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1
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Alshalawi W, Lee CS, Kim IK, Lee YS. Initial experience of abdominal total mesorectal excision for rectal cancer using the da Vinci single port system. JOURNAL OF MINIMALLY INVASIVE SURGERY 2023; 26:208-214. [PMID: 38098354 PMCID: PMC10728682 DOI: 10.7602/jmis.2023.26.4.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 12/21/2023]
Abstract
From November 2021 to February 2022, 15 patients underwent total abdominal mesorectal excision for rectal cancer using the da Vinci single port system. The clinical and pathological results were analyzed retrospectively. All surgeries were performed without conversion. The mean distance from the tumor to the anal verge was 10 cm (range, 2-15 cm). The mean operative time was 191 minutes, the median docking time was 4 minutes (range, 2-10 minutes), and the estimated blood loss was 20 mL (range, 20-50 mL). The mean number of lymph nodes harvested was 16.5, the mean distal resection margin was 3.52 cm, and all patients had circumferential and distal tumor-free resection margins. One patient had minor anastomotic leakage. The mean length of hospital stay was 5.8 ± 2.5 days. Abdominal total mesorectal excision using the da Vinci single port system for rectal cancer is technically feasible and safe, with acceptable pathological and short-term clinical outcomes.
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Affiliation(s)
- Wed Alshalawi
- Division of Colorectal Surgery, Department of General Surgery, King Saud Medical City, Riyadh, Saudia Arabia
| | - Chul Seung Lee
- Division of Colorectal Surgery, Department of Surgery, Hansol Hospital, Seoul, Korea
| | - In Kyeong Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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2
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Uk Bae S. Current Status and Future of Robotic Surgery for Colorectal Cancer-An English Version. J Anus Rectum Colon 2022; 6:221-230. [PMID: 36348945 PMCID: PMC9613410 DOI: 10.23922/jarc.2022-047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022] Open
Abstract
Robotic surgical systems were created in part to solve several constraints of laparoscopic surgery and offer technical advantages. With a substantial body of evidence that demonstrates its efficacy in the treatment of rectal cancer, robotic surgery will soon become another conventional treatment. However, further investigations and randomized trials focusing on primary endpoints are needed to establish some advantages for robot-assisted colon surgery. Da Vinci Single-SiteⓇ and SPⓇ platforms were developed to overcome the shortcomings of single-port laparoscopic surgery. Despite the currently insufficient evidence, it appears that the SP platform addresses many of the limitations of single-port transabdominal or transanal surgery. Robotic transanal minimally invasive surgery and total mesorectal excision were developed to overcome some of the limitations of conventional platforms, using wristed instrumentation to enhance dexterity and ergonomics. Studies on the effectiveness and viability of this novel approach are ongoing. The near-infrared fluorescence technique, real-time stereotactic navigation technology, and other surgical data platforms based on artificial intelligence incorporated into the robotic system will play an important role in improving outcomes. Robotic systems for advanced colorectal cancer offer technical advantages for complex and precise surgeries. If the cost of robotic surgery is reduced by expanding its indications and enhancing competition among different robotic platforms, it will provide clinical benefits to more patients and reduce social healthcare costs.
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Affiliation(s)
- Sung Uk Bae
- Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, Korea
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3
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Bae SU. Robotic surgery for colorectal cancer. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022; 65:577-585. [DOI: 10.5124/jkma.2022.65.9.577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/24/2022] [Indexed: 01/05/2025] Open
Abstract
Background: Robotic surgical systems were created partly to solve several constraints of laparoscopic surgery and to offer technical advantages. With a substantial body of evidence demonstrating its efficacy in rectal cancer treatment, robotic surgery will soon become another conventional treatment. However, further investigations and randomized trials focusing on primary endpoints are necessary to establish some advantages of robot-assisted colon surgery.Current Concepts: Da Vinci Single-Site and SP platforms (Intuitive Surgical Inc.) were developed to overcome the shortcomings of single-port laparoscopic surgery. Despite the currently insufficient evidence, it seems that the SP platform addresses several limitations of single-port transabdominal or transanal surgery. Robotic transanal minimally invasive surgery and total mesorectal excision were developed to overcome conventional platforms’ limitations, using wristed instrumentation to enhance dexterity and ergonomics. Studies on the effectiveness and viability of this novel approach are ongoing. The near-infrared fluorescence technique, real-time stereotactic navigation technology, and other surgical data platforms based on artificial intelligence incorporated into the robotic system will play an important role in improving outcomes.Discussion and Conclusion: Robotic systems for advanced colorectal cancer offer technical advantages for complex and precise surgeries. If robotic surgery costs are reduced by expanding its indications and enhancing competition among different robotic platforms, it will provide clinical benefits to more patients and reduce social healthcare costs.
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4
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Jung WB. Current status of robotic surgery for colorectal cancer: A review. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Won Beom Jung
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Korea
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5
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Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities. Curr Treat Options Oncol 2022; 23:961-979. [PMID: 35438444 PMCID: PMC9174118 DOI: 10.1007/s11864-022-00984-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/09/2022]
Abstract
The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.
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6
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Farinha R, Puliatti S, Mazzone E, Amato M, Rosiello G, Yadav S, De Groote R, Piazza P, Bravi CA, Koukourikis P, Rha KH, Cacciamani G, Micali S, Wiklund P, Rocco B, Mottrie A. Potential Contenders for the Leadership in Robotic Surgery. J Endourol 2021; 36:317-326. [PMID: 34579555 DOI: 10.1089/end.2021.0321] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Purpose: To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. Materials and Methods: A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci® system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Results: Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I®, Versius®, and Senhance® are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. Conclusions: The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.
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Affiliation(s)
- Rui Farinha
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium.,Urology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Urology Department, Lusíadas Hospital, Lisbon, Portugal
| | - Stefano Puliatti
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium.,Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Elio Mazzone
- Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Amato
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium.,Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Rosiello
- Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - Siddharth Yadav
- Department of Urology & Renal Transplant, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ruben De Groote
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium
| | - Pietro Piazza
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium.,Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlo Andrea Bravi
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium.,Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - Periklis Koukourikis
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.,Second Department of Urology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Koon Ho Rha
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Giovanni Cacciamani
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, California, USA
| | - Salvatore Micali
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bernardo Rocco
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium.,Department of Urology, OLV, Aalst, Belgium
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7
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Abstract
Robotic transanal surgery is the culmination of major developments in rectal cancer management and minimally invasive surgery. It is the result of continuous efforts to tackle the challenges inherent to rectal cancer surgery. This latest technology holds great promise and excitement for the care of the rectal cancer patient. In this article, we will describe the evolution of transanal rectal cancer surgery and describe how the convergence of transanal transabdominal, transanal endoscopic microsurgery, transanal minimally invasive surgery (TAMIS), transanal total mesorectal excision (taTME), and the different robotic platforms have culminated in the development of single port robotic transanal minimally invasive surgery (SP rTAMIS) and single port robotic transanal total mesorectal excision (SP rtaTME). We will describe the indications, technical aspects, outcomes, benefits, and limitations of the SP rTAMIS and SP rtaTME.
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Affiliation(s)
- John H Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Rafael E Perez
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jean F Salem
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
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8
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Sebastián-Tomás JC, Martínez-Pérez A, Martínez-López E, de'Angelis N, Gómez Ruiz M, García-Granero E. Robotic transanal total mesorectal excision: Is the future now? World J Gastrointest Surg 2021; 13:834-847. [PMID: 34512907 PMCID: PMC8394387 DOI: 10.4240/wjgs.v13.i8.834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.
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Affiliation(s)
- Juan Carlos Sebastián-Tomás
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University, Valencia 46002, Spain
- Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti 70021, Italy
| | - Elías Martínez-López
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti 70021, Italy
| | - Marcos Gómez Ruiz
- Department of General and Digestive Surgery, Hospital Universitario Marqués de Valdecilla, Santander 39008, Spain
- Grupo de Investigación en Innovación Quirúrgica, Instituto de Investigación Biomédica Valdecilla (IDIVAL), Santander 39008, Spain
| | - Eduardo García-Granero
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario y Politécnico la Fe, Valencia 46026, Spain
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9
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Video Demonstration of an Initial Single-Port Robotic Transanal Total Mesorectal Excision. Dis Colon Rectum 2021; 64:e472-e473. [PMID: 34001710 DOI: 10.1097/dcr.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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10
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Rondelli F, Sanguinetti A, Polistena A, Avenia S, Marcacci C, Ceccarelli G, Bugiantella W, De Rosa M. Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art. J Pers Med 2021; 11:jpm11060584. [PMID: 34205596 PMCID: PMC8233761 DOI: 10.3390/jpm11060584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022] Open
Abstract
Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.
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Affiliation(s)
- Fabio Rondelli
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Alessandro Sanguinetti
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Andrea Polistena
- Department of General and Laparoscopic Surgery–University Hospital, University of Rome, “Umberto I”, 00161 Rome, Italy;
| | - Stefano Avenia
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Claudio Marcacci
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Graziano Ceccarelli
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
| | - Walter Bugiantella
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
| | - Michele De Rosa
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
- Correspondence:
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11
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Ye J, Shen H, Li F, Tian Y, Gao Y, Zhao S, Liu B, Tong W. Robotic-assisted transanal total mesorectal excision for rectal cancer: technique and results from a single institution. Tech Coloproctol 2021; 25:693-700. [PMID: 32955640 DOI: 10.1007/s10151-020-02337-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Total mesorectal excision (TME) has greatly reduced the local recurrence rate of rectal cancer after colorectal surgery. Transanal TME (TaTME) is potentially a suitable option for patients with mid and low rectal cancer. Robotic systems overcome the limitations of laparoscopic surgery. The aim of this study was to investigate the safety and feasibility of robotic-assisted transanal total mesorectal excision (RTaTME) in patients with rectal cancer. METHODS The clinical data of patients who underwent RTaTME for rectal cancer between May 2017 and January 2020 were reviewed. The perioperative data and short-term outcomes of all the patients were retrospectively analysed. Last follow-up was in May 2020. RESULTS A total of 13 patients had RTaTME during the 36-month study period. The median docking time was 18 (IQR 16-20) minutes, median transanal phase time was 95 (IQR 74-100) minutes, median total operation time was 240 (IQR 195-270) minutes, median estimated blood loss was 60 (IQR 50-100) ml, the median number of lymph nodes retrieved was 15 (IQR 13-16) and median length of postoperative hospital stay was 7 (IQR 6-10) days. There was no mortality. Three (23%) patients suffered a postoperative complication including one anastomotic leak and one prolonged ileus, none of them required any intervention. Patients were followed up for a median of 15 (IQR 11-18) months, and no local tumour recurrences, metastasis or deaths were reported. CONCLUSIONS Our preliminary results suggest that RTaTME for rectal cancer is feasible. This innovative approach may offer patients potential benefits-further studies are needed.
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Affiliation(s)
- J Ye
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
- Department of General Surgery, The People's Hospital of Shapingba District, Chongqing, 404000, China
| | - H Shen
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - F Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Y Tian
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Y Gao
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - S Zhao
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - B Liu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - W Tong
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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12
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Marks JH, Salem JF, Adams P, Sun T, Kunkel E, Schoonyoung H, Agarwal S. SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME). Tech Coloproctol 2021; 25:721-726. [PMID: 33881657 DOI: 10.1007/s10151-021-02449-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME). METHODS This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up. RESULTS There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality. CONCLUSIONS SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.
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Affiliation(s)
- J H Marks
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA.
| | - J F Salem
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
| | - P Adams
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
| | - T Sun
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
| | - E Kunkel
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
| | - H Schoonyoung
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
| | - S Agarwal
- Lankenau Medical Center Division of Colorectal Surgery, Marks Colorectal Surgical Associates, Wynnewood, PA, USA
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13
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Longchamp G, Meyer J, Abbassi Z, Sleiman M, Toso C, Ris F, Buchs NC. Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence. Dig Dis 2020; 39:325-333. [PMID: 33011726 DOI: 10.1159/000511959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.
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Affiliation(s)
- Gregoire Longchamp
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland,
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Ziad Abbassi
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Marwan Sleiman
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
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14
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A novel technique of securing a clear surgical space using a silicone disc during transanal total mesorectal excision. Tech Coloproctol 2020; 24:895-896. [PMID: 32303929 DOI: 10.1007/s10151-020-02223-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
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Hu JM, Chu CH, Jiang JK, Lai YL, Huang IP, Cheng AYM, Yang SH, Chen CC. Robotic transanal total mesorectal excision assisted by laparoscopic transabdominal approach: A preliminary twenty-case series report. Asian J Surg 2019; 43:330-338. [PMID: 31320234 DOI: 10.1016/j.asjsur.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopy-assisted robotic transanal total mesorectal excision is a novel surgical technique for rectal cancer resection. Compared to prior DaVinci Si system case series, this case series is the first to report robotic taTME assisted by laparoscopy (r-taTME) in which the "transanal team" operates via the DaVinci Xi system. As a result, we aim to delineate and discuss preliminary findings from our robotic taTME experiences. METHODS A total of twenty patients (twelve males) who underwent robotic taTME assisted by laparoscopy (r-taTME) between January 2016 and November 2016 at a single institution were documented. Surgical outcomes, including complications, pathological outcomes, and short-term results, were then retrospectively analyzed. RESULTS All patients underwent r-taTME via a two-team approach. The "abdominal team" operated via a single port method (ileostomy site), while the "transanal team" operated via the DaVinci Xi system. The mean patient age was 56.7 ± 14.3 years (range 31-79), and the mean distance from tumor to anal verge was 6.0 ± 2.7 cm (range 2-10). The mean estimated intraoperative blood loss was 88 ± 107 ml (range 30-500), and circular stapling was utilized to restore continuity in 80% of study patients. The overall postoperative complication rate was 35%, and the mean distal margin length was 3.1 ± 1.3 cm. There were three patients who had a circumferential margin (CRM) involved by cancer cells (≤1 mm). CONCLUSION Our preliminary series report demonstrates that utilization of r-taTME assisted by laparoscopy is safe and feasible. Development of a novel transanal approach that allows single-port access alongside a multi-arm robotic system may increase the convenience and efficiency of future operation.
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Affiliation(s)
- Je-Ming Hu
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Andy Yi-Ming Cheng
- Department of Medicine, Division of Hospital Medicine, University of Pittsburgh Medical Center Shadyside Hospital, United States of America
| | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Atallah S, Parra-Davila E, Melani AGF. Assessment of the Versius surgical robotic system for dual-field synchronous transanal total mesorectal excision (taTME) in a preclinical model: will tomorrow's surgical robots promise newfound options? Tech Coloproctol 2019; 23:471-477. [PMID: 31069556 DOI: 10.1007/s10151-019-01992-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting. METHODS Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver. RESULTS Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system. CONCLUSIONS This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.
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Affiliation(s)
- S Atallah
- Department of Colorectal Surgery, EndoSurgical Center of Florida, Florida Hospital, 100 N. Dean Road, Orlando, FL, 32825, USA.
| | - E Parra-Davila
- Department of Surgery, Good Samaritan Hospital, West Palm Beach, FL, USA
| | - A G F Melani
- Department of Surgery, IRCAD, Latin America, Rio de Janeiro, Brazil
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Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database. Ann Surg 2019; 267:521-526. [PMID: 27997470 DOI: 10.1097/sla.0000000000002112] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center. SUMMARY BACKGROUND DATA The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pelvic dissection. Oncological outcome data is presently lacking. METHODS Patients who underwent total mesorectal excision or tumor-specific mesorectal excision for rectal cancer between April 2009 and April 2016 via a robotic approach were identified from a prospective single-institution database. The circumferential resection margin (CRM), distal resection margin, and TME completeness rates were determined. Kaplan-Meier analysis of disease-free survival and overall survival was performed for all patients treated with curative intent. RESULTS A total of 276 patients underwent robotic proctectomy during the study period. Robotic surgery was performed initially by 1 surgeon with 3 additional surgeons progressively transitioning from open to robotic during the study period with annual increase in the total number of cases performed robotically. Seven patients had involved circumferential resection margins (2.5%), and there were no positive distal or proximal resection margins. One hundred eighty-six patients had TME quality assessed, and only 1 patient (0.5%) had an incomplete TME. Eighty-three patients were followed up for a minimum of 3 years, with a local recurrence rate of 2.4%, and a distant recurrence rate of 16.9%. Five-year disease-free survival on Kaplan-Meier analysis was 82%, and 5-year overall survival was 87%. CONCLUSIONS Robotic proctectomy for rectal cancer can be performed with good short and medium term oncological outcomes in selected patients.
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Andolfi C, Umanskiy K. Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery. J Laparoendosc Adv Surg Tech A 2018; 29:152-158. [PMID: 30325690 DOI: 10.1089/lap.2018.0571] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery. METHODS With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery. RESULTS Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function. CONCLUSION Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.
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Affiliation(s)
- Ciro Andolfi
- Department of Surgery, Section of Colon and Rectal Surgery, and Center for Simulation, The University of Chicago Pritzker School of Medicine , Chicago, Illinois
| | - Konstantin Umanskiy
- Department of Surgery, Section of Colon and Rectal Surgery, and Center for Simulation, The University of Chicago Pritzker School of Medicine , Chicago, Illinois
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19
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Medina MG, Tsoraides SS, Dwyer AM. Review and update: robotic transanal surgery (RTAS). Updates Surg 2018; 70:369-374. [PMID: 30120742 DOI: 10.1007/s13304-018-0580-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/05/2018] [Indexed: 02/06/2023]
Abstract
As the field of surgery advances, new approaches have allowed surgeons additional flexibility to perform further interventions with minimal or no external incisions. For many years, single site access (SSA) has been used for transanal procedures, and platforms allowing modified endoscopic approaches have been available. These platforms have limitations related to access, visualization, dexterity, camera control, and instrumentation. Recently, surgical robotics companies have developed and introduced new technologies and platforms, which may help address some of these limitations. Comprehensive internet, open access, and medical and industry conference reviews of robotic surgery platforms and technology available for use in SSA surgery were conducted and 30 articles were found using keywords "robotic surgery, transanal, single site, robotic transanal surgery". A PubMed, Medline, Journals @OVID and open access search for data related to these platforms and technologies was also performed yielding 11 articles. Abstracts were reviewed for those written in the English language, leaving 40 articles which were then filtered for those pertaining to robotic surgery, transanal. 58 abstracts were found, duplicates were eliminated, and the remaining 35 articles were read in their entirety by two reviewers. Several new and existing platforms are identified for use in SSA surgery for transanal surgery as well as abdominal and transoral surgery. These are reviewed, including brand, features, approved and suggested uses, and potential limitations. New robotic technologies serve to enhance the ability of surgeons to perform SSA surgery. This next generation of robotic surgery technology overcomes some of the limitations of preceding endoscopic SSA surgery technology and will enhance the advancement of robotic transanal surgery, but outcomes and performance data are still limited.
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Affiliation(s)
- Melissa G Medina
- University of Illinois College of Medicine at Peoria, Office of Graduate Medical Education, Peoria, IL, USA.,Department of General Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Steven S Tsoraides
- University of Illinois College of Medicine at Peoria, Office of Graduate Medical Education, Peoria, IL, USA.,Department of General Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Anthony M Dwyer
- University of Illinois College of Medicine at Peoria, Office of Graduate Medical Education, Peoria, IL, USA.
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20
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Ngu JCY, Kuo LJ, Kung CH, Chen CL, Kuo CC, Chang SW, Chen CC. Robotic transanal minimally invasive surgery for rectal cancer after clinical complete response to neoadjuvant chemoradiation. Int J Med Robot 2018; 14:e1948. [PMID: 30073747 DOI: 10.1002/rcs.1948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 07/08/2018] [Accepted: 07/10/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Full-thickness local excision (FTLE) for rectal cancer showing clinical complete remission (cCR) after neoadjuvant chemoradiation therapy (NCRT) is associated with good oncological results. The purpose of this study was to report the results of robotic transanal minimally invasive surgery for such patients. METHODS Patients were treated with a 5-fluorouracil-based NCRT regimen. The determination of cCR was based on digital rectal examination, colonoscopy, and magnetic resonance imaging. RESULTS Six patients underwent transanal FTLE using the da Vinci Xi surgical system. The median operative time was 106.5 minutes, and the estimated blood loss was minimal. The mean length of hospital stay was 4.2 days. After 18.2 months of follow-up, none of the patients developed local recurrences or distant disease. CONCLUSIONS With the use of robotic technology, FTLE can be performed with relative ease and can be considered as a viable alternative to radical resection or a "Watch and Wait" strategy.
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Affiliation(s)
| | - Li-Jen Kuo
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Huei Kung
- Department of Diagnostic Radiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chi-Long Chen
- Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Chun Kuo
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sheng-Wei Chang
- Division of Acute Care Surgery and Traumatology, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Che Chen
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
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Abstract
Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.
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Affiliation(s)
- Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA - .,Minimally Invasive and New Technologies in Oncologic Surgery (MINTOS) Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Penna M, Cunningham C, Hompes R. Transanal Total Mesorectal Excision: Why, When, and How. Clin Colon Rectal Surg 2017; 30:339-345. [PMID: 29184469 DOI: 10.1055/s-0037-1606111] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances in minimally invasive surgery. The technique aims to overcome the constraints posed by a narrow rigid pelvis and poor TME visualization that are encountered during "top-down" rectal surgery. A more accurate pelvic dissection should subsequently result in safer oncological resections and better preservation of pelvic autonomic nerves. taTME is an advanced complex technique that requires dedicated training and experience in TME surgery. Initial results from small cohorts are promising and confirmation by randomized controlled trials is eagerly awaited.
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Affiliation(s)
- Marta Penna
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Christopher Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Roel Hompes
- Surgical Oncology and Gastrointestinal Surgery, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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23
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Atallah S. Assessment of a flexible robotic system for endoluminal applications and transanal total mesorectal excision (taTME): Could this be the solution we have been searching for? Tech Coloproctol 2017; 21:809-814. [PMID: 29063220 DOI: 10.1007/s10151-017-1697-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/23/2017] [Indexed: 02/07/2023]
Affiliation(s)
- S Atallah
- Center for Colon and Rectal Surgery, Florida Hospital, Winter Park, FL, USA.
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24
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Ngu JCY, Tsang CBS, Koh DCS. The da Vinci Xi: a review of its capabilities, versatility, and potential role in robotic colorectal surgery. ROBOTIC SURGERY (AUCKLAND) 2017; 4:77-85. [PMID: 30697566 PMCID: PMC6193435 DOI: 10.2147/rsrr.s119317] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Xi is the latest da Vinci surgical system approved for use in colorectal surgery. With its novel overhead architecture, slimmer boom-mounted arms, extended instrument reach, guided targeting, and integrated auxiliary technology, the Xi manages to address several limitations of earlier models. The versatility of this new system allows it to be implemented in a wide range of colorectal procedures - from complex multiquadrant colectomies to challenging mesorectal dissections in the pelvis. While commonly criticized for its cost and prolonged operative time, robotic colorectal surgery holds the potential for enhanced ergonomics, superior precision, and a reduction in the learning curve involved in training an expert surgeon. This review appraises the existing literature on robotic colorectal surgery while elaborating how the improved capabilities of the Xi serve to usher in a new era of minimally invasive colorectal surgery.
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Affiliation(s)
| | - Charles Bih-Shiou Tsang
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore
- Colorectal Clinic Associates, Mount Elizabeth Novena Specialist Center, Singapore
| | - Dean Chi-Siong Koh
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore
- Colorectal Clinic Associates, Mount Elizabeth Novena Specialist Center, Singapore
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25
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Robotic Surgery for Colon and Rectal Cancer: Current Status, Recent Advances, and Future Directions. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0348-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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26
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27
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Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.
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Affiliation(s)
- Matthew Whealon
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Vinci
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, Orange, California
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29
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Affiliation(s)
- Rahila Essani
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA
| | - Roberto Bergamaschi
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA.
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30
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Araujo SEA, Perez RO, Seid VE, Bertoncini AB, Klajner S. Laparo-endoscopic Transanal Total Mesorectal Excision (TATME): evidence of a novel technique. MINIM INVASIV THER 2016; 25:278-87. [DOI: 10.1080/13645706.2016.1199435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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31
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Keller DS, Haas EM. Transanal Minimally Invasive Surgery: State of the Art. J Gastrointest Surg 2016; 20:463-9. [PMID: 26608195 DOI: 10.1007/s11605-015-3036-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/17/2015] [Indexed: 01/31/2023]
Abstract
The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.
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Affiliation(s)
- D S Keller
- Colorectal Surgical Associates, Houston, TX, USA
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - E M Haas
- Colorectal Surgical Associates, Houston, TX, USA.
- Division of Minimally Invasive Colorectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
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32
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Simillis C, Hompes R, Penna M, Rasheed S, Tekkis PP. A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery? Colorectal Dis 2016; 18:19-36. [PMID: 26466751 DOI: 10.1111/codi.13151] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/21/2015] [Indexed: 12/17/2022]
Abstract
AIM The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome. METHOD A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME. RESULTS Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%. CONCLUSION TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.
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Affiliation(s)
- C Simillis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - R Hompes
- Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - M Penna
- Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - S Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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33
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Atallah S, DuBose A, Larach SW. Towards the development of simultaneous two-field robotic surgery. Tech Coloproctol 2015; 20:71-3. [PMID: 26585960 DOI: 10.1007/s10151-015-1403-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 11/03/2015] [Indexed: 12/24/2022]
Affiliation(s)
- S Atallah
- Florida Hospital, Winter Park, FL, USA.
| | - A DuBose
- Florida Hospital, Winter Park, FL, USA
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34
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Buchs NC, Nicholson GA, Ris F, Mortensen NJ, Hompes R. Transanal total mesorectal excision: A valid option for rectal cancer? World J Gastroenterol 2015; 21:11700-11708. [PMID: 26556997 PMCID: PMC4631971 DOI: 10.3748/wjg.v21.i41.11700] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/21/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.
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35
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Lee GC, Sylla P. Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery. Clin Colon Rectal Surg 2015; 28:181-93. [PMID: 26491411 DOI: 10.1055/s-0035-1555009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.
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Affiliation(s)
- Grace Clara Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Patricia Sylla
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Yip HC, Chiu PWY. Recent advances in natural orifice transluminal endoscopic surgery†. Eur J Cardiothorac Surg 2015; 49 Suppl 1:i25-30. [PMID: 26494866 DOI: 10.1093/ejcts/ezv364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.
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Affiliation(s)
- Hon-chi Yip
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Philip Wai-yan Chiu
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China Department of Surgery, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
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Dimitriou N, Michail O, Moris D, Griniatsos J. Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes. World J Gastrointest Oncol 2015; 7:55-70. [PMID: 26191350 PMCID: PMC4501926 DOI: 10.4251/wjgo.v7.i7.55] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/28/2015] [Accepted: 05/26/2015] [Indexed: 02/05/2023] Open
Abstract
Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.
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Transanal total mesorectal excision for rectal cancer. Surg Today 2015; 46:641-53. [DOI: 10.1007/s00595-015-1195-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/19/2015] [Indexed: 12/15/2022]
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Robotic-assisted transanal total mesorectal excision: the key against the Achilles' heel of rectal cancer? Ann Surg 2015; 261:e120-1. [PMID: 25844970 DOI: 10.1097/sla.0000000000001089] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Atallah S, Martin-Perez B, Keller D, Burke J, Hunter L. Natural-orifice transluminal endoscopic surgery. Br J Surg 2015; 102:e73-92. [PMID: 25627137 DOI: 10.1002/bjs.9710] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/20/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial. METHODS A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully. RESULTS Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation. CONCLUSION NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.
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Affiliation(s)
- S Atallah
- Department of Colon and Rectal Surgery, Florida Hospital, Orlando, Florida
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Robotic transanal surgery for local excision of rectal neoplasia, transanal total mesorectal excision, and repair of complex fistulae: clinical experience with the first 18 cases at a single institution. Tech Coloproctol 2015; 19:401-10. [PMID: 25708682 DOI: 10.1007/s10151-015-1283-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/11/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Robotic transanal surgery represents a natural evolution of transanal minimally invasive surgery. This new approach to rectal surgery provides the ability to perform local excision of rectal neoplasia with precision. Robotic transanal surgery can also be used to perform more advanced procedures including repair of complex fistulae and transanal total mesorectal excision. METHODS Data from patients who underwent transanal robotic surgery over a 33-month period were retrospectively reviewed. Patients underwent three types of procedures using this approach: (a) local excision of rectal neoplasia, (b) transanal total mesorectal excision, and (c) closure of complex fistulae, such as rectourethral fistulae. RESULTS Eighteen patients underwent robotic transanal surgery during the 33-month study period. Of these, nine patients underwent local excision of rectal neoplasia; four patients underwent transanal total mesorectal excision; four patients underwent repair of rectourethral fistulae; and one patient underwent repair of an anastomotic fistula. Of the patients undergoing robotic transanal surgery for local excision, 6/9 were resections of benign neoplasia, while 3/9 were resections for invasive adenocarcinoma. There was no fragmentation (0/9) noted on any of the locally excised specimens, while one patient (1/9) had a positive lateral margin. During the mean follow-up of 11.4 months, no recurrence was detected. Four patients underwent robotic-assisted transanal total mesorectal excision for curative intent resection of rectal cancer confined to the distal rectum. Mesorectal quality was graded as complete or near complete, and an R0 resection was performed in all four cases. Other transanal robotic procedures performed were the repair of rectourethral fistulae (n = 3) and anastomotic fistula (n = 1). This approach was met with limited success, and only half of the rectourethral fistulae were closed. CONCLUSIONS Robotic transanal surgery for local excision, transanal total mesorectal excision, and repair of fistulae is feasible, although these new approaches represent a work-in-progress. Improvement in platform design will likely facilitate the ability to perform more complex procedures. Further research with robotic transanal approaches is necessary to determine whether or not this approach can provide patients with significant benefit.
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Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, Melzer A, Mintz Y, Morales-Conde S, Rhodes M, Satava R, Tang CN, Vilallonga R. European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 2015; 29:253-88. [PMID: 25380708 DOI: 10.1007/s00464-014-3916-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 12/14/2022]
Abstract
Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.
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Affiliation(s)
- Amir Szold
- Technology Committee, EAES, Assia Medical Group, P.O. Box 58048, Tel Aviv, 61580, Israel,
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Transanal total mesorectal excision: full steam ahead. Tech Coloproctol 2015; 19:57-61. [PMID: 25560966 DOI: 10.1007/s10151-014-1254-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023]
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Abstract
Surgery for IBD is in constant evolution; it does not appear that the introduction of biologicals has had a major effect on the chance of a patient being operated on or not. Pouch surgery had its heydays in the 80s and 90s and has since then become less frequent, but the number of patients undergoing surgery still seem about the same from one year to the other. Likewise, there is no substantial evidence that surgery for Crohn's disease is diminishing. There have been fears that patients on biological treatment have an increased risk of postoperative complications. The issue is not completely settled but it is likely that patients on biological treatment who come to surgery are those who do not benefit from biologicals. Thus, they are compromised in that they have an ongoing inflammation, are in bad nutritional state, and might have several other known risk factors for a complicated postoperative course. These factors and perhaps not the biologicals per se is what surgeons should consider. During the recent years, we have seen several new developments in IBD surgery; the ileorectal anastomosis is being used for ulcerative colitis and laparoscopic surgery usually resulting in a shorter hospital stay, less pain, and better cosmetics. We have also seen the introduction of robotic surgery, single incision minimal invasive surgery, transanal minimal invasive surgery, and other approaches to minimize surgical trauma. Time will show which of these innovations patients will benefit from.
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Affiliation(s)
- Tom Øresland
- Clinic for Surgical Sciences, Univ of Oslo, Akerhus University Hospital , Lorenskog , Norway
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Devaraj B, Kaiser AM. Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms. World J Surg Proced 2015; 5:1. [DOI: 10.5412/wjsp.v5.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
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Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum 2015; 58:145-53. [PMID: 25489707 DOI: 10.1097/dcr.0000000000000265] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We performed a prospective pilot study of robotic-assisted laparoscopic transanal proctectomy with total mesorectal excision for the surgical treatment of rectal cancer. This study was to assess the feasibility and safety of robotic-assisted laparoscopic transanal total mesorectal excision. TECHNIQUE All patients underwent robotic-assisted laparoscopic left colon mobilization, robotic-assisted laparoscopic transanal total mesorectal excision, ultralow mechanical colorectal or handsewn coloanal anastomosis, and a diverting loop ileostomy. Four patients with stage III disease received long-course preoperative chemoradiation before surgery. MAIN OUTCOME MEASURES Primary and secondary end points included the assessment of pathological examination and postoperative morbidity. RESULTS Between August 2013 and January 2014, 4 men and 1 woman underwent robotic-assisted laparoscopic transanal total mesorectal excision. Patient age and BMI were 57 ± 13.9 years and 25.8 ± 2,7 kg/m. Tumors were located an average of 5 ± 1 cm from the anal verge and were preoperatively staged as T2N0M0 (1 patient) and T2N1M0 (4 patients). Mean operative time was 398 ± 88 minutes with no intraoperative complications. Mean length of hospital stay was 6 ± 1 days. A Clavien II, grade B anastomotic leakage developed in 1 patient postoperatively. In all cases, pathological examination of the total mesorectal excision specimens showed complete mesorectal excision with negative proximal, distal, and circumferential margins. All patients were disease-free at their initial 3-month follow-up. CONCLUSIONS Robotic-assisted laparoscopic transanal total mesorectal excision is a feasible and safe option for the surgical management of early-stage rectal cancers. Robotic technology with endowristed instruments and 3-dimensional high-definition imaging are of great help in overcoming the limitations of traditional laparoscopic transanal surgery. Long-term functional and oncological assessments of outcome are needed.
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Araujo SE, Crawshaw B, Mendes CR, Delaney CP. Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence. Tech Coloproctol 2014; 19:69-82. [PMID: 25380741 DOI: 10.1007/s10151-014-1233-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 10/29/2014] [Indexed: 12/14/2022]
Abstract
Achieving a clear distal or circumferential resection margins with laparoscopic total mesorectal excision (TME) may be laborious, especially in obese males and when operating on advanced distal rectal tumors with a poor response to neoadjuvant treatment. Transanal (TaTME) is a new natural orifice translumenal endoscopic surgery modality in which the rectum is mobilized transanally using endoscopic techniques with or without laparoscopic assistance. We conducted a comprehensive systematic review of publications on this new technique in PubMed and Embase databases from January, 2008, to July, 2014. Experimental and clinical studies written in English were included. Experimental research with TaTME was done on pigs with and without survival models and on human cadavers. In these studies, laparoscopic or transgastric assistance was frequently used resulting in an easier upper rectal dissection and in a longer rectal specimen. To date, 150 patients in 16 clinical studies have undergone TaTME. In all but 15 cases, transabdominal assistance was used. A rigid transanal endoscopic operations/transanal endoscopic microsurgery (TEO/TEM) platform was used in 37 patients. Rectal adenocarcinoma was the indication in all except for nine cases of benign diseases. Operative times ranged from 90 to 460 min. TME quality was deemed intact, satisfactory, or complete. Involvement in circumferential resection margins was detected in 16 (11.8 %) patients. The mean lymph node harvest was equal or greater than 12 in all studies. Regarding morbidity, pneumoretroperitoneum, damage to the urethra, and air embolism were reported intraoperatively. Mean hospital stay varied from 4 to 14 days. Postoperative complications occurred in 34 (22.7 %) patients. TaTME with TEM is feasible in selected cases. Oncologic safety parameters seem to be adequate although the evidence relies on small retrospective series conducted by highly trained surgeons. Further studies are expected.
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Affiliation(s)
- S E Araujo
- Department of Gastroenterology, University of Sao Paulo Medical School, 627 Albert Einstein Ave, Suite 219, São Paulo, SP, 05652-901, Brazil,
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Wolthuis AM, Overstraeten ADBV, D’Hoore A. Laparoscopic natural orifice specimen extraction-colectomy: A systematic review. World J Gastroenterol 2014; 20:12981-12992. [PMID: 25278692 PMCID: PMC4177477 DOI: 10.3748/wjg.v20.i36.12981] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 03/28/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.
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Sustainability of an Enhanced Recovery After Surgery Program (ERAS) in Colonic Surgery. World J Surg 2014; 39:526-33. [DOI: 10.1007/s00268-014-2744-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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