- Email: [email protected]
Preliminary results of robotic colorectal surgery at the National Cancer Institute, Cairo University
Journal of the Egyptian National Cancer Institute (2016) 28, 169–174
Cairo University
Journal of the Egyptian National Cancer Institute www.elsevier.com/locate/jnci www.sciencedirect.com
Full Length Article
Preliminary results of robotic colorectal surgery at the National Cancer Institute, Cairo University Ashraf Saad Zaghloul, Ahmed Mostafa Mahmoud * Surgical Oncology Department, National Cancer Institute, Cairo University, Egypt Received 16 January 2016; revised 8 May 2016; accepted 21 May 2016 Available online 13 June 2016
KEYWORDS Minimally invasive surgery; Robotic-assisted; Colorectal cancer; Egypt
Abstract Background: The available literature on minimally invasive colorectal cancer demonstrates that laparoscopic approach is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety. Reports have shown that robotic surgery may overcome some of the pitfalls of laparoscopic intervention. Objective of the work: To evaluate early results of robotic colorectal surgery, in a cohort of Egyptian patients, regarding operative time, operative and early post-operative complications, hospital stay and pathological results. Patients and methods: A case series study which was carried out in surgical department at National Cancer Institute, Cairo University. Ten Egyptian cases of colorectal cancer (age ranged from 30 to 67, 5 males and 5 females) were recruited from the period of April 2013 to April 2014. Robotic surgery was performed to all cases. Results: Three patients had low anterior resection, three anterior resection, one total proctectomy, one abdominoperineal resection, one left hemicolectomy and one colostomy. The study reported no mortalities and two morbidities. The mean operative time was 333 min. The conversion to open was done in only one patient. A total mesorectal excision with negative circumferential margin was accomplished in all patients, distal margin was positive in one patient. Mean lymph nodes removed was 10.7. Mean hospital stay was 7.4 days. Conclusion: To the best of our knowledge, this is the first study reporting the outcomes of robotic colorectal cancer intervention in Egyptian patients. Our preliminary results suggest that roboticassisted surgery for colorectal cancer can be carried out safely and according to oncological principles. Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction * Corresponding author. Mobile: +20 01001729571. E-mail address: [email protected] (A.M. Mahmoud). Peer review under responsibility of The National Cancer Institute, Cairo University.
The most important advance in rectal surgery over the last 30 years was development of total mesorectal excision (TME). TME is associated with reduction of local recurrence rate to less than 10% and improve survival [1].
http://dx.doi.org/10.1016/j.jnci.2016.05.003 1110-0362 Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
170 The development of minimally invasive approach in colorectal disease began with first report of laparoscopic assisted colectomy in 1991 [2]. The available literature on minimally invasive TME for rectal cancer demonstrates that laparoscopic TME is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety [3]. The proposed advantages of minimally invasive colorectal surgeries (MIC) over open colectomies include improved intra operative visualization of pelvis, less stress on patient, less post-operative pain, improved cosmoses, shorter duration of ileus and briefer hospitalization [4]. More recently, robotic assisted laparoscopic colorectal surgery has become an intriguing technique most beneficial for procedures requiring rectal resection. This technology provides visualization and reach for these complex pelvic procedures [5]. The 1st robotic assisted colorectal resection was reported in Japan by Hashizume et al. in 2002 [6]. The use of robotics for the treatment of rectal cancer has recently been shown to be feasible [7–10]. The general advantages of the Da Vinci robotic system are a three-dimensional view, hand-tremor filtering, fine dexterity, and motion scaling, providing an absolute benefit when the operative field is narrow and fixed and sharp dissection is necessary [11]. There are no available data on the outcome of robotic intervention in cancer surgery in developing countries and the only data available are those of American, European and Asian experiences. Within this context, the present study aims to report our initial experience with robotic colorectal surgery in a series of 10 consecutive Egyptian patients, regarding operative time, operative & early post-operative complications, hospital stay and pathological results. Patients and methods A case series study included 10 cases of colorectal cancer. Patients were recruited from the surgical department of the National Cancer Institute, Cairo University and operated by Robot da Vinci Si Surgical System (Intuitive Surgical, USA) over a period of one year. Their age ranged from 30 to 67 years. They were 5 males and 5 females. The patients provided informed consent. Patients with previous laparotomy, patients presented with intestinal obstruction, patients with severe cardiac or pulmonary disease were excluded from robotic surgery. The study was approved by local ethics committee. All rectal cancer patients with T3d, T3c, T4, N2, obturator, internal iliac, presacral lymph nodes and extensive intravascular mural invasion were subjected to long course preoperative neoadjuvant chemo-irradiation. Accordingly five patients received preoperative neoadjuvant treatment. Patient demographics, pathological, operative and perioperative outcomes were recorded prospectively into our departmental database and analyzed. Surgical technique For tumors of the upper rectum, a partial mesorectal excision (PMSE) is done and for tumors of the mid and low rectum, total mesorectal resection was done (TME). In cases of very low tumors without invasion to the rectal sphincters, inter-
A.S. Zaghloul, A.M. Mahmoud sphincteric or total proctectomy resection with specimen extraction through the anus and hand sewn coloanal anastomosis was performed. Abdominoperineal resection (APR) was proposed to patients with sphincter invading lesions or with very low tumors. Full robotic technique was done in all cases. The operation was carried out with the aid of the four-arm Da Vinci robotic system. The patient was placed in a modified lithotomy position and then tilted into a steep Trendelenburg position with the left side maximally elevated. The Da Vinci system is docked (Fig. 1) coming in over the patient’s left hip at an acute angle of about 30° in relation to the operating table. The two working ports were placed 12–14 cm from symphysis pubis in midclavicular line (Fig. 2). The two working arms usually carry a grasper on the left connected to bipolar cautery and hook with monopolar cautery on the right. The third robotic arm on the patient left side carries another grasper and is used for additional retraction. Medial to lateral mobilization with high ligation of inferior mesenteric artery (IMA) and vein (IMV) was carried out with clips (Figs. 3 and 4), then dissection continue in retroperitoneal space dropping the left ureter and left gonadal vessels. Mobilization of splenic flexure is done if needed. After completion of colon mobilization, dividing the peritoneum in front of sacral promontory going in the retro rectal space, then dissection continues circumferentially along the mesorectal fascia down to the planned rectal section line. Arms two and three, under control of the surgeon‘s left hand are used for dissection and retraction of the bladder or rectum as needed (Figs. 5 and 6). Once the distal transection cut is prepared the assistant divides the distal rectum using articulating linear stapler through a 12 mm laparoscopic port inserted in the right lower quadrant (Fig. 7). Delivery of the specimen through Pfannenstiel incision, dividing the proximal sigmoid at the proper distance, then introduction of the anvil of EEA (end to end anastomosis circular stapler), then purse string suture is done at the cut end (Fig. 8). Creating pneumoperitoneum again and end to end anastomosis was done using a EEA (Fig. 9). Results A total of 10 patients underwent robotic colorectal resections. patient clinical data are listed in Table 1. Mean age for patients was 47.4 years (range 30–67), equal number of male and female patients were involved. The patient BMI ranges from 24.8 to 39.5 with median 29.21. All patients presented with bleeding per rectum, 6 patients (60%) presented with rectal mass and 3 cases (30%) presented with change in bowel habits. Regarding tumor location, most patients (60%) had tumors in the lower rectum (<7 cm), upper rectum tumors were in 3 patients (30%) and one patient (10%) presented with tumor in the descending colon. The histopathologic data are presented in Table 2. Distal margin was positive in one patient (10%), circumferential margin was negative in all cases. Half of patients (50%) were stage II, 3 cases were stage I (30%), while 2 patients were stage III. Mean distal margin was 4.6 cm (range 0–15) and mean number of lymph nodes removed was 10.7 (range 5–23). Regarding operative data; one patient (10%) was estimated to be inoperable, 3 patients (30%) underwent low anterior
Results of robotic colorectal surgery at the National Cancer Institute
Figure 1
171
Port placement.
Figure 3
Figure 2
Docking.
resection (LAR) and the same number underwent anterior resection (30%). One patient (10%) had total proctocolectomy and coloanal anastomosis, and one (10%) had Lt hemicolectomy and abdominoperineal resection. The remaining one case (10%) underwent colostomy for locally advanced rectal cancer (T4) post neoadjuvant RTH and CTH, the tumor was fixed to the sacrum. Means for docking and robotic times were
IMA is skeletonized at its origin.
39.5 min (range 30–50) and 4.9 h (range 3–7) respectively. The mean total operative time was 333 min (range 215–465). Estimated blood loss ranged from 200 to 500 cc (mean 340 cc). The mean hospital stay was 7.4 days (range 5–16) (Table 3). Considering morbidity and mortality, the study showed no mortalities or intraoperative bleeding (>1000 cc blood loss). Only one case (10%) needs reoperation and 2 cases (20%) had prolonged post-operative ileus (Table 4). Discussion Proponents of the robotic technique claim that endowristed robotic instruments allow a surgeon to approach the rectum from different directions and angles, thus permitting precise retraction and sharp dissection [12].
172
A.S. Zaghloul, A.M. Mahmoud
Figure 4
IMV is ligated with clips.
Figure 6
Figure 5
Anterior dissection.
Posterior dissection.
This current study describes the short term outcomes of 10 consecutive Egyptian rectal cancer cases performed at the National Cancer Institute, Cairo University. Prolonged operative time is often described as one of the major drawbacks of robotic surgery. Our study reported a mean operative time of 333 min, this time compared favorably to previous studies done by Spinoglio et al. and Sawada et al. [13,14] which reported a mean operative time of 383.3 min, and 417 min respectively. However other studies reported a shorter time of operation [9,14]. This difference is mainly due to the less experience attributed to the novelty of the procedure in our country. Most authors reported a very low conversion rate for robotic colorectal operations [15–17]. This goes in accordance with our study which reported only one case (10%) which was converted to open. The reason behind this conversion in our case was mainly due to that the tumor was locally advanced and when converted to open procedure, the tumor was irresectable and only colostomy was done.
Figure 7
Rectal transection using articulating linear stapler.
Owing to the precise dissection and to the significant magnification, the blood loss in our study ranged between 200 and 500 cc. All studies reported the same results of blood loss not exceeding the 500 cc [9,18]. This indicates that the blood loss was significantly lower for robotic surgeries than laparoscopic surgeries and thus may reduce the probability of transfusion. There was no occurrence of anastomotic leak in our study; however Pigazzi et al. reported a 10.5% leak [19]. We can refer this discrepancy to the fact that we always perform protective ileostomy in low anastomosis. Only one case needed reoperation (10%) which goes in agreement with percentage (10.4%) of a study done by Hellan et al. [16]. Two patients (20%) had prolonged postoperative ileus. This stands in contrast to studies done by Pigazzi et al. [19] and Hellan et al. [16], which reported lower percentage of prolonged ileus >6 days. This may be explained by many factors as the prolonged operative time in our cases and lack of routinely epidural analgesia.
Results of robotic colorectal surgery at the National Cancer Institute Table 2
Extracorporeal anvil insertion and purse string
Percentage/range
Stage I Stage II Stage III Number of removed LN Distal margin (cm) Positive circumferential margin Positive distal margin
3 (30%) 5 (50%) 2 (20%) 10.7 (5–23) 4.6 (0–15) 0 1 (10%)
Table 1
Operative data.
Variable
Percentage/range
Type of operation Low anterior resection Total proctectomy & colo-anal anastomosis APR Anterior resection Lt hemicoloctomy Colostomy Docking time (minutes) Robotic time (hours) Total operative time (min) Blood loss (cc) Hospital stay (days) Conversion to open
3 (30%) 1 (10%) 1 (10%) 3 (30%) 1 (10%) 1 (10%) 39.5 (30–50) 4.9 (3–7) 333 (215–480) 340 (300–500) 7.4 (5–16) 1 (10%)
Table 4
Figure 9
Histopathological data.
Variable
Table 3
Figure 8 suturing.
173
Morbidity and mortality.
Variable
Number of patients (%)
Intraoperative bleeding (more than 1000 cc) Re-operation Postoperative ileus Mortality
0 1 (10%) 2 (20%) 0
End to end anastomosis using a circular stapler.
Clinical presentation of patients.
Variable
Number of patients (%)
Bleeding per rectum Rectal mass Change in bowel habits
10 (100%) 6 (60%) 3 (30%)
Tumor location Upper rectum (>11 cm) Left colon Lower rectum (<7 cm)
3 (30%) 1 (10%) 6 (60%)
In our study, the mean hospital stay was 7 days, which is comparable to that of the Pigazzi et al. study (8.3 days) [19]. In terms of oncologic outcome, the distal margin clearance was obtained in all our cases except for one patient. The mean number of harvested lymph nodes was 10.7 in our study which was to some extent less than that of open and laparoscopic series [18] and other robotic studies. The Pigazzi et al. study [19]
reported mean lymph nodes of 14.1, and in Hellan et al. and Luca et al. studies, the mean harvest was 13 and 18.5 respectively [16,17]. As observed by other authors, we agree that Da Vinci system facilitates nerve sparing TME [20,21]. Robotic TME seems to enhance microdissection accuracy, leading to better, safer and more comfortable mesorectal dissection with a lower risk of positive CRM. The disadvantage of the use of Robotics in colorectal surgery has been paid to the high cost that is associated with this technique. Several studies have reported that the cost of robotic colorectal surgery is higher than that of laparoscopic surgery [22,23]. This fact stand behind the limitation of its widespread application in many countries [24]. Comparing laparoscopic colorectal surgery to robotic colorectal surgery is beyond the scope of this study, however laparoscopic surgery has a steep learning curve especially for rectal cancer, where the integrity of total mesorectal excision (TME) influences outcomes, one of potential benefits of robotic surgery is to facilitate less experienced surgeons to perform minimal axis surgery [25–27].
174 Hence, future studies should assess the cost-effectiveness of robotic colorectal surgeries based on long term oncologic outcomes and functional results. Our impression in the studied group is that the maximum benefit of robotic colorectal surgery is in lower rectal tumors, that is to overcome the constrains of narrow pelvic space for adequate total mesorectal excision, and to precisely dissect and protect autonomic pelvic nerves for preservation of potency and continence. On the other hand, we cannot ignore the great advantages of the technique itself where a console operator can use three working arms with articulated instruments and stable controllable camera plate form, in addition to a skilled assistant with two assistant trocars, that is to say five working trocars or five hands with unlimited advantage of accurate and magnified oncologically safe dissection.
A.S. Zaghloul, A.M. Mahmoud
[10]
[11]
[12]
[13]
[14]
Conclusion Robotic colorectal surgery is safe and applicable approach in our patients. Colorectal cancer surgeons who lack extensive laparoscopic experience and wish to perform a transition from open to minimally invasive surgery may benefit from this modality. Future studies are necessary to assess the long term oncological outcomes of the robotic colorectal surgery in comparison with open and laparoscopic procedures and thereafter determine the feasibility of its widespread application.
[15]
[16]
[17]
Conflict of interest [18]
None declared. References [1] Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision 1978–1997. Arch Surg 1998;133:894–9. [2] Redwine DB, Sharpe DR. Laparoscopic segmental resection of the sigmoid colon for endometriosis. J Laparoendosc Surg 1991;1:217–20. [3] Ohtani H, Tamamori Y, Azuma T, Mori Y, Nishiguchi Y, Maeda K, et al. Meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for rectal cancer. J Gastrointest Surg 2011;15:1375–85. [4] Haas EM, Pedraza R. Minimally invasive colorectal surgery. Cir Cir 2012;80:1–2. [5] Ragupathi M, Ramos-Valadez DI, Pedraza R, Haas EM. Robotic assisted single-incision laparoscopic partial cecectomy. Int J Med Rob 2010;6:362–7. [6] Hashizume M, Shimada M, Tomikawa M, Ikeda Y, Takahashi I, Abe R, et al. Early experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system. Surg Endosc 2002;16:1187–91. [7] D’Annibale A, Morpurgo E, Fiscon V, Trevisan P, Sovernigo G, Orsini C, et al. Robotic and laparoscopic surgery for treatment of colorectal disease. Dis Colon Rectum 2004;47:2162–8. [8] Pigazzi A, Ellenhorn JDI, Ballantyne GH, Paz IB. Roboticassisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg Endosc 2006;20:1521–5. [9] Baik SH, KO YT, Kang CM, Lee WJ, Kim NK, Sohn SK, et al. Robotic tumor-specific mesorectal excision of rectal cancer:
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Cairo University
Journal of the Egyptian National Cancer Institute www.elsevier.com/locate/jnci www.sciencedirect.com
Full Length Article
Preliminary results of robotic colorectal surgery at the National Cancer Institute, Cairo University Ashraf Saad Zaghloul, Ahmed Mostafa Mahmoud * Surgical Oncology Department, National Cancer Institute, Cairo University, Egypt Received 16 January 2016; revised 8 May 2016; accepted 21 May 2016 Available online 13 June 2016
KEYWORDS Minimally invasive surgery; Robotic-assisted; Colorectal cancer; Egypt
Abstract Background: The available literature on minimally invasive colorectal cancer demonstrates that laparoscopic approach is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety. Reports have shown that robotic surgery may overcome some of the pitfalls of laparoscopic intervention. Objective of the work: To evaluate early results of robotic colorectal surgery, in a cohort of Egyptian patients, regarding operative time, operative and early post-operative complications, hospital stay and pathological results. Patients and methods: A case series study which was carried out in surgical department at National Cancer Institute, Cairo University. Ten Egyptian cases of colorectal cancer (age ranged from 30 to 67, 5 males and 5 females) were recruited from the period of April 2013 to April 2014. Robotic surgery was performed to all cases. Results: Three patients had low anterior resection, three anterior resection, one total proctectomy, one abdominoperineal resection, one left hemicolectomy and one colostomy. The study reported no mortalities and two morbidities. The mean operative time was 333 min. The conversion to open was done in only one patient. A total mesorectal excision with negative circumferential margin was accomplished in all patients, distal margin was positive in one patient. Mean lymph nodes removed was 10.7. Mean hospital stay was 7.4 days. Conclusion: To the best of our knowledge, this is the first study reporting the outcomes of robotic colorectal cancer intervention in Egyptian patients. Our preliminary results suggest that roboticassisted surgery for colorectal cancer can be carried out safely and according to oncological principles. Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction * Corresponding author. Mobile: +20 01001729571. E-mail address: [email protected] (A.M. Mahmoud). Peer review under responsibility of The National Cancer Institute, Cairo University.
The most important advance in rectal surgery over the last 30 years was development of total mesorectal excision (TME). TME is associated with reduction of local recurrence rate to less than 10% and improve survival [1].
http://dx.doi.org/10.1016/j.jnci.2016.05.003 1110-0362 Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
170 The development of minimally invasive approach in colorectal disease began with first report of laparoscopic assisted colectomy in 1991 [2]. The available literature on minimally invasive TME for rectal cancer demonstrates that laparoscopic TME is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety [3]. The proposed advantages of minimally invasive colorectal surgeries (MIC) over open colectomies include improved intra operative visualization of pelvis, less stress on patient, less post-operative pain, improved cosmoses, shorter duration of ileus and briefer hospitalization [4]. More recently, robotic assisted laparoscopic colorectal surgery has become an intriguing technique most beneficial for procedures requiring rectal resection. This technology provides visualization and reach for these complex pelvic procedures [5]. The 1st robotic assisted colorectal resection was reported in Japan by Hashizume et al. in 2002 [6]. The use of robotics for the treatment of rectal cancer has recently been shown to be feasible [7–10]. The general advantages of the Da Vinci robotic system are a three-dimensional view, hand-tremor filtering, fine dexterity, and motion scaling, providing an absolute benefit when the operative field is narrow and fixed and sharp dissection is necessary [11]. There are no available data on the outcome of robotic intervention in cancer surgery in developing countries and the only data available are those of American, European and Asian experiences. Within this context, the present study aims to report our initial experience with robotic colorectal surgery in a series of 10 consecutive Egyptian patients, regarding operative time, operative & early post-operative complications, hospital stay and pathological results. Patients and methods A case series study included 10 cases of colorectal cancer. Patients were recruited from the surgical department of the National Cancer Institute, Cairo University and operated by Robot da Vinci Si Surgical System (Intuitive Surgical, USA) over a period of one year. Their age ranged from 30 to 67 years. They were 5 males and 5 females. The patients provided informed consent. Patients with previous laparotomy, patients presented with intestinal obstruction, patients with severe cardiac or pulmonary disease were excluded from robotic surgery. The study was approved by local ethics committee. All rectal cancer patients with T3d, T3c, T4, N2, obturator, internal iliac, presacral lymph nodes and extensive intravascular mural invasion were subjected to long course preoperative neoadjuvant chemo-irradiation. Accordingly five patients received preoperative neoadjuvant treatment. Patient demographics, pathological, operative and perioperative outcomes were recorded prospectively into our departmental database and analyzed. Surgical technique For tumors of the upper rectum, a partial mesorectal excision (PMSE) is done and for tumors of the mid and low rectum, total mesorectal resection was done (TME). In cases of very low tumors without invasion to the rectal sphincters, inter-
A.S. Zaghloul, A.M. Mahmoud sphincteric or total proctectomy resection with specimen extraction through the anus and hand sewn coloanal anastomosis was performed. Abdominoperineal resection (APR) was proposed to patients with sphincter invading lesions or with very low tumors. Full robotic technique was done in all cases. The operation was carried out with the aid of the four-arm Da Vinci robotic system. The patient was placed in a modified lithotomy position and then tilted into a steep Trendelenburg position with the left side maximally elevated. The Da Vinci system is docked (Fig. 1) coming in over the patient’s left hip at an acute angle of about 30° in relation to the operating table. The two working ports were placed 12–14 cm from symphysis pubis in midclavicular line (Fig. 2). The two working arms usually carry a grasper on the left connected to bipolar cautery and hook with monopolar cautery on the right. The third robotic arm on the patient left side carries another grasper and is used for additional retraction. Medial to lateral mobilization with high ligation of inferior mesenteric artery (IMA) and vein (IMV) was carried out with clips (Figs. 3 and 4), then dissection continue in retroperitoneal space dropping the left ureter and left gonadal vessels. Mobilization of splenic flexure is done if needed. After completion of colon mobilization, dividing the peritoneum in front of sacral promontory going in the retro rectal space, then dissection continues circumferentially along the mesorectal fascia down to the planned rectal section line. Arms two and three, under control of the surgeon‘s left hand are used for dissection and retraction of the bladder or rectum as needed (Figs. 5 and 6). Once the distal transection cut is prepared the assistant divides the distal rectum using articulating linear stapler through a 12 mm laparoscopic port inserted in the right lower quadrant (Fig. 7). Delivery of the specimen through Pfannenstiel incision, dividing the proximal sigmoid at the proper distance, then introduction of the anvil of EEA (end to end anastomosis circular stapler), then purse string suture is done at the cut end (Fig. 8). Creating pneumoperitoneum again and end to end anastomosis was done using a EEA (Fig. 9). Results A total of 10 patients underwent robotic colorectal resections. patient clinical data are listed in Table 1. Mean age for patients was 47.4 years (range 30–67), equal number of male and female patients were involved. The patient BMI ranges from 24.8 to 39.5 with median 29.21. All patients presented with bleeding per rectum, 6 patients (60%) presented with rectal mass and 3 cases (30%) presented with change in bowel habits. Regarding tumor location, most patients (60%) had tumors in the lower rectum (<7 cm), upper rectum tumors were in 3 patients (30%) and one patient (10%) presented with tumor in the descending colon. The histopathologic data are presented in Table 2. Distal margin was positive in one patient (10%), circumferential margin was negative in all cases. Half of patients (50%) were stage II, 3 cases were stage I (30%), while 2 patients were stage III. Mean distal margin was 4.6 cm (range 0–15) and mean number of lymph nodes removed was 10.7 (range 5–23). Regarding operative data; one patient (10%) was estimated to be inoperable, 3 patients (30%) underwent low anterior
Results of robotic colorectal surgery at the National Cancer Institute
Figure 1
171
Port placement.
Figure 3
Figure 2
Docking.
resection (LAR) and the same number underwent anterior resection (30%). One patient (10%) had total proctocolectomy and coloanal anastomosis, and one (10%) had Lt hemicolectomy and abdominoperineal resection. The remaining one case (10%) underwent colostomy for locally advanced rectal cancer (T4) post neoadjuvant RTH and CTH, the tumor was fixed to the sacrum. Means for docking and robotic times were
IMA is skeletonized at its origin.
39.5 min (range 30–50) and 4.9 h (range 3–7) respectively. The mean total operative time was 333 min (range 215–465). Estimated blood loss ranged from 200 to 500 cc (mean 340 cc). The mean hospital stay was 7.4 days (range 5–16) (Table 3). Considering morbidity and mortality, the study showed no mortalities or intraoperative bleeding (>1000 cc blood loss). Only one case (10%) needs reoperation and 2 cases (20%) had prolonged post-operative ileus (Table 4). Discussion Proponents of the robotic technique claim that endowristed robotic instruments allow a surgeon to approach the rectum from different directions and angles, thus permitting precise retraction and sharp dissection [12].
172
A.S. Zaghloul, A.M. Mahmoud
Figure 4
IMV is ligated with clips.
Figure 6
Figure 5
Anterior dissection.
Posterior dissection.
This current study describes the short term outcomes of 10 consecutive Egyptian rectal cancer cases performed at the National Cancer Institute, Cairo University. Prolonged operative time is often described as one of the major drawbacks of robotic surgery. Our study reported a mean operative time of 333 min, this time compared favorably to previous studies done by Spinoglio et al. and Sawada et al. [13,14] which reported a mean operative time of 383.3 min, and 417 min respectively. However other studies reported a shorter time of operation [9,14]. This difference is mainly due to the less experience attributed to the novelty of the procedure in our country. Most authors reported a very low conversion rate for robotic colorectal operations [15–17]. This goes in accordance with our study which reported only one case (10%) which was converted to open. The reason behind this conversion in our case was mainly due to that the tumor was locally advanced and when converted to open procedure, the tumor was irresectable and only colostomy was done.
Figure 7
Rectal transection using articulating linear stapler.
Owing to the precise dissection and to the significant magnification, the blood loss in our study ranged between 200 and 500 cc. All studies reported the same results of blood loss not exceeding the 500 cc [9,18]. This indicates that the blood loss was significantly lower for robotic surgeries than laparoscopic surgeries and thus may reduce the probability of transfusion. There was no occurrence of anastomotic leak in our study; however Pigazzi et al. reported a 10.5% leak [19]. We can refer this discrepancy to the fact that we always perform protective ileostomy in low anastomosis. Only one case needed reoperation (10%) which goes in agreement with percentage (10.4%) of a study done by Hellan et al. [16]. Two patients (20%) had prolonged postoperative ileus. This stands in contrast to studies done by Pigazzi et al. [19] and Hellan et al. [16], which reported lower percentage of prolonged ileus >6 days. This may be explained by many factors as the prolonged operative time in our cases and lack of routinely epidural analgesia.
Results of robotic colorectal surgery at the National Cancer Institute Table 2
Extracorporeal anvil insertion and purse string
Percentage/range
Stage I Stage II Stage III Number of removed LN Distal margin (cm) Positive circumferential margin Positive distal margin
3 (30%) 5 (50%) 2 (20%) 10.7 (5–23) 4.6 (0–15) 0 1 (10%)
Table 1
Operative data.
Variable
Percentage/range
Type of operation Low anterior resection Total proctectomy & colo-anal anastomosis APR Anterior resection Lt hemicoloctomy Colostomy Docking time (minutes) Robotic time (hours) Total operative time (min) Blood loss (cc) Hospital stay (days) Conversion to open
3 (30%) 1 (10%) 1 (10%) 3 (30%) 1 (10%) 1 (10%) 39.5 (30–50) 4.9 (3–7) 333 (215–480) 340 (300–500) 7.4 (5–16) 1 (10%)
Table 4
Figure 9
Histopathological data.
Variable
Table 3
Figure 8 suturing.
173
Morbidity and mortality.
Variable
Number of patients (%)
Intraoperative bleeding (more than 1000 cc) Re-operation Postoperative ileus Mortality
0 1 (10%) 2 (20%) 0
End to end anastomosis using a circular stapler.
Clinical presentation of patients.
Variable
Number of patients (%)
Bleeding per rectum Rectal mass Change in bowel habits
10 (100%) 6 (60%) 3 (30%)
Tumor location Upper rectum (>11 cm) Left colon Lower rectum (<7 cm)
3 (30%) 1 (10%) 6 (60%)
In our study, the mean hospital stay was 7 days, which is comparable to that of the Pigazzi et al. study (8.3 days) [19]. In terms of oncologic outcome, the distal margin clearance was obtained in all our cases except for one patient. The mean number of harvested lymph nodes was 10.7 in our study which was to some extent less than that of open and laparoscopic series [18] and other robotic studies. The Pigazzi et al. study [19]
reported mean lymph nodes of 14.1, and in Hellan et al. and Luca et al. studies, the mean harvest was 13 and 18.5 respectively [16,17]. As observed by other authors, we agree that Da Vinci system facilitates nerve sparing TME [20,21]. Robotic TME seems to enhance microdissection accuracy, leading to better, safer and more comfortable mesorectal dissection with a lower risk of positive CRM. The disadvantage of the use of Robotics in colorectal surgery has been paid to the high cost that is associated with this technique. Several studies have reported that the cost of robotic colorectal surgery is higher than that of laparoscopic surgery [22,23]. This fact stand behind the limitation of its widespread application in many countries [24]. Comparing laparoscopic colorectal surgery to robotic colorectal surgery is beyond the scope of this study, however laparoscopic surgery has a steep learning curve especially for rectal cancer, where the integrity of total mesorectal excision (TME) influences outcomes, one of potential benefits of robotic surgery is to facilitate less experienced surgeons to perform minimal axis surgery [25–27].
174 Hence, future studies should assess the cost-effectiveness of robotic colorectal surgeries based on long term oncologic outcomes and functional results. Our impression in the studied group is that the maximum benefit of robotic colorectal surgery is in lower rectal tumors, that is to overcome the constrains of narrow pelvic space for adequate total mesorectal excision, and to precisely dissect and protect autonomic pelvic nerves for preservation of potency and continence. On the other hand, we cannot ignore the great advantages of the technique itself where a console operator can use three working arms with articulated instruments and stable controllable camera plate form, in addition to a skilled assistant with two assistant trocars, that is to say five working trocars or five hands with unlimited advantage of accurate and magnified oncologically safe dissection.
A.S. Zaghloul, A.M. Mahmoud
[10]
[11]
[12]
[13]
[14]
Conclusion Robotic colorectal surgery is safe and applicable approach in our patients. Colorectal cancer surgeons who lack extensive laparoscopic experience and wish to perform a transition from open to minimally invasive surgery may benefit from this modality. Future studies are necessary to assess the long term oncological outcomes of the robotic colorectal surgery in comparison with open and laparoscopic procedures and thereafter determine the feasibility of its widespread application.
[15]
[16]
[17]
Conflict of interest [18]
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