Robotic-assisted stereotactic real-time navigation: initial clinical experience and feasibility for rectal cancer surgery
Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting.
After pre-clinical assessment, and configuration of a robotic-assisted navigational system, two patients with locally advanced rectal cancer were selected for enrollment into a pilot study designed to assess the feasibility of navigation coupled with the robotic da Vinci Xi platform via TilePro interface. In one case, fluorescence-guided surgery was also used as an adjunct for structure localization, with local administration of indocyanine green into the ureters and at the tumor site.
Each operation was successfully completed with a robotic-assisted approach; image-guided navigation provided computed accuracy of ± 4.5 to 4.6 mm. The principle limitation encountered was navigation signal dropout due to temporary loss of direct line-of-sight with the navigational system’s infrared camera. Subjectively, the aid of navigation assisted the operating surgeon in identifying critical anatomical planes. The combination of fluorescence with image-guided surgery further augmented the surgeon’s perception of the operative field.
The combination of stereotactic navigation and robotic surgery is feasible, although some limitations and technical challenges were observed. For complex surgery, the addition of navigation to robotics can improve surgical precision. This will likely represent the next step in the evolution of robotics and in the development of digital surgery.
KeywordsDigital surgery TaTME Rectal cancer Robotic colorectal Augmented reality Da Vinci navigation Stereotactic navigation Image-guided surgery Fluorescence-guided surgery
The authors wish to thank Laura Galorneau, Zack Demetriou, Meraj Baig, Tina Langaee, Meghann Vizintos, Janelle Abravaya, Brian Solomon, and Lauren Skesavage for there assistance with this research.
No funding was received for this study.
Compliance with ethical standards
Conflict of interest
Dr. S. Atallah reports consultancy (such as consulting fees, honoraria) from Medtronic, Applied Medical, ConMed, Inc, and Medrobotics. Dr. S. Larach holds stock options with Applied Medical. Dr. J. Marescaux is president of both IRCAD and IHU Strasbourg, which are partly funded by Karl Storz, Medtronic, and Siemens Healthcare though he has no direct conflict of interest with content discussed in this manuscript. Dr. A.G.F. Melani receives remuneration (payment for services not otherwise identified as salary such as consulting fees, honoraria) from Medtronic, Ethicon, Intuitive Surgical, and Verb Surgical though he has no direct conflicts of interest with content discussed in this manuscript. Dr. E. Parra-Davila receives remuneration (payment for services not otherwise identified as salary such as consulting fees, honoraria) from Medtronic, Ethicon, Intuitive Surgical, and Verb Surgical though he has no direct conflicts of interest with content discussed in this manuscript. Dr. L. Romagnolo has received remuneration (honoraria) from Medtronic, Inc. and Johnson & Johnson.
This research was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained in accordance with the standards set forth by hospital regulations.
Supplementary material 1 (MP4 14,66,599 kB)
- 7.Wijsmuller AR, Giraudeau C, Leroy J, Kleinrensink GJ, Rociu E, Romagnolo LG, Melani AGF, Agnus V, Diana M, Soler L, Dallemagne B, Marescaux J, Mutter D (2018) A step towards stereotactic navigation during pelvic surgery: 3D nerve topography. Surg Endosc 32(8):3582–3591PubMedPubMedCentralCrossRefGoogle Scholar
- 15.Kuo LJ, Ngu JC, Tong YS, Chen CC (2017) Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach. Int J Colorectal Dis 32(2):249–254. https://doi.org/10.1007/s00384-016-2686-3 CrossRefPubMedGoogle Scholar
- 22.Porpiglia F, Checcucci E, Amparore D, Autorino R, Piana A, Bellin A, Piazzolla P, Massa F, Bollito E, Gned D, De Pascale A, Fiori C (2018) Augmented-reality robot-assisted radical prostatectomy using hyper-accuracy three-dimensional reconstruction (HA3DTM) technology: a radiological and pathological study. BJU Int. https://doi.org/10.1111/bju.14549 PubMedCrossRefGoogle Scholar
- 24.Furukawa J, Miyake H, Tanaka K, Sugimoto M, Fujisawa M (2014) Console-integrated real-time three-dimensional image overlay navigation for robot-assisted partial nephrectomy with selective arterial clamping: early single-centre experience with 17 cases. Int J Med Robot 10(4):385–390PubMedCrossRefGoogle Scholar
- 33.Kurimoto M, Hayashi N, Kamiyama H, Nagai S, Shibata T, Asahi T, Matsumura N, Hirashima Y, Endo S (2004) Impact of neuronavigation and image-guided extensive resection for adult patients with supratentorial malignant astrocytomas: a single-institution retrospective study. Minim Invasive Neurosurg 47(5):278–283PubMedCrossRefGoogle Scholar
- 37.Wagner M, Gondan M, Zöllner Wünscher C, Nickel JJ, Albala F, Groch L, Suwelack A, Speidel S, Maier-Hein S, Müller-Stich L, Kenngott BP HG (2016) Electromagnetic organ tracking allows for real-time compensation of tissue shift in image-guided laparoscopic rectal surgery: results of a phantom study. Surg Endosc 30(2):495–503PubMedCrossRefGoogle Scholar
- 46.Nagata J, Fukunaga Y, Akiyoshi T, Konishi T, Fujimoto Y, Nagayama S, Yamamoto N, Ueno M (2016) Colonic marking with near-infrared, light-emitting, diode-activated indocyanine green for laparoscopic colorectal surgery. Dis Colon Rectum 59(2):e14–e18. https://doi.org/10.1097/DCR.0000000000000542 CrossRefPubMedGoogle Scholar
- 48.Mondal SB, Gao S, Zhu N, Habimana-Griffin L, Akers WJ, Liang R, Gruev V, Margenthaler J, Achilefu S (2017) Optical see-through cancer vision goggles enable direct patient visualization and real-time fluorescence-guided oncologic surgery. Ann Surg Oncol 24(7):1897–1903PubMedPubMedCentralCrossRefGoogle Scholar
- 51.Jones JE, Busi SB, Mitchem JB, Amos-Landgraf JM, Lewis MR (2018) Evaluation of a tumor-targeting, near-infrared fluorescent peptide for early detection and endoscopic resection of polyps in a rat model of colorectal cancer. Mol Imaging. https://doi.org/10.1177/1536012118790065 PubMedPubMedCentralCrossRefGoogle Scholar
- 52.Kim J, Do EJ, Moinova H, Bae SM, Kang JY, Hong SM, Fink SP, Joo J, Suh YA, Jang SJ, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Choe J, Yang SK, Markowitz SD, Kim SY, Myung SJ (2017) Molecular imaging of colorectal tumors by targeting colon cancer secreted protein-2 (CCSP-2). Neoplasia 19(10):805–816PubMedPubMedCentralCrossRefGoogle Scholar