International Journal of Colorectal Disease

, Volume 31, Issue 12, pp 1807–1815 | Cite as

Learning curve in robotic rectal cancer surgery: current state of affairs

  • Rosa M. Jiménez-Rodríguez
  • Mercedes Rubio-Dorado-Manzanares
  • José Manuel Díaz-Pavón
  • M. Luisa Reyes-Díaz
  • Jorge Manuel Vazquez-Monchul
  • Ana M. Garcia-Cabrera
  • Javier Padillo
  • Fernando De la Portilla
Review

Abstract

Introduction

Robotic-assisted rectal cancer surgery offers multiple advantages for surgeons, and it seems to yield the same clinical outcomes as regards the short-time follow-up of patients compared to conventional laparoscopy. This surgical approach emerges as a technique aiming at overcoming the limitations posed by rectal cancer and other surgical fields of difficult access, in order to obtain better outcomes and a shorter learning curve.

Material and methods

A systematic review of the literature of robot-assisted rectal surgery was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in October 2015 in PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials, for articles published in the last 10 years and pertaining the learning curve of robotic surgery for colorectal cancer. It consisted of the following key words: “rectal cancer/learning curve/robotic-assisted laparoscopic surgery”.

Results

A total of 34 references were identified, but only 9 full texts specifically addressed the analysis of the learning curve in robot-assisted rectal cancer surgery, 7 were case series and 2 were non-randomised case-comparison series. Eight papers used the cumulative sum (CUSUM) method, and only one author divided the series into two groups to compare both. The mean number of cases for phase I of the learning curve was calculated to be 29.7 patients; phase II corresponds to a mean number 37.4 patients. The mean number of cases required for the surgeon to be classed as an expert in robotic surgery was calculated to be 39 patients.

Conclusion

Robotic advantages could have an impact on learning curve for rectal cancer and lower the number of cases that are necessary for rectal resections.

Keywords

Minimally invasive surgery Robotic surgery Rectal surgery Rectal cancer Learning curve 

References

  1. 1.
    Miyajima N, Fukunaga M, Hasegawa H, Tanaka J, Okuda J, Watanabe M, Japan Society of Laparoscopic Colorectal Surgery (2009) Results of a multicenter study of 1,057 cases of rectal cancer treated by laparoscopic surgery. Surg Endosc 23:113–118CrossRefPubMedGoogle Scholar
  2. 2.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726CrossRefPubMedGoogle Scholar
  3. 3.
    Staudacher C, Vignali A (2010) Laparoscopic surgery for rectal cancer: the state of the art. World J Gastrointest Surg 2:275–282CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lujan J, Gonzalez A, Abrisqueta J, Hernandez Q, Valero G, Abellán I, Frutos MD, Parrilla P (2014) The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity. Cir Esp 92:485–490CrossRefPubMedGoogle Scholar
  5. 5.
    Park IJ, Choi GS, Lim KH, Kang BM, Jun SH (2009) Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer. J Gastrointest Surg 13:275–281CrossRefPubMedGoogle Scholar
  6. 6.
    Tekkis PP, Senagore AJ, Delaney CP, Fazio VW (2005) Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83–91CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB (2006) Robotic assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg Endosc 20:1521–1525CrossRefPubMedGoogle Scholar
  8. 8.
    Jiménez Rodríguez RM, Díaz Pavón JM, De la Portilla De Juan F, Prendes Sillero E, Cadet Dussort JMH, Padillo J (2011) Prospective, randomized, short-term outcome study: robotic assisted laparoscopic surgery versus conventional laparosocpic surgery in colorectal carcinoma resection. Cir Esp 89:432–438CrossRefPubMedGoogle Scholar
  9. 9.
    Kwak JM, Kim SH, Kim J, Son DN, Baek SJ, Cho JS (2011) Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case–control study. Dis Colon rectum 54:151–156Google Scholar
  10. 10.
    Akmal Y, Baek JH, McKenzie S, Garcia-Aguilar J, Pigazzi A (2012) Robot-assisted total mesorectal excision: is there a learning curve? Surg Endosc 26:2471–2476CrossRefPubMedGoogle Scholar
  11. 11.
    Jimenez-Rodriguez RM, Diaz-Pavon JM, de la Portilla de Juan F, Prendes-Sillero E, Dussort HC, Padillo J (2013) Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Color Dis 28:815–821CrossRefGoogle Scholar
  12. 12.
    Bokhari MB, Patel CB, Ramos-Valadez DI, Ragupathi M, Haas EM (2011) Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg Endosc 25:855–860CrossRefPubMedGoogle Scholar
  13. 13.
    Kim YW, Lee HM, Kim NK, Min BS, Lee KY (2012) The learning curve for robot-assisted total mesorectal excision for rectal cancer. Surg Laparosc Endosc Percutan Tech 22:400–405CrossRefPubMedGoogle Scholar
  14. 14.
    Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum metho. Surg Endosc 29:1679–1685CrossRefPubMedGoogle Scholar
  15. 15.
    Sng KK, Hara M, Shin JW, Yoo BE, Yang KS, Kim SH (2013) The multiphasic learning curve for robot-assisted rectal surgery. Surg Endosc 27:3297–3307CrossRefPubMedGoogle Scholar
  16. 16.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH (2011) S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg Endosc 25:240–248CrossRefPubMedGoogle Scholar
  17. 17.
    Park EJ, Kim CW, Cho MS, Baik SH, Kim DW, Min BS, Lee KY, Kim NK (2014) Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3 phase learning process comparison. Surg Endosc 28:2821–2831CrossRefPubMedGoogle Scholar
  18. 18.
    Kim HJ, Choi GS, Park JS, Park SY (2014) Multidimensional analysis of the learning curve for robotic total mesorectal excision for rectal cancer: lessons from a single surgeon’s experience. Dis Colon rectum 57:1066–1074Google Scholar
  19. 19.
    Park EJ, Kim CW, Cho MS, Baik SH, Kim DW, Min BS, Lee KY, Kim NK (2014) Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer? A comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries. Medicine (Baltimore) 93:e109CrossRefGoogle Scholar
  20. 20.
    Melich G, Hong YK, Kim J, Hur H, Baik SH, Kim NK, Sender Liberman AS, Min BS (2015) Simultaneous development of laparoscopy and robotic provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves. Surg Endosc 29:558–568CrossRefPubMedGoogle Scholar
  21. 21.
    Foo CC, Law WL (2016) The learning curve of robotic-assisted low rectal resection of a novice rectal surgeon. World J Surg 40:456–462CrossRefPubMedGoogle Scholar
  22. 22.
    Huang CW, Yeh YS, Ma CJ, Choy TK, Huang MY, Huang CM, Tsai HL, Hsu WH, Wang JY (2015) Robotic colorectal surgery for laparoscopic surgeons with limited experience: preliminary experiences for 40 consecutive cases at a single medical center. BMC Surg 18(15):73CrossRefGoogle Scholar
  23. 23.
    Bege T, Lelong B, Esterni B, Turrini O, Guiramand J, Francon D, Mokart D, Houvenaeghel G, Giovannini M, Delpero JR (2010) The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution’s experience. Ann Surg 251:249–253CrossRefPubMedGoogle Scholar
  24. 24.
    Kayano H, Okuda J, Tanaka K, Kondo K, Tanigawa N (2011) Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer. Surg Endosc 25:2972–2979CrossRefPubMedGoogle Scholar
  25. 25.
    Son GM, Kim JG, Lee JC, Suh YJ, Cho HM, Lee YS, Lee IK, Chun CS (2010) Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J Laparoendosc Adv Surg Tech A 20:609–617CrossRefPubMedGoogle Scholar
  26. 26.
    Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2009) Influence of learning curve on short-term results after laparoscopic resection for rectal cancer. Surg Endosc 23:403–408CrossRefPubMedGoogle Scholar
  27. 27.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–34CrossRefPubMedGoogle Scholar
  28. 28.
    Heal RJ, Husband EM, Rayall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefGoogle Scholar
  29. 29.
    Biondo S, Ortiz H, Lujan J, Codina-Cazador A, Espin E, García-Granero E, Kreisler E, de Miguel M, Alos R, Echeverria A (2010) Quality of mesorectum after laparoscopic resection for rectal cancer—results of an audited teaching programme in Spain. Color Dis 12:24–31CrossRefGoogle Scholar
  30. 30.
    Ortiz H, Wibe A, Ciga MA, Lujan J, Codina A, Biondo S (2013) Spanish Rectal Cancer Project. Impact of a multidisciplinary team training programme on rectal cancer outcomes in Spain. Color Dis 15:544–551CrossRefGoogle Scholar
  31. 31.
    Ortiz H, Codina A, Grupo Colaborador Proyecto Vickingo (2013) The Spanish Association of surgeon’s audited teaching programme for rectal cancer. Results after six years. Cir Esp 91:496–503CrossRefPubMedGoogle Scholar
  32. 32.
    Adamina M, Champagne BJ, Hoffman L, Ermlich MB, Delaney CP (2011) Randomized clinical trial comparing the cost and effectiveness of bipolar vessel sealers versus clips and vascular staplers for laparoscopic colorectal resection. Br J Surg 98:1703–1712CrossRefPubMedGoogle Scholar
  33. 33.
    Sanabria A, Vega V, Dominguez LC, Espitia E, Serna A, Osorio C (2014) The evolution of laparoscopy in abdominal surgery: a meta-analysis of the effect on infectious outcomes. Minim Invasive Ther Allied Technol 23:74–86CrossRefPubMedGoogle Scholar
  34. 34.
    Laurent C, Leblanc F, Bretagnol F, Capdepont F, Rullier E (2008) Long term wound advantages of the laparoscopic approach in rectal cancer. Br J Surg 95:903–908CrossRefPubMedGoogle Scholar
  35. 35.
    Rottoli M, Bona S, Rosati R, Elmore U, Bianchi PP, Spinelli A, Bartolucci C, Montorsi M (2009) Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival. Ann Surg Oncol 16:1279–1286CrossRefPubMedGoogle Scholar
  36. 36.
    Park S, Kim NK (2015) The role of robotic surgery for rectal cancer: overcoming technical challenges in laparoscopic surgery by advanced techniques. J Korean Med Sci 30:837–846CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Luján J, Valero G, Hernández Q, Sánchez A, Frutos MD, Parrilla P (2009) Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 96:982–989CrossRefPubMedGoogle Scholar
  38. 38.
    Van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ (2013) Colorectal cancer laparoscopic or open resection II (COLOR II) Study Group. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218CrossRefPubMedGoogle Scholar
  39. 39.
    Jackson TD, Kaplan GG, Arena G, Page JH, Rogers SO Jr (2007) Laparoscopic versus open resection for colorectal cancer: a metaanalysis of oncologic outcomes. J Am Coll Surg 204:439–446CrossRefPubMedGoogle Scholar
  40. 40.
    Noel JK, Fahrbach K, Estok R, Cella C, Frame D, Linz H, Cima RR, Dozois EJ, Senagore AJ (2007) Minimally invasive colorectal resection outcomes: short term comparison with open procedures. J Am Coll Surg 204:291–307CrossRefPubMedGoogle Scholar
  41. 41.
    Targarona EM, Balagué C, Pernas JC, Martinez C, Berindoague R, Gich I, Trias M (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247:642–649CrossRefPubMedGoogle Scholar
  42. 42.
    Weber PA, Merola S, Wasielewski A, Ballantyne GH (2002) Telerobotic-assisted laparoscopic right and sigmoid colectomies for benign disease. Dis Colon rectum 45:1689–1694Google Scholar
  43. 43.
    Lee SH, Lim S, Kim JH, Lee KY (2015) Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis. Ann Surg Treat Res 89:190–201CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Yang Y, Wang F, Zhang P, Shi C, Zou Y, Qin H, Ma Y (2012) Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann Surg Oncol 19:3727–3736CrossRefPubMedGoogle Scholar
  45. 45.
    Ortiz Oshiro E, Sanchez Egido I, Moreno Sierra J, Perez CF, Diaz JS, Fernandez Represa JA (2012) Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta-analysis. Int J Med Robot 8:360–370CrossRefPubMedGoogle Scholar
  46. 46.
    Byrn JC, Hrabe JE, Charlton ME (2014) An initial experience with 85 consecutive robotic-assisted rectal dissections: improved operating times and lower costs with experience. Surg Endosc 28:3101–3107CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Rosa M. Jiménez-Rodríguez
    • 1
  • Mercedes Rubio-Dorado-Manzanares
    • 2
  • José Manuel Díaz-Pavón
    • 1
  • M. Luisa Reyes-Díaz
    • 1
  • Jorge Manuel Vazquez-Monchul
    • 1
  • Ana M. Garcia-Cabrera
    • 1
  • Javier Padillo
    • 2
  • Fernando De la Portilla
    • 1
  1. 1.Department of General and Digestive Surgery, Colorectal UnitHospital Universitario Virgen del RocíoSevillaSpain
  2. 2.Department of General and Digestive SurgeryHospital Universitario Virgen del RocíoSevillaSpain

Personalised recommendations