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482
J. Shin and S.W. Lee
Fig. 31.8 Defi ning the duodenum on a right colectomy. The ileocolic
pedicle is elevated with the duodenum under the proximal vessel
( arrow )
cally. More extensive injury needs to be repaired by open
approach. Careful dissection should be maintained during dissection of the right branch of the middle colic vessels. Injury
to gastrocolic trunk of Henle (vein connecting gastroepiploic
vein and the right branch of the middle colic vein) located in
this area can result in severe bleeding that is very diffi cult to
control, since it drains into SMV. To avoid this, vigilance and
care should be maintained when dissecting over the pancreas.
If bleeding occurs, wide exposure and a precise use of a bipolar energy device can control the bleeding in most cases.
Major Vascular Pedicle Ligation
There are many different ways to control and divide the
major vascular pedicles. Laparoscopic staplers are safe but
not as precise and versatile as the energy devices. In dividing
major named vessels, only two types of energy devices
(ultrasonic and bipolar) have been used. When properly
applied, both devices can be very effective. A disadvantage
associated with an ultrasonic device is that it usually does
not allow the user to control when the vessels are transected
(Video 31.2 , Courtesy of David Longcope, MD). On the
other hand, a bipolar energy device allows multiple application of the sealing using the energy, and the vessels are only
transected when the surgeon decides it. Bipolar energy
devices are not effective in sealing calcifi ed vessels. A vessel
loop should be made available in the OR for all laparoscopic
colon cases (Video 31.3 ).
Fig. 31.9 Thermal injury to duodenum can occur during ligation of
ileocolic vessels if the duodenum is not safely dissected away and the
tip of a bipolar device is not clearly visualized
one has a diffi culty identifying the duodenum, more proximal dissection should be carried out.
In dissecting the duodenum away from the mesocolon, one
must be mindful of two potential complications: (1) injury to
the duodenum and (2) avulsion of the gastrocolic trunk of
Henle. Thermal injury to the duodenum can happen if the tip
of energy device is too close to the duodenum while dividing
ileocolic or middle colic pedicle (Fig. 31.9 ). It is imperative to
visualize the entire length of the active blade. A blunt injury to
the duodenum can also result from aggressive dissection of the
middle colic vessels. Therefore, direct manipulation of the
duodenum should be minimized. If the injury should occur, it
needs to be immediately recognized and repaired. Small or
partial thickness injury can be suture repaired laparoscopi-
The Right Ureter
The right gonadal vessels and the ureter are typically located
safely away from the dissection plane during laparoscopic
right colectomy and therefore they do not need to be identifi ed routinely. The potential injury to the right ureter may
occur while incising the base of the terminal ileal mesentery
from the retroperitoneum (Video 31.4 ). It is useful to look
for the ureter coursing over the iliac bifurcation before starting dissection in this area. A thorough dissection from the
medial side prior to and strong ventral and cephalad retraction of the terminal ileum during the detachment of the ileal
mesentery can help avoid this complication.
Unique Complication: Sigmoidectomy
Key Concept: Similar to a right colectomy, a sigmoid colectomy has certain structures at higher risk of injury. Proper
identifi cation of the left ureter, avoidance of splenic injury,
and handling the IMA/IMV and middle colic vessels are key
aspects to a safe dissection.
31 Laparoscopic Complications
483
Exposure/Mobilization of the Left Kidney
Patients are placed in the Trendelenburg position with the
left side of the patient tilted up. The transverse colon along
with the greater omentum is placed in the cephalad direction
over the liver. Loops of the terminal ileum are allowed to fall
to the patient’s right side. As described previously, it is common to get too deep into the retroperitoneum during medialto- lateral approach. It is essential to maintain the correct
dissection plane in order to minimize the risk of injury to the
ureter and gonadal vessels. From a lateral approach, it is
important to follow the correct plane (i.e., stay more medial)
during the cephalad dissection toward the splenic fl exure, as
it is often a natural tendency to stray too lateral and fi nd
yourself behind the left kidney.
Identifying the Ureter
Several retrospective studies have shown that laparoscopic
colectomy has higher incidence of ureteral injury compared
to open colectomy [ 10 , 11 ]. In a study that reviewed inci-
dence of ureteral injury from laparoscopic vs. open colectomy in a single institution between 2005 and 2010 [ 11 ], the
incidence of injury from laparoscopic colectomy was 0.66 %
(7/1,060) compared to open, 0.15 % (7/4,669; p = 0.007). As
shown in open surgery, preoperative ureteral stenting did not
decrease the rate of injury but facilitated identifi cation of
injury. It remains to be seen whether the incidence will
decrease as surgical community becomes more experienced
with the procedure. Regardless, ureteral injury results in high
morbidity, and every effort should be made to avoid it. Early
identifi cation of urinary tract injuries is critical in minimizing morbidity and preserving renal function. Although routine use of ureteral stent is not recommended, placement in
select patients who are at high risk for ureter injury such as
prior history of pelvic surgery, history of infectious or infl ammatory colitis, or large tumor is reasonable.
Identifi cation of the left ureter is the key step in perform-
ing a laparoscopic sigmoidectomy. The inferior mesenteric
pedicle should not be divided until the left ureter is clearly
identifi ed and dissected away from the mesentery. When performing medial-to-lateral dissection during laparoscopic sigmoidectomy, it is important to create a wide enough window
dorsal to the inferior mesenteric artery into the retroperitoneum so that the left ureter and the gonadal vessel can be
identifi ed. At this level, the left ureter is located medial to the
gonadal vessels. If the left ureter cannot be identifi ed through
this window, one should consider a possibility that the dissection plane is too deep and the ureter and the gonadal vessels are still attached to colon mesentery. This is likely to be
the case if you see the bare psoas muscle or iliac vessels. An
alternative to this approach is to create a window proximally,
between IMA and IMV near their origins. One must be aware
that the left ureter is located lateral to the gonadal vessels at
Fig. 31.10 Alternative mesenteric window between IMV and IMA
near its origin. Note that ureter runs lateral to gonadal vessel in this area
this level (Fig. 31.10 ). In sigmoidectomy for diverticulitis,
where retroperitoneal infl ammation makes identifi cation of
the ureter diffi cult, this approach can be useful, since the
proximal ureter should be free of infl ammatory process.
Another option is to fi nd the ureter by mobilizing the colon
from lateral to medially. If all attempts fail, the case should
be converted to either hand assisted or open. In hand-assisted
cases, the left ureter can be dissected directly through the
hand-access incision. If all of these fail, the case needs to be
converted to open procedure or consideration of an intraoperative stent placement to facilitate identifi cation.
Splenic Flexure
We use so called the “omega” maneuver to take down splenic
fl exure. We start the dissection by detaching the greater
omentum from the distal transverse colon and getting into
the lesser sac. It is advisable to start this dissection near the
mid- transverse colon where the anterior and posterior leaflets of the greater omentum are fused together. In obese
patients with fatty omentum, sometimes it may be necessary
to divide the gastrocolic ligament and the omentum just inferior to stomach in order to access lesser sac more reliably.
Once you are in the lesser sac, it is important to triangulate
the tissues (Fig. 31.11 ) in order to avoid causing inadver-
tent thermal injury to transverse colon. The greater omentum
and the colon should be retracted dorsally and laterally away
from each other, while the camera is directed down from a
plane above the horizon to obtain a full view of the course
of the colon distal to the dissection fi eld. Short application
of bipolar energy is preferred. Blunt dissection in this area,
especially near the spleen, should be avoided, as bleeding
from torn omental vessel or capsular tear can signifi cantly
impede and delay the operation.
484
J. Shin and S.W. Lee
Fig. 31.11 Triangulation of tissues prevents inadvertent thermal
injury to the transverse colon while taking down splenic fl exure
Once the dissection along the transverse colon is carried
out as far distally as possible, an approach from lateral aspect
of the left colon is commenced. The Gerota’s fascia is dissected and retroperitoneal attachment between the Gerota’s
fascia and descending colon is sharply divided using an
energy device. The Gerota’s fascia over the left kidney is
intimately associated with the splenic fl exure of the colon.
During splenic fl exure mobilization, it is therefore possible
to inadvertently mobilize the left kidney along with proximal
left colon. The best way to avoid this is to dissect and separate the Gerota’s fascia away from the colon mesentery as
much as possible during medial-to-lateral dissection prior to
lateral mobilization the fl exure. The Gerota’s fascia should
be dissected as far laterally as possible toward the Toldt fascia and toward the splenic fl exure from the medial approach.
It is also important to stay as close to the colon as possible
when dividing the lateral attachments of the proximal left colon
near the splenic fl exure. As you approach the spleen, anterior
and caudal traction of splenic fl exure exposes splenocolic ligament, which is divided using an energy device (Video 31.5 ).
Redo Operation and Conversion
Key Concept: A laparoscopic approach to recurrent operations should be undertaken with caution, focusing on correct
tissue planes and a willingness to add additional ports or
conversion as needed. Remember, conversion does not
equate to failure and often indicates a wise surgeon.
Re-operative surgery is common, but can be technically
challenging. Although history of previous surgery is not a
contraindication to laparoscopy, it should not be attempted
until adequate technical profi ciency is achieved. Patients
who undergo a successful laparoscopy can expect the usual
short-term benefi ts associated with laparoscopy, although
conversion rates are signifi cantly higher in re-operative
laparoscopic surgery. Key components to a successful reoperative laparoscopic surgery consist of having a clear
understanding of pathophysiology and a detailed knowledge
of prior surgical procedures. It is important to obtain and
review previous operative and medical records. In patients
who had previous colon resections, it is essential to know
which of the named mesenteric vessels were taken during the
previous operations so that a potential segmental ischemia of
the colon can be avoided. In select patients, additional imaging may be helpful.
Forty percent of bowel injuries during laparoscopy occur
during initial entry into the abdomen. Although there are no
prospective randomized trials comparing different techniques
of access methods, it is prudent to enter the abdomen using
the open Hasson technique away from the previous incisions.
Upon entry, a careful inspection for potential damages to the
small intestines adherent to abdominal wall must be carried
out. After a quick initial survey of the extent and type of
adhesions, a decision to convert should be entertained early
in the operation. The adhesions between the small intestines
and the abdominal wall are much easier to deal with laparoscopically than either extensive inter-loop intestinal adhesions or adhesions to pelvic structures. Early conversion
should be considered in patients with either extensive interloop or pelvic adhesions, especially when they are impeding
progress, though if away from the disease process should be
left alone.
Regardless of surgeon’s level of skill and experience, the
possibility of conversion to open approach is unavoidable.
Conversion should be considered as a solution to overcome
the limitation of laparoscopic surgery rather than complication
and more often than not refl ects good surgical judgment [ 12 ].
There has been a signifi cant controversy over whether
conversion to the open approach during laparoscopic colectomy has negative impact on patient outcomes. Multiple
studies have shown that patient who were converted during
laparoscopic colectomies, when compared with those who
had successful laparoscopic colectomies, had longer operative time, increased blood loss, higher wound infection rate,
and longer length of stay [ 13 , 14 ]. What is alarming is that
some studies suggest that converted patients may do worse
than the open-surgery patients. Hewett and colleagues
recently reported results from an Australasian randomized
study comparing laparoscopic with open surgery for cancer.
In this study, converted patients had longer operative time,
longer hospitalization, and higher infection rate than laparoscopic or open patients [ 15 ]. Other studies point to no worse
outcome [
16 ]. One reason for the discrepancy in reported
31 Laparoscopic Complications
485
outcomes is a lack of standard defi nition of conversion.
Another more important and clinically more relevant factor
is recognition that not all conversions are equal. Belizon and
colleagues reported that clinical impact of conversion
depends on whether the case is converted early (<30 min) or
late [ 12 ]. After initial laparoscopic assessment of risk for
conversion, early proactive conversion is likely to result in
favorable outcome. In contrast, reactive conversion undertaken late in the operation in response to intraoperative complications, such as enterotomy or bleeding, is likely to result
in poorer outcomes. Unfortunately, most studies do not differentiate between the two types of conversions, and selection bias likely plays a large role in the outcomes of these
studies.
An important learning principle is that early conversion
based on initial laparoscopic intraoperative fi ndings may be
critical in avoiding complications in patients who are at an
already high risk of conversion. For example, studies have
shown that laparoscopic colectomies for sigmoid diverticulitis are more likely to convert [
12 ]. Several studies have
shown that hand-assisted laparoscopic colectomy is associated with signifi cantly lower conversion rate and, as a result,
lower postoperative complication rates when compared with
“straight” laparoscopy [ 17 , 18 ]. Advantages associated with
hand-assisted laparoscopy were more dramatic when dealing
with complicated diverticulitis with either abscess or fi stulae. An argument for routine use of hand-assisted laparoscopic surgery for certain indications, such as sigmoid
diverticulitis, is strong, although this is certainly open for
debate.
Our approach to re-operative laparoscopy is as follows.
We enter the abdomen using the open technique away from
the previous incisions and lateral to rectus sheath. After an
initial inspection, we quickly decide whether to proceed laparoscopically or not. If we do decide to proceed laparoscopically, the abdominal wall in the area of planned ports is
cleared and all the ports are inserted. We then separate the
greater omentum from the intestines. This will allow the
transverse colon and the greater omentum to be retracted in
the cephalad direction away from the operative fi eld. Next,
we separate the small intestines from the colon by taking
down adhesions sharply. It is prudent to set aside a fi xed
amount of time after which conversion should be considered.
If no signifi cant surgical progress has been made during that
time, there should not be any hesitation in converting to an
alternate approach.
Not all cases have to be converted to open. In straight
laparoscopic cases, you can consider converting to HALS
or place additional ports. For example, if you encounter
locally invasive sigmoid cancer, or dense inter-loop adhesions in lower abdomen, HALS gives you an option of
interchanging hand-assisted laparoscopy with open
approach.
Summary Pearls
Laparoscopic colon surgery is associated with many shortterm outcome advantages when compared with open surgery.
In expert hands, it is safe and may offer less potential for complications. Unfortunately complications are unavoidable
regardless of skill levels. We should be aware of both common
and unique complications that are associated with laparoscopic colorectal surgery. It is crucial to recognize them immediately and deal with them as quickly as possible. In this
chapter we described some of the strategies to avoid these
complications. Having a consistent and systematic surgical
approach is essential in avoiding or minimizing complications
in any type of surgery. Although controversial, conversion in
certain situations can lead to increase in complications.
Reactive conversion late in the procedure in response to an
unexpected injury is likely to lead to poorer outcomes. In contrast, early proactive conversion in patients who are at high
risk for conversion likely will minimize the risk of complications. In either situation, it is important that you remember it is
the patient who takes all the risks and your job as a minimally
invasive surgeon is to minimize or avoid them altogether.
References
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Utilization of laparoscopy in colorectal surgery for cancer at academic medical centers: does site of surgery affect rate of laparoscopy? Am Surg. 2011;77(10):1300–4.
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complication of laparoscopy. Br J Surg. 2004;91(10):1253–8.
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thermal spread using monopolar and bipolar diathermy, the
Harmonic Scalpel and the Ligasure. Br J Surg. 2010;97(3):
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8. Milsom JW, Bohm B, Nakajima K. Surgical energy source.
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9. Azevedo JL, Azevedo OC, Miyahira SA, Miguel GP, Becker OM,
Hypólito OH, et al. Injuries caused by Veress needle insertion for
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11. Palaniappa NC, Telem DA, Ranasinghe NE, Divino CM. Incidence
of iatrogenic ureteral injury after laparoscopic colectomy. Arch
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14. Gonzalez R, Smith CD, Mason E, Duncan T, Wilson R, Miller J,
et al. Consequences of conversion in laparoscopic colorectal surgery. Dis Colon Rectum. 2006;49(2):197–204.
15. Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA,
Rieger NA, et al. Short-term outcomes of the Australasian
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Ann Surg. 2008;248(5):728–38.
16. Casillas S, Delaney CP, Senagore AJ, Brady K, Fazio VW. Does
conversion of a laparoscopic colectomy adversely affect patient
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Laparoscopy, Robotics, and Endoscopy
Deborah S. Keller and Conor P. Delaney
Key Points
• Incorporating emerging technologies into practice
is critical to the advancement of skills but needs to
be weighed against the true (not perceived) benefi ts
they offer the patient.
• Laparoscopy offers continued benefi ts for colorectal
surgery, even when compared to newer technologies.
• The learning curve for new techniques is individualized, variable, and has a direct impact on
outcomes.
• Cost should be a major consideration when deciding
on which approach to undertake for colorectal disease.
Laparoscopy: Introducing Technology in Colorectal Surgery
Key Concept : Laparoscopy is a safe and effective technique
that optimizes patient outcomes . Health - care effi ciencies
continue to improve with increased incorporation of laparoscopy . For inexperienced minimally invasive surgeons or in
diffi cult cases , hand - assisted laparoscopy may offer a bridge
to laparoscopic surgery with comparable patient benefi ts .
Colorectal surgery has embraced technology as a means
to improve effi ciency and patient outcomes. Over the last
20 years, there has been a gradual evolution from conven-
D. S. Keller , MD
Division of Colorectal Surgery, Department of Surgery ,
University Hospitals Case Medical Center, Case Western Reserve
University , Cleveland , OH , USA
C. P. Delaney , MD, MCh, PhD, FRCSI, FACS, FASCRS (
Division of Colorectal Surgery, Department of Surgery ,
University Hospitals Case Medical Center,
Case Western Reserve University , 11100 Euclid Avenue, 7 Lakeside ,
Cleveland , OH 44106 , USA
e-mail: conor.delaney@uhhospitals.org
*)
3 2
tional open to laparoscopic colorectal surgery (LC). The
expanded use of laparoscopy has been the most successful technological advance in improving early postoperative
outcomes and reducing health-care costs in colorectal surgery. Although there were initial concerns about the oncological safety of LC [ 1 , 2 ], the landmark Clinical Outcomes
of Surgical Therapy (COST) Trial demonstrated the safety,
oncologic equivalency, and apparent benefi ts in secondary endpoints [i.e., return of bowel function, length of stay
(LOS), pain] for the laparoscopic group [ 3 ]. Subsequently,
multiple randomized controlled trials and a Cochrane Review
further affi rmed the oncologic equivalence, safety, reductions in pain and postoperative ileus, preservation of normal
pulmonary function, improved cosmesis, shorter LOS, and
better quality of life with LC versus open colorectal surgery
(OC) [ 4 – 10 ]. When viewed in a broader sense, LC is associ-
ated with better resource utilization through lower rates of
post-discharge nursing facilities when compared to conventional OC [ 11 ].
The transition to laparoscopic rectal resection (LRR) has
been slower for the colorectal fi eld to integrate. The safety
of LRR for rectal cancer was less clearly defi ned initially, as
early controlled trials concentrated on the oncologic safety
of colon cancer [ 3 , 5 ]. Initial concerns over proper oncologic
margins, local recurrence, sexual dysfunction, and appropriate training measures hindered widespread acceptance, even
to this day [ 12 ]. Data such as the UK MRC-CLASICC Trial
Group has expanded the safety profi le of LRR, fi nding no
difference in overall survival, disease-free survival, local
recurrence, wound recurrence, or quality of life between the
laparoscopic and open approaches [ 13 , 14 ]. Further trials [ 15 –
25 ] and meta-analyses [ 26 – 28 ] affi rmed the equivalent onco-
logical outcomes for LRR in the treatment of primary rectal
cancer. The randomized comparison of open versus laparo-
The online version of this chapter (doi: 10.1007/978-1-4614-9022-
) contains supplementary material, which is available to
7_32
authorized users.
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_32, © Springer Science+Business Media New York 2014
487
488
D.S. Keller and C.P. Delaney
scopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy (COREAN) trial found laparoscopic
surgery after preoperative chemoradiotherapy for mid or low
rectal cancer is not only safe and oncologically equivalent to
open resection but also associated with improved short-term
benefi ts, including earlier recovery of bowel function, better
physical functioning, and fewer micturition, gastrointestinal,
and defecation problems [
19 ].
Despite the proven advantages, the integration of laparoscopic technology into clinical practice has been slow. The steep
learning curve is a major factor limiting widespread use [ 29 –
32 ]. Previous studies suggested LC requires at least 50 cases to
gain profi ciency [ 33 – 35 ], with a minimum of 20 laparoscopic
colon cancer operations required for inclusion into clinical trials
[ 3 , 36 ]. In rectal cases, the narrow confi nes of the bony pelvis,
standard practice of autonomic nerve- sparing total mesorectal
excision (TME), and limited angulation of current stapling technology make laparoscopic surgery even more challenging [ 37 ].
Hand-Assisted Laparoscopic Surgery (HALS)
Key Concept : Hand - assisted laparoscopic surgery ( HALS )
has been proposed as a technology that might help bridge or
speed the laparoscopic learning curve , with equivalent
results to traditional straight laparoscopic colectomy .
With HALS, a sleeve appliance is used to maintain pneumoperitoneum, while the operator’s hand is inserted through a
small incision into the abdomen. As with standard laparoscopic
surgery, the surgeon visualizes the operative fi eld with a video
monitor but has the advantage of his assisting hand, allowing
tactile feedback and assistance in retraction, palpation, and dissection (Video 32.1a and b ) [ 38 ]. HALS may be useful for sur-
geons exclusively trained in open surgery, as the tactile
feedback and hand-eye coordination may allow this technique
to be easier to master [ 39 , 40 ]. A randomized trial comparing
surgeon performance, technical skills, and operative error in a
HALS versus straight laparoscopic colectomy simulator model
found better performances with the HALS approach, suggesting the HALS procedure may be technically easier to perform
[ 41 ]. HALS can also be effective in reoperative patients with a
higher likelihood of conversion. In a comprehensive review of
nearly 1,000 minimal access colectomies performed over a
3-year period, the authors found that, in their hands, HALS
substantially reduced operative time and conversion rates compared to conventional LC and increased the number of minimal
access colectomies performed [ 42 ]. Thus, HALS may bridge
the technical divide between minimal laparoscopic and open
procedures, expanding minimally invasive colorectal surgery
for those less profi cient in straight laparoscopy.
Laparoscopy is appropriate for the majority of benign
colorectal and malignant colon procedures. Reported contraindications include hemodynamic instability, inability to tolerate
pneumoperitoneum, labile cardiac status, ascites, cirrhosis,
portal hypertension, intraperitoneal mesh, peritonitis, and
mechanical bowel obstruction. With increasing experience, the
absolute contraindications are diminishing – with past absolutes
like malignant disease, obesity, pregnancy, and previous abdominal operations now mostly relative to the surgeon’s experience.
Laparoscopic resection for rectal cancer has proven feasible,
and oncologic outcomes are promising from the initial studies,
but still not oncologically equivalent. While ongoing trials are
attempting to clarify the role of LRR for cancer, the continued
implementation of LRR using meticulous oncologic techniques
by experienced surgeons for select patients is appropriate [
43 ].
Both SAGES and ASCRS recognize that LRR is an alternative
to traditional resection of benign disease involving the rectum
and encourage the development of properly designed studies to
evaluate the safety, effi cacy, and benefi ts of this approach.
Nevertheless, initial outcomes have been promising.
Future Direction: Robotic Technology
Key Concept : Robotic technology holds promise in improved
mechanics with reduced conversion rates , but further experience and long - term data are needed to defi ne patient outcomes and evaluate fi nancial implications .
Robotics is the current emerging technologic trend in sur-
gery. Since achieving market dominance in prostate surgery,
benefi cial outcomes have been suggested for robotic technology in colorectal surgery [ 44 , 45 ]. The application of robotic
technology offers new possibilities for performing procedures
remotely, and some consider it may help overcome the limitations of laparoscopic surgery [ 46 ]. Robotics has the advan-
tage of wristed, powered instruments, and 3-D HD vision that
delivers highly accurate depth perception (Fig. 32.1 ). Even
though laparoscopic 3-D camera systems are now available,
these systems lack the stable view offered by the robotic system and may be associated with side effects of headaches,
dizziness, and nausea [
ergonomic for performing routine segmental colectomies via
single incision, by crossing the robotic instruments and reassigning control of the arms in a more natural fashion [
While prospective data are awaited, retrospective case series
support that robotic technology may offer increased precision
and accuracy of anatomical dissection over conventional laparoscopic surgery [ 49 ], thereby facilitating more complex
procedures (see Video 28.1 ). Furthermore, robotic technol-
ogy may have a smaller learning curve compared to laparoscopic colorectal surgery, requiring only 20–40 cases to be
competent in the technique; however, the evidence is inconclusive thus far [
Authors of some early robotic colectomy trials have suggested clinical benefi ts. Robotics may also afford better
nerve function after TME. A nonrandomized review of
47 ]. The robot is presumed to be more
48 ].
50 ].
32 Laparoscopy, Robotics, and Endoscopy
a
489
b
c
Fig. 32.1 Robotic technology. ( a ) The robotic console, ( b ) proper robotic arm positioning, ( c ) Robotic instrumentation placed with aid of bedside
assistant
490
D.S. Keller and C.P. Delaney
Fig. 32.2 Pelvic hypogastric nerves ( arrows ) seen on laparoscopy
(Courtesy Matthew Mutch, MD)
urogenital function after robot-assisted total mesorectal excision for rectal cancer showed faster recovery of normal voiding, erectile function, and sexual desire compared to patients
who underwent laparoscopic TME [ 51 ]. As laparoscopy did
not show improved sexual and urinary dysfunction outcomes
over open TME in rectal cancer patients [ 52 ], there is hope
that robotics might improve these outcomes (Fig. 32.2 ). A
trend toward less postoperative blood loss [ 49 , 53 ] and early
recovery of functional outcomes has been described,
although one of these papers was compared to open surgery.
Robotic resections have also shown lower conversion rates to
open procedures in some series. A recent meta-analysis supported that the conversion to open rate may be reduced with
robotics over laparoscopy in both benign and malignant
colorectal cases [ 49 , 54 – 57 ].
Robotics may have the most promise in the management
of rectal cancer [ 56 , 58 ]. Results from the MRC-CLASICC
trial’s evaluation of laparoscopic versus open surgery for
colorectal cancer raised early concerns of adequate TME,
risks of higher positive circumferential resection margins,
overall male sexual and erectile dysfunction, and worse overall survival in patients converted to open operation [ 13 , 14 ,
18 , 59 ]. Worse overall survival has not been validated to
date. One recent prospective study showed a signifi cantly
higher complete mesorectal grade in the robotic versus the
laparoscopic group for rectal cancer [ 57 ]. At present there
are no studies showing a signifi cant benefi t in the oncologic
outcomes of circumferential resection margin, distal resection margin, or lymph node yield [ 55 , 56 , 60 ], although mul-
tiple prospective randomized controlled trials are ongoing to
defi nitively evaluate outcomes for rectal cancer. The
ROLARR trial [ 61 ], a worldwide superiority trial of robot-
assisted versus standard laparoscopic surgery for the curative
treatment of rectal cancer, is currently underway. The
Table 32.1 Early outcomes from robot-assisted colorectal surgery
Author N Conclusion
Diverticulitis
Zimmern [
Abodeely [
Ragupathi [
Rectal prolapse
de Hoog [
Zimmern [
Abodeely [
Bokhari [
Right hemicolectomy
de Souza [
Luca [
From Complications, Considerations, and Consequences of Colorectal
Surgery: Unique Complications of Robotic Surgery (Courtesy of Sonia
Ramamoorthy MD and Vincent Obias, MD)
Lap laparoscopic, LN lymph node, EBL estimated blood loss, LOS
length of stay
62 ] 16 Safe
Low conversion rate
63 ] 22 Safe
No conversion, no leaks
64 ] 24 Safe (complicated
diverticulitis)
No conversions
Low complication rate
65 ] 20 Safe
High recurrence rate
62 ] 8 Safe
63 ] 10 Safe
66 ] 5 Safe
67 ] 40 (vs. lap) Safe
Outcomes comparable to lap
Higher cost with robotics
Longer procedure time with
robotics
68 ] 33 (vs. open) Oncologic outcomes similar
Increased EBL with open
Reduced LOS with robotics
Higher cost with robotics
Longer op time with robotics
ROLARR trial is investigating differences in rate of conversion to open operation, rate of pathological involvement of
circumferential resection margin, 3-year local recurrence,
disease-free and overall survival rates, and also operative
morbidity and mortality, quality of life, and cost- effectiveness.
The ACOSOG Z6051 trial is also underway, comparing outcomes between minimally invasive and open rectal resection, including pure laparoscopic, laparoscopy- assisted,
robot-assisted, or hand-assisted methods in the minimally
invasive group. Results of these trials will help guide the
future role of robotics in rectal cancer (Table 32.1 ).
The future use of robotic technology in non-prostatic
surgery will be determined as time goes on. For colorectal surgery, most studies show similar outcomes to straight
laparoscopic colectomy [ 69 – 71 ]; however, long-term out-
come data is needed. In several meta-analyses, no advantage
was reported in days to passing fl atus, LOS, complications,
oncological outcomes, anastomotic leakage, or postoperative morbidity and mortality, suggesting equivalent safety
[ 49 , 54 – 56 , 60 ]. Operative times and costs are routinely
increased by robotics. Although robotic colorectal surgery
32 Laparoscopy, Robotics, and Endoscopy
491
may facilitate a reduction in conversion to open surgery, the
trials currently in process will help elucidate this fi nding.
Similarly, prospective data are required to support the ability
of the robot to improve nerve function and mesorectal grade
after TME. The cost implications of any improvements will
require evaluation. Overall, robotic surgery for colon and
rectal cancer appears feasible and safe; however, the current
literature only evaluates short-term outcomes, and data on
local recurrence and survival is awaited.
Other issues related to the immature technology deserve
attention. The costs are immense with no proven benefi t to
justify the additional expenditure at present. At a price of
more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2,000 per case for the cost of singleuse instruments, robotic surgery is the most expensive
approach. Barbash and colleagues reported if robot-assisted
surgeries completely replace conventional surgeries, as is the
trend in prostatectomy, an additional $1.5 billion in additional
health-care costs would be generated annually – more than
$2.5 billion when including the amortized costs of the robots
[
72 ]. A recent Journal of the American Medical Association
study evaluated the uptake of robotically assisted hysterectomy, costs, and complications compared to the laparoscopic
approach [ 73 ]. In reviewing nearly 265,000 women who
underwent hysterectomy between 2007 and 2010 for benign
gynecologic disorders, the authors found robotically assisted
hysterectomy dramatically increased from 0.5 to 9.5 %. The
robotic cases added an average of $2,189 per procedure, compared to traditional laparoscopic surgery, without any signifi cant benefi t in outcomes or complications. Looking at the
growth trend, the authors found using robotics for all routine
hysterectomies would add an unnecessary $1 to $1.9 billion
in unnecessary health-care costs each year [ 73 ].
Aggressive marketing may be a factor for the continued
growth. Both industry reports and the American College of
Gynecologists president noted many patients are learning
about the claimed advantages of robotic surgery from widespread marketing hype and an aggressive salesforce [
74 , 75 ].
To examine if hospitals are misleading patients about the benefi ts of robotic surgery to increase patient volume, Jin et al.
performed a systematic analysis of 400 US hospital websites.
The authors found 41 % described robotic surgery; of those,
78 % used manufacturer-provided stock images, and 33 %
linked directly to the manufacturer’s website. Unsupported
claims of clinical advantages (86 %) and improved cancer
control (32 %) were also found, while no sites mentioned
risks of robotic surgery. The authors concluded hospitals
overestimate benefi ts, underestimate risks, and are strongly
infl uenced by the robotic system manufacturer [
76 ].
A learning curve is always present when any new technology is introduced, during which an increase in complication rates can be expected. With robotics, there is no
expert consensus on how much training is needed despite
rapidly expanding use [ 72 ]. Expectantly, major complica-
tion data and legal issues are mounting. A series of liability cases against Intuitive Surgical have begun litigation,
exposing the company’s failure in its commitments to
properly train surgeons to use the da Vinci robotic surgery suite safely [ 74 ]. With these issues, investor anxi-
ety is growing. An industrial research report on Intuitive
Surgical questioned the company’s stock price and market
position given the lack of clinical evidence of superior
surgical outcomes and gathering storm of legal liability
from failure to adequately disclose risks leading to surgical complications [
77 ].
These factors have culminated in the American College
of Gynecologists President James T. Breeden’s statement
against the routine use of robotics. Dr. Breeden highlighted
an absence of strong evidence that robotic hysterectomy is
even as good as, and far more costly than, minimally invasive surgical techniques for routine surgical care. Aggressive
direct-to-consumer marketing may mislead the public into
believing that they are the best choice. Patients should be
advised that robotic surgery should be reserved for complex,
specifi c conditions [ 75 ].
Single-Incision Laparoscopy Surgery
Key Concept : Single - incision laparoscopic colectomy provides the potential for improved cosmesis , postoperative
pain , and recovery time at the drawback of higher costs ,
operating time , and technical skill required .
Single - incision laparoscopic surgery ( SILS ) was introduced
to further the enhanced outcomes of traditional laparoscopy.
SILS was fi rst reported in 1999 for cholecystectomy [ 78 ] then
extended to laparoscopic colectomy in 2008 by Remzi et al.
[ 79 ] and Bucher et al. [ 80 ]. SILS uses a single port within the
umbilicus with three or more working channels incorporated
in the single port. Straight or articulating instruments are used
via a fi xed platform or small low-profi le adjacently placed
trans-fascial trocars, theoretically allowing intracorporeal triangulation of parallel instruments (Video 32.2 , Courtesy of
Virgilio George, MD). Studies have proven SILS is feasible
and safe [ 81 – 86 ]. From early reports, SILS has similar post-
operative outcomes and complications to traditional laparoscopic surgery. Operative time, conversions, estimated blood
loss, surgical site infection, and hospital readmissions were all
similar [ 87 ]. Although some reports noted longer operative
times, the results are generally comparable with conventional
LC. SILS even has demonstrated benefi ts over traditional
laparoscopic surgery, including better cosmesis, reduced pain,
and faster recovery [
incision is a major draw. The potential advantages of a small
skin incision include not only better cosmetic result but also a
lower rate of port-site-related complications (Fig. 32.3 ) [ 89 ].
88 ]. The cosmetic benefi t of a single