Thistechniquehastheadvantageofusingtherobotforcompletionofthe wholeprocedure.Itisreportedthatasurgeonwhoisinexperiencedin laparoscopycanstillperformaminimallyinvasivecolorectalprocedure usingthistechnique.However,theauthorsofthischapterbelievethat bothapproachesrequireadvancedlaparoscopicexperience.Thesenior authorusesthesingle-dockingapproachandflipsarm3fromtheright upperquadranttrocartotheleftlateraltrocarforthepelvicpartwhen usingthedaVinciSiplatform.Inthisapproach,therobotdoesnotneed tobemovedorrepositioned,exceptforthedescribedarmchange/flip. Afterthecolonhasbeencompletelymobilized,theboweldistaltothe pathologyistransectedwithalaparoscopicorroboticlinear-cutting stapler.Endocutterstaplercanbeintroducedthroughtherightlower quadranttrocarafterupsizingtoa12-mmport.Thissitecanultimately beusedasthespecimenextractionaswellasthestomalocationincases whereadivertingileostomyisneeded.Usually,onefiringofthestapleris satisfactorytostapleandcutacrosstheboweldependingonthelevelof thetransection.Thisstepcanalsobeachievedusingtherobotic EndoWrist(IntuitiveSurgicalInc.Sunnyvale,CA,USA)45-mmstapler, asdiscussedearlier.Thisisa54-degree-wristedarticulatingrobotic staplerandmayprovideadvantageinconfinedspacessuchasdeepinthe pelvis.Afterspecimenextraction,theextractionsiteissealedand peritonealaccessregained.Inthisapproach,maintenanceofthe pneumoperitoneumcanbeachievedindifferentways:ourgeneral preferenceistousetheAlexisbundlewoundprotectorswith“acap” (AlexislaparoscopicsystemwithKiiFiosFirstEntry,AppliedMedical, RanchoSantaMargarita,CA,USA)orwoundprotectorcombinedwithan inchPenrosedrainandpenetratingtowelclamps.In2014,Intuitive Surgicalmarketedanewplatform,thedaVinciXisystem,thataddressed afewlimitationsofitspredecessor.ThedaVinciXicomeswitha lightweightcamerathatfacilitatesitscontrolandisinterchangeable betweenports.Oneofthemajoradvantagesisthatitallowsforamuch moresuperiormulti-quadrantsurgeryandthussplenicflexure mobilizationbecomeslesschallenging.Therefore,flippingroboticarms betweentheportsaregenerallynotrequired(Fig.17-11).

Byfarthemostsignificantpotentialadvantageofroboticversusthe laparoscopictechniqueisthelowerconversionratetoopen.Overthepast twodecades,thelaparoscopictechniquehasbeencontinuouslyevolving andsurgeons’experiencehasbeenincreasing;however,theCOlorectal cancerLaparoscopicorOpenResectionIItrialreportedaconversionrate of17%.Furthermore,20yearslater,therehasbeennosignificantchange intherateofearlypostoperativecomplications,exceptforadecreasein positivesurgicalmarginsnotedinthepast3years.Althoughthiscouldbe somewhatfrustrating,italsogivesroomtoanticipatebetterresultswitha newertechniqueifonewouldconsiderthatlaparoscopicsurgeryhas offeredthemaximumthatitcouldpossiblyachieve.

Moststudiesreportlongeroperativetimewithroboticrectalsurgery, whichconcurswithourinstitutionaldatawheremeanoperativetimewas 172minutesforlaparoscopicsurgeryversus267minutesforRS, P<0.0001.InasystematicreviewbyMaketal.,meanoperativetimeof RSwas281minutescomparedto242minutesforlaparoscopicsurgery. MostauthorsidentifiedthelongertimetakenwithRStobedueto dockingandchangingoftheroboticarms,alimitationthatcouldperhaps beovercomebytheintroductionofthedaVinciXisystem.Theauthors alsoanticipatethatassurgeonsandoperatingroomstaffgainexperience withtherobotictechnique,thiswouldverylikelyreduceoperativetimein thefuture.

OneofthemajordrawbacksofRSisthecost.Datafromourinstitute comparingcostofproctectomybetweenopen,laparoscopic,andRS proceduresconcludedthatRScosts30%more.However,thesedata includedsurgeon’slearningcurveandmultipleproceduresthatwere bundledintheanalysis.ANationwideInpatientSample(NIS)studyby Juoetal.fromJohnsHopkinsfoundastatisticallysignificanthigher overallhospitalizationcostofroboticversuslaparoscopiccolectomy ($14,847vs.$11,966).Yet,Halabietal.intheirreviewofNISfrom2009 to2010demonstratedanincreaseinroboticrectalsurgerycases performedfrom1,188casesin2009to2,380casesin2010.Onewould wonderwhy?Whyincuranadditivecostontheinstitutionespeciallywith thecurrenteraofhealthreformwhentherearecheaper,equallyeffective, andalsominimallyinvasivetechniquesathand?Here,wehighlightagain thattheanatomyofthehumanpelvisisoneofthemostchallengingtoa colorectalsurgeonandcolorectalsurgeonsgraspanyvalidatedimproved outcome.Inaretrospectivereviewof488proctectomiesforcurative intentbyourinstitution,patientsweregroupedbysurgicalapproach (open,laparoscopic,androbotic).Allgroupshadsimilardemographics, characteristics,andtreatmentdetails.Althoughsignificantoutcome differenceswerefoundinoperativeandanesthesiatimefortherobotic group,oneshouldgivecreditwhencreditisduearguingthatthese patientshadashorterhospitalstayandlessoverallcomplications comparedtotheopengroup.Inapropensity-score-matchanalysis,Kim etal.concludedthatRShadsimilarshort-termperioperativeoutcomes comparedtolaparoscopicsurgeryandatahighercost,asonewould expect.Resultsofacost-consciousapproachstudydonebythesenior authorofthischaptershowedthatwhenwecomparedrestorative proctectomiesdoneopenandrobotically,afterthefirstyearroboticcases donebyhigh-volumesurgeons,thecostinbothgroupswascomparable (P=0.02forthefirstyear,thenP=0.14).However,owingtothefact thatthetechniqueisstillinitsinfancy,literatureislackingonlong-term outcomes.Webelievethatuntillong-termoutcomesprovenon-inferior, theargumentofhighercostcannotbetotallyvalidated,atleastnotona surgeon’sfrontier.

Generally,whenlaparoscopicandroboticanteriorresectionsare compared,theroboticapproachisassociatedwithasignificantlylonger operativetime.Comparingoperativetimesbetweenapproachesis difficultbecauseofthelackofauniformstudydesignandlearningcurve. However,webelievethatthepresenceofatrainedandexperienced surgicalteamintheoperatingroomisimportant,asistheexperienceof thesurgeon.

Noseverecomplicationsormortalitieswerereportedafterrobotic anteriorresectionforrectalcancer,andpostoperativemorbidityand mortalityratesweresimilartothoseofthelaparoscopygroup.Similarly, a92%overallandan89%disease-free3-yearsurvivalrateweredetected afterroboticanteriorresection,whichwerecomparabletothoseinthe laparoscopygroup.