Robotic systems (the da Vinci Surgical System) may offer considerable advantages, particularly in rectal surgery operated in the confined pelvis. This study was carried out on the assumption that a robotically naive, yet laparoscopically experienced surgeon successfully transferred to a robotic environment. We assessed immediate surgical outcomes of robotic intersphincteric resection (ISR) as an initial experience of a single surgeon.
We analyzed the data of 19 consecutive patients with rectal cancer who underwent robot ISR between January 2009 and March 2012. Its immediate surgical outcomes were compared with those of 19 patients who underwent laparoscopic ISR as a control group of the same cohort.
There was no significant difference in the mean operating time between robotic and laparoscopic group (261.6±57.7 minutes, 222.37±68.2 minutes, P=0.064). Mean distal resection margin was 1.5±2.2 and 1.1±0.9 in robotic and laparoscopic groups, respectively (P=0.464). Three patients in each group had a circumferential margin clearance of less than 1 mm. Two patients in each group suffered from anastomotic leakeage. There were no significant differences in date of flatus passage and dietary intake, and the length of postoperative hospital stay between both groups.
Robotic ISR is a safe and feasible procedure and its early short-term surgical outcomes are comparable to those of laparoscopic surgery.
Robotic systems (the da Vinci Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) have been adopted in various surgical fields such as urologic and gynecologic procedures with good results [
As with any new surgical technique, however, there is an related learning curve. This learning curve includes operative outcomes and oncological outcomes. This study was conducted under the assumption that experienced laparoscopic surgeon could overcome the learning curve for robotic surgery quickly and easily. In this study, we compared operative and pathologic outcomes of robotic surgery at an early period with those of laparoscopic surgery at a late period of a single surgeon.
We retrospectively analyzed immediate surgical outcomes of the 19 patients undergoing robotic intersphincteric resection (ISR) compared with those of 19 patients undergoing laparoscopic ISR for rectal cancer as a control group of the same cohort. All operations were performed by a single surgeon who has performed laparoscopic colorectal surgery more than 300 cases. These rectal cancer surgeries were performed between January 2009 and March 2012 at Kyung Hee University Medical Center. Data were collected in a prospectively maintained database that was further supplemented by retrospective chart review.
Under the general anesthesia, the patient was placed in modified lithotomy position by using Allen’s stirrups. All laparoscopic surgery and robotic surgery were executed in the order of 1) ligation of the inferior mesenteric vessels, 2) left colonic mobilization, 3) pelvic dissection, 4) intersphincteric dissection, 5) rectal reconstruction, and 6) ileostomy creation. For laparoscopic group, steps 1-4 were performed using a laparoscopic approach. For robotic group, whereas, steps 1-2 were performed using a laparoscopic approach and steps 3-4 using a robotic approach. Coloanal anastomosis was performed via a hand-sewn end to end manner with absorbable interrupted sutures. Finally, a loop ileostomy was created in the area of the right lower quadrant.
Patient factors and demographics were assessed including age, sex, body mass index, American Society of Anesthesiologists (ASA) score, history of previous abdominal surgery, tumor location from anal verge, tumor size, pathologic stage and preoperative concurrent chemoradiation therapy (CCRT).
Perioperative factors were compared of including operating time, transfusion rate and conversion rate. Oncologic adequacy was assessed including the number of harvested lymph nodes (LNs) and status of resection margins (distal, proximal, and circumferential margins).
Postoperative results included days to passing first flatus, resuming diet, the length of hospital stay and postoperative morbidity. Morbidity was defined as operation related complications including anastomotic leakage, paralytic ileus, wound problem, pulmonary problem, voiding difficulty and adjacent organ injury during surgery.
Data were analyzed using the PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were used to derive the mean±SD and were tested for statistical significance using the Student’s t-test. Proportions were evaluated using chi-square test or Fisher’s exact test. A P-value of less than 0.05 was considered significant.
General characteristics of the patients were presented in
Outcomes of postoperative recovery were presented at
Overall operation-related complication was not different between the two groups (3 patients in robotic group and 6 patients in laparoscopic group, P=0.379) (
ISR has been used to extend the opportunity for sphincter preservation in patients with low rectal cancer. Several studies reported the comparison between open and laparoscopic ISR for low rectal cancer [
Robotic systems have technical advantages over conventional laparoscopic surgery that overcome the limited manual dexterity of laparoscopic instruments and provide ambidexterity in narrow space. Especially, robotic systems make it easy to dissect left side of pelvic cavity with the surgeon’s right or left hand. In addition, strong and steady traction with robot arms and self-controlled camera system enables an operator to secure a clear view. Dissection of the lower part of the rectum using robotic systems could be helpful in gaining access to the operative field in any direction, allowing excellent visibility for determining the relationship of the lower rectum to the levator ani muscle, the presacral fascia to the fascia propria of the rectum, and seminal vesicle or vagina to Denonvilliers’ fascia [
We hypothesized that laparoscopically experienced surgeon was adequately prepared to perform safe and efficacious ISR by robotic approach, even at an early period of experience.
In one study, the first plateau of laparoscopic rectal resection was observed after 90 cases in learning curve for operating time [
Oncologic adequacy was assessed by LN clearance, circumferential margin clearance and distal margin clearance. In our study, the number of LN harvested and distal margin clearance were similar to previously reported studies [
This study has some limitations. It is a retrospective study of prospectively collective data, which has inherent selection bias. In addition, there is a lack of data on urologic and sexual function, which may have reflected the quality of rectal dissection. However, to the best of our knowledge, there are few studies comparing robotic and conventional laparoscopic ISR for low rectal cancer. Based on the results of the present study, a longer follow-up could be required to assess the long-term outcomes of local recurrence and cancer-free survival.
In conclusion, our results suggest that robotic ISR is a safe and feasible procedure for low rectal cancer and showed comparable outcomes with laparoscopic surgery. All operations were performed by a single surgeon who already has highly experienced laparoscopic rectal surgery. Especially, operating time in robotic ISR showed comparable to those in laparoscopic ISR for just less than 20 cases. This suggests that, for a skilled laparoscopic surgeon, robotic systems can contribute to reduce the technical difficulties of rectal resection without the requirement of a long learning time. In addition, recent studies reported that robotic surgery could provide an enhanced benefit to patients in the management of mid to low rectal cancer in terms of postoperative recovery and functional outcomes [
No potential conflict of interest relevant to this article was reported.
Characteristics of patients
Characteristic | Robot |
Laparoscopy |
P-value |
---|---|---|---|
Age (yr) | 58.8±0.7 | 64.2±8.1 | 0.091 |
Sex | 0.163 | ||
Male | 15 (78.9) | 11 (57.9) | |
Female | 4 (21.1) | 8 (42.1) | |
Body mass index (kg/m2) | 24.3±3.1 | 25.3±4.2 | 0.413 |
ASA score | 0.052 | ||
1 | 3 (15.8) | 0 (0.0) | |
2 | 14 (73.7) | 12 (63.2) | |
3 | 2 (10.5) | 7 (36.8) | |
Previous abdominal surgery | 4 (21.1) | 3 (15.8) | 0.676 |
Distance from anal verge (cm) | 4.6±2.7 | 3.8±1.1 | 0.206 |
Preoperative CCRT | 7 (36.8) | 11 (57.9) | 0.330 |
Tumor size (cm) | 3.3±1.8 | 3.2±3.8 | 0.897 |
TNM stage | 0.426 | ||
0 | 2 (10.5) | 0 (0.0) | |
I | 5 (26.3) | 8 (42.1) | |
II | 3 (15.8) | 4 (21.1) | |
III | 7 (36.8) | 4 (21.1) | |
IV | 2 (10.5) | 3 (15.8) |
Values are presented as number (%) or mean±SD.
ASA, American Society of Anesthesiologists; CCRT, concurrent chemoradiation therapy; TNM, tumor node metastasis.
Perioperative outcomes
Variable | Robot |
Laparoscopy |
P-value |
---|---|---|---|
Operating time (min)a) | 261.6±57.7 | 222.37±68.2 | 0.064 |
Conversion to open surgery | 0 (0.0) | 1 (5.3) | 0.311 |
Transfusion | 1 (5.3) | 1 (5.3) | 1.000 |
Protective stoma | 19 (100) | 19 (100) | 1.000 |
Inferior mesenteric artery ligation | 1.000 | ||
High | 15 (78.9) | 15 (78.9) | |
Low | 4 (21.1) | 4 (21.1) | |
Proximal margin (cm) | 15.8±7.1 | 16.4±7.0 | 0.816 |
Distal margin (cm) | 1.5±2.2 | 1.1±0.9 | 0.464 |
Circumferential margin (mm) | 6.72±0.43 | 6.61±0.58 | 0.949 |
Positive circumferential marginb) | 3 (15.8) | 3 (15.8) | 1.000 |
Retrieved lymph node | 12.0±3.9 | 15.7±6.3 | 0.033 |
Positive lymph node | 1.1±1.5 | 2.8±5.4 | 0.184 |
Values are presented as number (%) or mean±SD.
a)Operating time was defined as total operating time from skin incision to skin closure.
b)Positive circumferential margin was defined as circumferential margin clearance of less than 1 mm.
Postoperative recovery
Variable | Robot |
Laparoscopy |
P-value |
---|---|---|---|
Flatus passage (day) | 1.2±0.4 | 1.5±0.6 | 0.063 |
SIPS intake (day) | 0.68±0.6 | 1.0±0.6 | 0.102 |
Liquid or soft diet intake (day) | 1.3±0.5 | 1.6±0.8 | 0.080 |
Hospital stay (day) | 8.7±4.5 | 8.0±4.7 | 0.599 |
Values are presented as mean±SD.
SIPS, sips of water.
Operation related morbidity
Variable | Robot |
Laparoscopy |
P-value |
---|---|---|---|
Overall | 3 (15.8) | 6 (31.6) | 0.379 |
Anastomotic leakage | 2 (10.5) | 2 (10.5) | |
Paralytic ileus | 0 | 1 (5.3) | |
Wound problem | 0 | 1 (5.3) | |
Pulmonary complication | 0 | 0 | |
Voiding difficulty | 0 | 2 (10.5) | |
Trocar injury | 1 (5.3) | 0 |
Values are presented as number (%).