enhanced by the 3-D visuals afforded by the robot [12]. Newer technology and increased surgeon experience have surmounted some of the obstacles previously encountered in robotic colorectal resections. One major obstacle is the repositioning of the robot to target more than one field of dissection and the cumbersome task that it entails. In 2009, Hellan et al. reported their experience with total robotic LAR with TME and splenic flexure mobilization without repositioning the robot [13]. In our experience much of the added time can be cut down with an experienced team. Our preference is still to perform these cases as a hybrid procedure—laparoscopic splenic flexure mobilization and vascular pedicle transection combined with robotic TME [14]. Our longer operative times in rectal cases can be explained in part by our preference for performing a purse string single stapled anastomosis. Our follow-up time for LARs with CRT is longer than that for LARs without CRT. This is explained by the fact that we did not start using the robot in CRT patients until late 2007, whereas we had been using the robot in non-CRT cases since 2005.

Conclusions

Indications and techniques for robotic colorectal surgery have not yet been standardized. As more surgeons gain experience with its use, standardized indications and protocols for specific operative procedures will emerge. Further studies comparing oncologic and perioperative outcomes of robotic, laparoscopic, and open techniques are needed to determine the utility, cost, and place of this technology in the field of colorectal surgery.

Copyright information

© Société Internationale de Chirurgie 2010