Taggarshe D; Attuwaybi BO; Butler BN

Special Issue Article: Colorectal Cancer

Austin J Cancer Clin Res 2014;1(4): 1018.

Robotic Surgery in Colorectal Cancer

Taggarshe D¹*, Attuwaybi BO² and Butler BN²

¹Department of Surgery, Virginia Commonwealth University, USA

²Department of Surgery, University at Buffalo, USA

*Corresponding author: Taggarshe D, Department of Surgery, Virginia Commonwealth University, West Hospital 15th Floor, Room 15-408, Richmond Virginia 23298, USA

Received: September 16, 2014; Accepted: October 04,, 2014; Published: October 09, 2014

Abstract

Background: In the last two decades, colorectal surgery has seen a dramatic advancement in from open to laparoscopic and now, robotic surgery. The aim of this article is to review the role of robotic surgery in colorectal cancer, especially in comparison with laparoscopic surgery.

Methods: A literature search was performed using PUBMED and Google- Scholar for all papers published discussing Robotic surgery in colorectal cancer upto July 2014. We also reviewed articles comparing laparoscopic colorectal surgery versus robotic colorectal surgery.

Results: Robotic colectomies had a mean operative time of 224 minutes and mean estimated blood loss of 47.67 mls. The rate of conversions to open varied from 0% to 5%. Robotic colectomies were slightly longer compared to laparoscopic colectomies. But comparable with number of retrieved lymph nodes and postoperative morbidity.

Robotic rectal surgery had a mean operative time of 269 minutes (range, 170-700 minutes). Conversion rates for the robotic group were 0% - 8% in comparison with 0% - 22% for the laparoscopic group. The median anastomotic leak rate was 7.3% for the robotic group and 6.3% for the laparoscopic group. Rates of erectile dysfunction varied from 0% -36.6% after robotic surgery to 1% - 56.5% after laparoscopic surgery. With oncologic outcomes, robotic surgery was comparable with laparoscopic surgery.

Conclusions: Robotic surgery is safe, feasible and suitable for colorectal cancer. Compared to laparoscopic surgeries there are fewer conversions to open and blood loss, with comparable postoperative and oncologic outcomes.

Keywords: Robotic surgery; Colon cancer; Rectal cancer; Laparoscopic surgery

Introduction

The surgical management of colorectal cancer has changed since the inception of minimally invasive techniques. Major international trials have established the safety of laparoscopic surgery, with oncological outcomes comparable to open surgery in colorectal cancer [1-3]. Laparoscopic surgery has an edge over conventional open surgery with a decreased analgesia requirement, shorter length of stay, and an improved quality of life [4]. Laparoscopic surgery is associated with decreased postoperative morbidity and incisional hernias.

However, laparoscopic surgery has not gained wide acceptance and majority of colorectal resections in USA are still being performed open [5]. This has been due to a combination of the steep learning curve and the inherent limitations with laparoscopic surgery. Limitations of laparoscopic surgery include poor visualization with a two –dimension view resulting in poor depth perception, need of a trained assistant to hold the camera, poor ergonomics, straight instruments and enhanced tremor effects. Alternatives for laparoscopic surgery have been developed to overcome some of these limitations.

The Food and Drug Administration approved robotic assisted surgery with the da Vinci operating console in 2000. Weber et al demonstrated the feasibility of robotic assisted colectomies in 2002 [6]. The advantages of the da Vinci platform – da Vinci Si HD, which was used in most of the publications, include a three dimensional high definition camera, articulating instruments with seven degrees of freedom, a stable camera and operating platform, reduced physiological tremors, ergonomic comfort and superior dexterity. Robotic surgery can enable precision surgery in conditions with difficult target organ exposure such as narrow male pelvis, distal tumors and obese patients. Robotic surgery has exponentially increased in all specialties worldwide and in the US, along with a similar increase in robotic colorectal surgery [7].

The aim of this article is to review the use of robotic surgery in colon and rectal cancer and determine its safety and feasibility. The article also aims to compare it with laparoscopic surgery for colon and rectal cancers.

Materials and Methods

A literature search was performed using PUBMED and Google Scholar for all articles involving robotic surgery in colorectal cancer up to July 2014. The keywords used for search in combinations were “robotic surgery”, “colorectal cancer”, “rectal cancer”, “proctectomy”, “colectomy”, and “sigmoid resection”. The abstracts were examined and articles with application of robotic surgery in colorectal cancers were further reviewed. Furthermore, the reference lists of selected articles were searched manually. Only articles published in English were included. The included articles included randomized clinical trials, comparative studies and case series.

Data extracted included number of patients, operative details and outcomes. Costs involved with robotic surgery were included if mentioned in the articles. Operative details included type of surgery, operating time, estimated blood loss and intra operative complications. Pathological features included were number of retrieved lymph nodes in all cases and circumferential resection margin (CRM) status and distal resection margin (DRM) in rectal cancer. Postoperative outcomes included length of stay and postoperative complications.

Results

Sixty-five articles met the initial criteria for robotic surgery in colorectal cancer. Twelve articles with benign and malignant disease and six articles with inseparable colonic and rectal data were excluded. Articles (n=10) with data in overlapping periods from the same institutions were excluded. Nine articles meeting the criteria for robotic colectomies [8-16] and twenty-eight articles for robotic rectal surgery for cancer [11,17-43] were included for this review.

Robotic Colonic Surgery for Cancer

Clinical outcomes

The review identified 316 robotic colectomies for cancer. This included 233 right colectomies, 68 sigmoid resections, 3 total abdominal colectomies and 12 left hemicolectomies (Table 1). Ballantyne et al compared robotic right colectomies with medial to lateral dissection versus robotic colectomies with lateral to medial dissection [8]. Two articles reported on right colectomies with intracorporeal anastomosis [15,16].

Table 1: Studies on robotic colectomies for cancer.



  
    Author
    Study Design
    Number of cases
    Type of colectomy
    Operative time (Mean)
      In minutes
    EBL (ml)
    Conversion
      (%)
    LN retrieved
      (mean)
    Postop Morbidity
      %
    Leaks
      %
    LOS
      in days
    OS
    DFS
  
  
    Right colectomy
    Sigmoid resection
    Total abd colectomy
    Left hemi
  
  
    8
       
    Comparative
    16
    8 (Med to Lat)
      8 (Lat to med)
     
     
     
    253* (180-309)
      256* (228-350)
     
    12.5% to lap
    18* (3-35)
      12* (3-20)
    25%
      25%
    0
      0
    4* (2-9)
      5* (3-10)
     
     
  
  
    9
       
    Case series
    50
    50
     
     
     
    223.5* (180-270)
       
    20* (0-100)
    None
    18.76* (12-44)
    2%
    0
    7
    92% @3 yrs
    90% @3yrs
  
  
    10
       
    Case series
    3
    3
     
     
     
    130
     
     
     
     
     
    4.5
     
     
  
  
    11
       
    Case series
    42
    42
     
     
     
    158.9
    73.2
    2.38%
    19
    11.9%
     
    5.4
     
     
  
  
    12
       
    RCT
    35
    35
     
     
     
    195
    35.8
    None
    29.9
    17.14%
    2.85%
    7.9
     
     
  
  
    13
       
    Comparative
    101
    52
    34
    3
    12
    243
     
    5%
     
    22%
    5.1%
    6.42
     
     
  
  
    14
       
    Comparative
    34
     
    34
     
     
    252.5
    60.3
    None
    12
    10.3%
    0
    5.5
    92.1% @ 3 yrs
     
  
  
    15
       
    Case series
      (ICA)
    15
    15
     
     
     
    201.4
    41.7
    None
    24.2
    33.3%
    0
    7* (6-21)
     
     
  
  
    16
       
    Case series
      (ICA)
    20
    20
     
     
     
    327.5
    55
    None
    17.6
    3.33%
    0
    4.5



Table 1:  Studies on robotic colectomies for cancer.

The mean operative time was 224 minutes and mean estimated blood loss was 47.67 mls. The rate of conversions to open varied from 0% to 5%. Ballantyne et al reported one conversion to laparoscopy in the medial to lateral dissection for right colectomy due to bleeding [8]. The mean number of retrieved lymph nodes ranged from 12 to 30. Overall postoperative morbidity varied from 2% to 33%. This included wound infections, post op ileus, small bowel obstructions, anastomotic leaks and pneumonia. Reported anastomotic leak rates varied from 0% to 5.1%.

Laparoscopic vs. robotic colon surgery for cancer

Three articles (Table 2) compared robotic and laparoscopic colectomies for cancer: Park et al [12] reported on a randomized controlled trial for right colectomy and Lim et al [14] compared laparoscopic and robotic anterior resections for sigmoid cancer. Robotic colectomies were slightly longer. However they were comparable with regards to number of retrieved lymph nodes and postoperative morbidity.

Table 2: Studies comparing robotic and laparoscopic colectomies.



  
    Author
    Procedure
    Number of    cases
    Type of    colectomy
    Operative    time (Mean)
      In minutes
    EBL (ml)
    Conversion
      (%)
    LN retrieved
      (mean)
    Postop    Morbidity
      %
    Leaks %
    LOS
      in days
    Costs
  
  
    Right    colectomy
    Sigmoid    resection
    Total abd    colectomy
    Left hemi
  
  
    12
       
    Robot
      Lap
    35
      35
    35
      35
     
     
     
    195
      130
    35.8
      56.8
    None
      None
    29.9
      30.8
    17.14%
      20%
    2.85%
      0
    7.9
      8.3
    $1907.9#
      $1607.7
  
  
    13
       
    Robot
      Lap
    101
      162
    52
      88
    34
      59
    3
      0
    12
      14
    243
      254
     
    5%
      2%
     
    22%
      22%
    5.1%
      5.5%
    6.42
      6.74
     
  
  
    14
       
    Robot
      Lap
    34
      146
     
    34
      146
     
     
    252.5
      217.6
    60.3
      78.2
    None
      0.68%
    12
      16.5
    5.9%
      10.3%
    0
      1.4%
    5.5
      6.2



Table 2:  Studies comparing robotic and laparoscopic colectomies.

Robotic Rectal Surgery for Cancer

Surgical technique

The two well recognized techniques for robotic rectal surgery are: Total robotic technique and Hybrid technique. The total robotic technique involves performing the entire operation robotically which can be either via (1) single docking technique – requiring only one docking of the robotic cart but repositioning of the robotic arms depending on the operative fields, or (2) dual docking technique – requiring two separate dockings of the robotic cart for the separate operative fields. The hybrid technique on the other hand, uses laparoscopic surgery along with robotic surgery in combination for various aspects of the operation. The advantage of this hybrid approach is a shorter operating time, especially in rectal surgery as the splenic flexure can be mobilized laparoscopically, followed by robotic pelvic dissection. In this review, there were 10 articles using total robot technique, 10 articles using the hybrid technique, and 7 articles using a combination of either total robot or hybrid techniques. Park et al [33] used a reverse hybrid technique – which involves reversal of the operative sequence with robotic lymphovascular and rectal dissection prior to proximal laparoscopic colonic mobilization.

Clinical outcomes

The review identified 1895 robotic rectal resections for rectal cancer. This included 1389 anterior or low anterior resections, 333 coloanal anastomoses and 170 abdominal perineal resections. (Table 3) The remainder procedures were Hartmann’s procedures. The mean operative time was 269 minutes (range, 170-700 minutes). Estimated blood loss varied from minimal to 2000mls. There were no conversions from robotic rectal resections in seventeen articles. The remainder had varying conversion rates ranging from 0.7 -10%. A very early case series from Braumann et al in 2005 [17] consisting of five robotic cases had three conversions (including two robotic rectal resections with one conversion resulting in conversion in 50% of proctectomies).

Table 3: Studies on robotic rectal resections with outcomes.



  
    Author
    Study Design
    Procedure
    Number of    cases
    Type of    proctectomy
    Mean    Operative time
      (minutes)
    Mean EBL
      (mls)
    Conversion
    LN retrieved
      (Mean)
    CRM positive
    DRM
    Postop    Morbidity
    Leaks
    LOS
      (days)
  
  
    AR/
      LAR
    Coloanal anastom-osis
    APR
  
  
    17
    Case series
    Total
    2
    2
     
     
    240
    185
    50%
    NA
    NA
    NA
    -
    -
    18
  
  
    18
    Comparative
    Hybrid
    56
    56
     
     
    190.1
     
    None
    18.4
    7.1%
    4
    10.7%
    1.8%
    5.7
  
  
    19
    Case series
    Hybrid
    8
    2
    6
     
    193.8
    Minimal
    None
    15* (2-26)
    None
    >2
    12.5%
    0
    5* (4-30)
  
  
    20
    Comparative
    Hybrid
    29
    19
    5
    5
    202
    137
    None
    10.3
    None
    2.1
    26%
    6.8%
    11.9
  
  
    21
    Comparative
    Total/hybrid
    25
    18
     
    7
    240* (170-420)
     
     
    18* (7-34)
    None
    2* (1.5-4.5)
    16%
    4%
    6.5* (4-15)
  
  
    22
    Case series
    Total/hybrid
    143
    80
    32
    31
    297
     
    4.7%
    14.1
    0.7%
    2.9
    41.3%
    10.5%
    8.3
  
  
    11
    Case series
    Hybrid
    58
    47
     
    11
    338
    232
    1.7%
    14.1
    None
    NA
    25.9%
    3.44%
    7.76
  
  
    23
    Comparative
    Hybrid
    41
    33
    2
    6
    296
    200* (20-2000)
    7.31%
    13.1
    2.4%
    3.6
    22%
    7.3%
    6.5
  
  
    24
    Comparative
    Total
    52
    48
     
    4
    260* (190-570)
    100* (50-1000)
    4%
    20.5*
    4%
    2.6* (0.1-7)
    27%
    12%
    6* (4-51)
  
  
    25
    Case series
    Total/Hybrid
    389
    382
     
    6
    322.35
     
    0.7%
    15.7
    3.6%
     
    19%
    7%
    13.15
  
  
    26
    Case series
    Total
    20
    14
    5
    1
    306.75
     
    None
    17.8
    5.26%
    3.7
    23.8%
    0
    6.4
  
  
    27
    Comparative
    Total
    59
    54
    5
     
    270* (241-325)
     
    None
    20* (12-27)
    1.7%
    2.2* (1.5-3)
    32.2%
    13.6%
     
  
  
    28
    Case series
    Total
    29
     
    29
     
    325* (235-435)
    <50* (<50-1000)
    None
    16* (1-44)
    7%
    0.8* (0-4)
    37.93%
    10%
    9* (5-15)
  
  
    29
    Comparative
    Hybrid
    52
    52
     
     
    232.6
     
    None
    19.4
    1.9%
    2.8
    19.2%
    9.6%
    10.4
  
  
    30
    Comparative
    Hybrid
    80
    40
    21
    19
    303.5
    225
    10
    14.2
    None
    3.25
    33.75%
    9.83%
    7.55
  
  
    31
    Case series
    Total/hybrid
    30
    27
     
    3
    270* (175-480)
    50* (20-100)
    None
    15* (3-38)
    None
    4* (2-8)
    13.3%
     
    4* (4-20)
  
  
    32
    Comparative
    Total
    100
    55
    45
     
    188
     
    None
    20
    1%
    2.7
    11%
    2%
    7.1
  
  
    33
    Case series
    Reverse    hybrid
    30
    5
    19
    6
    369* (306-410)
    100* (75-200)
    None
    20* (14-25)
    None
     
    36.67%
    4.2%
    4* (3-6)
  
  
    34
    Comparative
    Total/hybrid
    17
    10
    7
     
    396.5
    188.8
    None
    16.5
    -
    -
    16.7%
    0
    10.7
  
  
    35
    Comparative
    Total
    50
    50#
     
     
    270* (240-315)
     
    None
    16.5
    None
    3
    10%
    10%
    8* (7-11)
  
  
    36
    Comparative
    Hybrid
    13
    5
     
    8
    528* (416-700)
    157* (50-550)
    8%
    16
    None
    -
    -
    20%
    13
  
  
    37
    Case series
    Total
    74
    49
    20
    5
    276
    53
    None
    20.5
    None
    3.1
    17.4%
    1.3%
    6.9
  
  
    38
    Comparative
    Hybrid
    40
     
    40
     
    235.5
    45.7
    None
    12.9
    7.5%
    1.4
    15%
    7.5%
    10.6

  
  
    39
    Case series
    Total/hybrid
    100
    69
    8
    23
    180* (100-330)
    150* (0-250)
    4%
    14* (4-32)
    1%
    3* (0.2-7)
    30%
    9%
    10* (6-38)
  
  
    40
    Case series
    Total
    200
    131
    55
    13
    270* (130-515)
    190* 0-1500)
    None
    17* (3-83)
    2.5%
    1.8* (0-22)
    33.5%
    9.5%
     
  
  
    41
    Case series
    Total/hybrid
    113
    82
    23
    8
    302* (135-683)
    17* (0-690)
    None
    32* (11-112)
    None
    2.6* (0.5-10)
    19.46%
    1.8%
    7* (6-24)
  
  
    42
    Comparative
    Total
    65
    44
    11
    9
    299
    0* (0-175)
    1.5%
    20.1
    None
    2.7* (1.6-4.4)
    41.5%
    7.1%
    6* (5-8)
  
  
    43
    Comparative
    Hybrid
    20
    15
     
    5
    240* (150-540)
    125* (50-650)
    None
    14* (3-22)
    None
    2* (0.5-5)
    40%
    0
    6* (4-31)



Table 3:  Studies on robotic rectal resections with outcomes.

In terms of postoperative outcomes, the median morbidity rate after robotic rectal surgery was 23% (range, 10%-40%) These include anastomotic leaks, postoperative bleeding, wound infections, pelvic abscesses, postoperative ileus, small bowel obstructions, pneumonia, urinary retentions and sexual dysfunctions. Reported anastomotic leaks ranged from 0% -14%; with a median rate of 7%. The median length of stay after robotic rectal surgery was 7.3 days (range, 4-51 days).

With oncological resections, the median number of lymph nodes harvested was 16.5 (range, 0-83). In thirteen articles, the circumferential resection margin was negative in all cases. In the remainder of the articles, when reported the circumferential resection margin positivity ranged from 0.7% - 7.1%. The median distal resection margin was 2.6 cm.

Laparoscopic vs. robotic rectal surgery

The review identified 12 articles comparing laparoscopic versus robotic rectal resections (Table 4) with 608 laparoscopic rectal resections and 567 robotic rectal resections. The mean operation time was longer with robotic surgery (284.2 minutes vs. 241.93 minutes for laparoscopic surgery). Conversion rates for the robotic group were 0% - 8% in comparison with 0% - 22% for the laparoscopic group. Nevertheless, nine articles had no conversions in the robotic group. The reasons cited for conversions in both groups were adhesions, obesity, narrow pelvis and bulky tumor.

Table 4: Comparison of robotic and laparoscopic rectal resections.



  
    Author
    Procedure
    Number of    cases
    Mean    Operative time (minutes)
    Mean EBL
      (mls)
    Conversion
    LN retrieved
      (Mean)
    CRM positive
    DRM in cm
    Postop    Morbidity
    Leaks
    Voiding    dysfunction
    Erectile    dysfunction
    LOS
      (days)
  
  
    18
    Robot
      Lap
    56
      57
    190.1
      191.1
     
    None
      10.5%
    18.4
      18.7
    7.1%
      8.8%
    4
      3.6
    10.7%
      19.3%
    1.8%
      7.0%
     
     
    5.7
      7.6
  
  
    20
    Robot
      Lap
    29
      37
    202
      208
    137.4
      127
    None
      18.9%
    10.3
      11.2
    None
      None
    2.1
      4.5
    26%
      32.8%
    6.8%
      2.7%
     
    5.5%
      16.6%
    11.9
      9.6
  
  
    21
    Robot
      Lap
    25
      25
    240* (170-420)
      237* (170-545)
     
    None
      4%
    18* (7-34)
      17* (8-37)
    None
      4%
    2* (1.5-4.5)
      2*� (1.8-3.5)
    16%
      24%
    4%
      8%
     
     
    6.5* (4-15)
      6* (4-20)
  
  
    23
    Robot
      Lap
    41
      41
    296
      315
    200* (20-2000)
      300* (17-1000)
    7.31%
      22%
    13.1
      16.2
    2.4%
      4.9%
    3.6
      3.8
    22%
      26%
    7.3%
      2.43%
     
     
    6.5
      6.6
  
  
    27
    Robot
      Lap
    59
      59
    270* (241-325)
      228* (177-254)
     
    None
      3.4%
    20* (12-27)
      21* (14-28)
    1.7%
      None
    2.2* (1.5-3)
      2* (1.2-3.5)
    32.2%
      27.11%
    13.6%
      10.2%
     
     
     
  
  
    29
       
    Robot
      Lap
    52
      123
    232.6
      158.1
     
    None
      None
    19.4
      15.9
    1.9%
      2.4%
    2.8
      3.2
    19.2%
      12.2%
    9.6%
      5.6%
     
     
    10.4
      9.8
  
  
    34
    Robot
      Lap
    17
      12
    396.5
      298.8
    188.8
      229.2
    None
      8.33%
    16.5
      14.1
    -
    -
    16.7%
      20%
    0
      0
     
     
    10.7
      9.6
  
  
    35
    Robot
      Lap
    50
      50
    270* (240-315)
      280* (240-350)
     
    None
      12%
    16.5
      13.8
    None
      12%
    3
      3
    10%
      22%
    10%
      14%
     
     
    8* (7-11)
      10* (8-14)
  
  
    36
    Robot
      Lap
    13
      59
    528* (416-700)
      344* (183-735)
    157* (50-550)
      200* (25-1500)
    8%
      17%
    16
      20
    None
      2%
    -
      -
    -
      -
    20%
      7%
     
     
    13
      8
  
  
    44
    Robot
      Lap
    165
      165
    309.7
      277.8
    133.0
      140.1
    0.6%
      1.8%
    15.0
      15.6
    4.2%
      6.7%
    1.9
      2.0
    20.6%
      27.9%
    7.3%
      10.8%
    2.4%
      4.2%
     
    10.8
      13.5
  
  
    38
    Robot
      Lap
    40
      40
    235.5
      185.4
    45.7
      59.2
    None
      None
    12.9
      13.3
    7.5%
      5%
    1.4
      1.3
    15%
      12.5%
    7.5%
      5%
     
     
    10.6
      11.3
  
  
    43
    Robot
      Lap
    20
      20
    240* (150-540)
      180* (140-480)
    125* (50-650)
      175* (50-900)
    None
      10%
    14* (3-22)
      11* (4-18)
     
    2* (0.5-5)
      2.1* (0.1-5.5)
    40%
      20%
    0
      0
     
     
    6* (4-31)
      7* (5-36)



Table 4:  Comparison of robotic and laparoscopic rectal resections.

The postoperative overall morbidity rates were similar in both groups with median morbidity of 19% (range, 10.7% - 40%) in the robotic group and 22% (range12%-32.8%) in the laparoscopic group. The median anastomotic leak rate was 7.3% (range 0% -20%) for the robotic group and 6.3% (range 0% - 14%) for the laparoscopic group. Maintenance of the integrity of the pelvic autonomic nervous system is essential during rectal surgery to avoid sexual and urinary dysfunction. The conventional open total mesorectal excision is associated with 0–12% patient urinary dysfunction and 10–35% sexual dysfunction [45-50]. In this review, eight articles assessed sexual and urinary dysfunction with rates of erectile dysfunction varying between 0% -36.6% after robotic surgery and 1% - 56.5% after laparoscopic surgery [20,32,33,35,38,39,51,52]. Functional outcomes were evaluated using the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function (IIEF) in three articles [35,38,52]. D’Annibale et al found that the IPSS scores were significantly increased 1 month after surgery in both laparoscopic and robotic surgery groups but normalized a year after surgery [35]. Erectile function was significantly worse a month after surgery in both groups, but completely restored a year later in the robotic group. The recovery was partial in the laparoscopic group. Park et al using questionnaire at 3 and 6 months post surgery, found worsening of erectile functional scores in both groups at 3 months [38]. However, the scores were significantly worse in the laparoscopic group. The scores improved in the 6-month questionnaire in both groups, with much better improvement in the robotic group. Kim et al reported that the IPSS scores worsened a month post surgery, but the recovery in urinary function was faster in the robotic group (3 months) versus the laparoscopic group (6 months) [52]. With regards to the IIEF scores, they reported worsening of scores at 1-month post surgery in both groups, but again a faster recovery in the robotic group at six months whereas the laparoscopic group had a gradual recovery in a year.

With oncological outcomes, robotic surgery was comparable with laparoscopic surgery. The median numbers of retrieved lymph nodes were 16.25 (range, 10-19.4) in the robotic group and 15.75 (range, 11-20) in the laparoscopic group. There was minimal difference in the two groups with regards to distal resection margins and status of circumferential resection margin.

Discussion

The role of laparoscopic colorectal cancer surgery has been established by the major trials (COST, COLOR and CLASSICC) [1- 3,53]. However, it has its limitations. Laparoscopic surgery can be technically demanding, especially in the pelvis and has a long learning curve. The main limitations of laparoscopic surgery lie in loss of depth perception, poor ergonomics, loss of dexterity and the need for a trained assistant. Physiological tremors of the camera holder can be a major disadvantage, especially at the end of a long case. Robotic surgery has been developed to overcome the limitations of laparoscopic surgery and improve the capability of colorectal surgery.

This review shows that robotic surgery for colorectal cancer is safe and feasible. We specifically selected only nine articles for robotic assisted colectomies and twenty-eight articles for robotic assisted rectal resections, as these are the ones on the use of robotic surgery in cancer. Similar to prior reports, we have found that robotic surgery is comparable to laparoscopic surgery with outcomes.

With colectomies and rectal surgery, robotic surgery had lower conversions. Better visualization with the robot, especially in the pelvis could be a factor for the same. Lower conversion rates have been shown to be associated with decreased postoperative morbidity and recurrence rates. The operative time was longer in the robotic groups, in both colectomies and rectal resections. Most of this is due to the time taken for docking the robot and undocking the robot. As surgeons are becoming proficient in robotic surgery, this time has decreased. Use of hybrid technique with laparoscopic mobilization of splenic flexure has helped in keeping operative times low, by avoiding the need for double docking.

Robotic surgery has been shown to have lower blood loss compared to laparoscopic surgery. However, with regards to other postoperative outcomes, the two techniques are comparable, except with sexual and urinary dysfunction after rectal surgery. In terms of oncologic outcomes, this review shows that robotic surgery is comparable with laparoscopic surgery with the number of retrieved lymph nodes. In rectal cancer, the circumferential margin and distal resection margins are comparable with laparoscopic rectal surgery. Identification and preservation of the pelvic autonomic nervous system is an integral part of rectal surgery. Urinary and sexual functional complications can occur due to injury to the superior hypogastric plexus, or pelvic plexus or both. The MRC CLASICC trial raised concerns that the rate of pelvic autonomic nerve injury maybe higher with laparoscopic total mesenteric excision compared to open [54]. Robotic surgery with its better visuals could enable identification of the nerves and the improved dexterity with the increased range of motion enable better dissection without injury to the nerves. In this review, we found that there was worsening of urinary and sexual dysfunctions in both robotic and laparoscopic surgery, but comparatively lower in robotic surgery. Furthermore studies showed that there was earlier recovery in function in the robotic group. One can therefore conclude that robotic surgery does enable in better dissection and lesser injury to pelvic autonomic system.

Robotic surgery is associated with higher costs. This includes the high cost of equipment and instrumentation, with a capital purchase cost of upto $2 Million. Maintenance of the robot can cost $100,000- $150,000 per year. The instruments have a ten-procedure life span that adds to the costs. Furthermore there are increased costs in setting up a specialized team, with the need for specialized training. The increase in operating time also contributes to increased costs. Studies have compared the costs with robotic and laparoscopic surgery in both benign and malignant colorectal disease [18,27,28,32,55-57]. These studies have shown that robotic surgery is more expensive than laparoscopic surgery. Most of these studies are from groups based in different countries. The differences in costs in health systems across the world can impact these costs.

This review is limited by the lack of studies of robotic colectomy for cancer. Most of the studies in the literature are case series or comparative studies. There is a need for a well-structured randomized controlled trial to ascertain the advantages of robotic surgery over laparoscopic surgery in colorectal cancer. The results of the ROLARR (Robotic versus Laparoscopic Resection for Rectal cancer) study, which is an international multicentric randomized trial, are much awaited [58].

In conclusion, we can opine from this review that robotic surgery is safe and feasible for colorectal cancer. Compared to laparoscopic surgery, there are fewer conversions and lesser blood loss, albeit with increased operating times. It is comparable with laparoscopic surgery for oncologic outcomes and postoperative outcomes. Although, robotic surgery is also associated with sexual and urinary dysfunction, an earlier recovery is seen in robotic surgery. The expenses associated with robotic surgery may need to be reduced in the future to increase its acceptance in colorectal cancer surgery.

References

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Citation: Taggarshe D, Attuwaybi BO and Butler BN. Robotic Surgery in Colorectal Cancer. Austin J Cancer Clin Res 2014;1(4): 1018. ISSN 2381-909X

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