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IMPACTOFOBESITYONROBOTIC SURGERY

Itisnotuncommonforcolorectalsurgeonstoanticipatehardshipwhen operatingonobesepatients.Inourinstitutionalreview,weconcluded thatinacomparablegroupofpatients(carefullycase-matchedgroupfor

patientdemographics,bodymassindex[34.9±7.2vs.35.2±5.0kg/m2, P=0.71],comorbiditiesandsurgicalandtumorcharacteristicsbetween roboticandlaparoscopicgroups),RSwasassociatedwithanearlier returntobowelfunctionandshorterhospitalstayby2days(P=0.02).

THECLEVELANDCLINICEXPERIENCE

Ourinitialinstitutionalexperiencepublishedlate2015includedourfirst 57casesusingthedaVinciSi.Asofdate,wehaveperformedover400 roboticprocedures,ofwhich215wereformalignantdiseases.Sincethe introductionofthedaVinciXisystem,ourinstitutehasperformed69 colorectalproceduresusingthenewtechnology.Theseniorauthorhas previouslydescribedhisexperienceusingthedaVinciSirobotsystem. ThedaVinciSisystemisdesignedtoworkbetterinthepelvisand requiresdoubledockingtotakedownthesplenicflexure.Thus,redockingincreasesoperativetimeandaffectstheflowoftheoperation becausethisrequiresrepositioningtheentireplatform.In2014,Intuitive Surgicalmarketedanewplatform,thedaVinciXisystem,thataddressed afewlimitationsofitspredecessor.Althoughitaddressedlimitationsof thepreviousplatform,thetechnologyisstillinitsinfancy.Oneofthe disadvantageswenotedintheXisystemisthatinthenewport placementsrecommendedbyIntuitiveSurgical,thereisatrendofthe portsconingtowardthepelvicdissection,asseeninFigure17-11.Deepin thepelvis,theinstrumentsbecomequiteparallelasopposedtotheSi systemwhereallthearmsarecomingfromawiderangle.Therefore,the triangulationeffectissomewhatcompromised.Toovercomethis limitation,differentportplacementscouldbetried.

p.143

p.144

Inapilotstudythatincludedtenpatientsineithergroup,Morellietal. publishedacase-matchedcomparisonofshort-termoutcomesoftheda VinciXiandSisurgicalsystemsinroboticTME.ThedaVinciXigroup hadastatisticallysignificantshorteroveralloperativetime(257.8vs.

353.5minutes,P<0.01);however,therewasnodifferenceinmean dockingtime(19.8vs.21.0minutes).Also,theirstudyresultsshoweda significantlyshorterlengthofhospitalstayinthedaVinciXigroup(6.3 vs.8.7days,P<0.01).Therewasnosignificantdifferenceinshort-term oncologicoutcomes,namely,lymphnodeharvest(19.0vs.17.5nodes), distalmargin(17.6vs.15.3mm)andqualityofmesorectum(completein allpatients).Althoughthestudyislimitedbythesmallnumberof patients,itwillencouragefurthersimilarstudiesfromexperienced minimallyinvasivecolorectalsurgeonsthatwillhelpshedlightonthe advantagesofthenewplatform.

FUTUREDIRECTIONS

Asthesurgicalcommunityeagerlyawaitslong-termresultsofthe ROboticversusLAparoscopicResectionforRectalCancertrial,the authorsbelievethatthedebateonthevalueandcost-effectivenesswill continuewhenitcomestoRS.Iftheliteraturecontinuestoshownoninferiority,itmightbedifficulttojustifyinthefuturetheuseofamore expensivetechniquewithnoaddedbenefit;however,ifmoredata becomesavailableonasuperiorincidenceofnegativecircumferential marginsandlong-termsuperioroncologicoutcomes,itwillbetimeto givecredittoatechniquewherecreditisdue,because“themoney”is invariablyinatechniquethatresultsinbetteroncologicoutcomes.

NaturalOrificeRoboticSurgery

Surgeonsstrivetoavoidlargeincisions,whichservetobenefitboth cosmesisandimprovedpostoperativepain.NOSEsparesatraditional4to5-cmincisionneededforspecimenextractionineitherlaparoscopicor roboticcolorectalsurgery.Furtherliteratureonthetopicisanticipated.

CONCLUSIONS

Inthescopeofrestorativeproctectomyforcancer,RSseemstooffer short-termoutcomesthatarecomparabletothoseofconventional laparoscopyintermsoflengthofhospitalstay,morbidity,andmortality. Inaddition,roboticproctectomycanbeperformedwithout compromisingoncologicprinciples,butdataforlong-termoutcomesare stilllimited.Prolongedoperatingtime,increasedcosts,andlearning curvearethemajordrawbacks.Inaddition,theroboticarmand equipmentarelargeandmayhavelimitedintracorporealrangeof motion.Therefore,itpoorlyfitsinefficienttractionofthecolonand multi-quadrantoperations.

Innovationinsurgerywillcontinuetoevolve,sowillscientificevidence ofthebenefitofsuchinnovations.Roboticrectalsurgeryisapromising frontierdespitelimitationsofcostandprobableprolongedoperative time,whichcouldarguablyimprovewithlearningandcompetitioninthe market.

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Chapter18

Hand-AssistedLowAnterior Resection

EricG.Weiss

INDICATIONSANDCONTRAINDICATIONS

Laparoscopicsurgeryforcoloncanceriswidelyacceptedasanequivalent oncologicprocedureforthemanagementofcoloncancerbasedon numerousprospectiverandomizedtrials.Increasingly,laparoscopyis beingutilizedasthestandardofcareoptionforcoloncancer.Several internationalandoneUStrialhavelookedattheuseoflaparoscopyin rectalcancer.TheUSrectalcancertrial,theAmericanCollegeof SurgeonsOncologyGroup(ACOSOG)Z6051,showedthatusinganonvalidatedcompositepathologicassessmentlaparoscopicrectalcancer pathologicspecimensmaynotbeequivalenttothosespecimensproduced usinganopentechnique.

Hand-assistedsurgerywasfirstintroducedinthe1990s.Sincethat timeimproveddevicesandsurgeonexperiencehavealloweditsselective adoptionbysurgeonsforperformanceofcolorectalsurgicaloperations. Similarbenefitsofstandardmultiportlaparoscopy,withtheadded benefitofshorteroperativetime,havebeenreportedinmultipleseries.

Hand-assistedsurgeryhasmultiplepotentialbenefitsinrectalcancer surgerythatmayallowadvantagessimilartothoseoflaparoscopic surgeryfortheabdominalportionsoftheprocedure,withadded theoreticalbenefitsinthepelvissimilartothoseofopensurgery. Philosophically,manysurgeonsdonotaccepthand-assistedsurgeryas “reallaparoscopy”andconsiderit“cheating.”However,emotionsaside, patientoutcomesandoncologicoutcomesarethetruemeasureofa technique.Hand-assistedlowanteriorresectionhasaroleinthe managementofrectalcancer.Inrecentyears,othertechniquessuchas robotic-assistedlowanteriorresectionandtransanaltotalmesorectal excisionprovideotheralternativesthatmayormaynotultimatelyhave

benefitsoverstandardlaparoscopy.

Hand-assistedsurgeryallowsanyorallofthetraditionalstepsin laparoscopytobedoneintracorporeallyorallowssomepartstobedone inanopenmannerthroughthehand-assistdevice.Forlowanterior resection,theuseofthehandasaretractorinthepelvisgivesbroad,wide tension,creatingaretractionthatisoftendifficultusingmultiport laparoscopy.Inaddition,transactingtherectuminthepelviswitha standardsinglefiringofastaplerismorecost-effectiveandavoids tangentialoverseeingplacementofmultipleendoscopicstaplelines acrosstherectalstump.Theendresultisaloweranastomoticleakrate.

Anyoperationconsideredacceptableforlaparoscopyisacceptable procedureforhand-assistedsurgeryand,similarly,contraindications wouldbethesame.

PREOPERATIVEPLANNING

Mostlowanteriorresectionsareperformedforrectalcarcinoma.A standardpreoperativeevaluationisperformedbymostsurgeons.Other indicationsincludelargerectalpolypsnotamenabletoendoscopicor transanalapproaches,completionproctectomiesforinflammatorybowel disease,andredopelvicoperationsforpriorfailedanastomoses.

Regardlessofindications,certainpreoperativeconsiderationsare necessaryforallpatientsandconditions.Becausetherectalreservoirwill beremovedcompletelyorinpart,thestatusoftheanalsphinctersis important.Thisissuecanbeaddressedbypreoperativelyquestioningthe patientregardingbowelfunctionandcontinenceandassessingsphincter tonebydigitalrectalexaminationandbyanalmanometry.

Rectalreservoirreplacementshouldbeconsideredanddiscussedwith thepatient.Postoperativefunctioncanbeimprovedbytheadditionofa colonicJ-pouch.Otherwise,useaside-to-endanastomosisinpatients withlessthan5cmofrectumremainingafterlowanteriorreaction.The majorimpactonfunctionisseeninthefirst2yearsaftertheoperation.

p.147

p.148

Atorbelow4cm,thecolorectalanastomoticleakrateisashighas16– 25%andadivertingileostomyshouldbediscussedandanenterostomal therapyconsultandinformedconsentobtained.

Ifthepatienthasarectalcancer,preoperativelocalstaging,witha high-resolution,small-fieldpelvicmagneticresonanceimagingis recommended.Localstagingwithendorectalultrasoundisstill acceptable.Preoperativeconsiderationsforneoadjuvant chemoradiotherapyshouldbebasedonNationalComprehensiveCancer Networkguidelines.Presentationbeforeamultidisciplinarytumorboard asnotedintheStandardsManualoftheAmericanCollegeofSurgeons CommissiononCancerNationalAccreditationProgramforRectalCancer shouldbeundertaken.Stagingformetastaticdiseasewith carcinoembryonicantigenbloodtestingandacomputedtomography scanofthechest,abdomen,andpelvisshouldalsobeutilizedinall patients.

Priorpelvicsurgery,remoteuseofradiationtherapy,alargemass overlyingaureter,orinvolvementofotherpelvicstructuresshouldlead onetoconsidercystoscopyandureteralstentplacementinaneffortto reduceandidentifyureteralinjuries.

Thoroughdiscussionandinformedconsentregardingcancer-specific

outcomes,functionaloutcomes,sexualandurinaryfunctionfollowing surgery,adjuvanttherapy,andothercomplicationsshouldbeheldatthe timeofinformedconsent.

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