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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_917_Библиотеки_им_академика_М_И_Перельмана.pdf
368
E. M. Haas and A. V. Hayman
superior hypogastric plexus that runs anterior to the aortic bifurcation, with increased
risk of defecatory and urinary dysfunction, compromised blood supply, thus increasing the risk of anastomotic leak. If, indeed, there is regional lymph node involvement between the takeoff of the left colic artery and the IMA, this may be a marker
for more distant tumor spread up the paraaortic chain and thus represent occult
metastatic (M1) disease. Most studies comparing oncologic outcomes following
high versus low IMA ligation during LAR for cancer did not report any signicant
difference in oncologic outcomes but did highlight functional differences favoring
low ligation (Table 23.1) [5–8]. Our approach is to carefully examine the crosssectional imaging prior to resection to assess for any lymph node involvement near
the bifurcation and to perform selective high ligation.
A more important question of whether laparoscopic LAR is oncologically
equivalent to open low anterior resection. Multiple well-publicized trials have had
conicting results, as summarized in Table23.2 [2, 3, 9]. Three multinational and
multi-institutional randomized trials, evaluated outcomes of laparoscopic versus
open TME for rectal cancer performed by expert laparoscopic colon and rectal
surgeons. Because of the early timeline of follow-up, long-term oncologic results
(i.e., overall and disease-free survival) were not yet available. Consequentially, a
proxy measure of oncologic efcacy was used to compare the pathologic results
via a composite score of negative margins (circumferential radial and distal) and
Table 23.2 Results of randomized controlled trials of laparoscopic versus open total mesorectal
excision for rectal cancer
Fleshman etal.
JAMA 2015.
(ACOSOG Z6051
trial) [2]
Stevenson etal.
JAMA 2015.
(ALACART trial) [3]
Jeong etal. Lancet
Oncol 2010.
(COREAN trial) [9]
Jeong etal. Lancet
Oncol 2014 [11]
Fleshman etal. Ann
Surg 2019 [10]
CRM circumferential resection margin, TME total mesorectal excision, DFS disease-free survival,
LN lymph nodes
a
Establishing “noninferiority” of laparoscopic versus open approach was the end point chosen by
the authors of these trials. Therefore, a nonsignicant p-value (p≥0.05) suggests that there are
insufcient data to conclude that laparoscopy was “not not inferior” to an open approach.
Conversely, signicant p-value (<0.05) would suggest that laparoscopy was not inferior to an open
approach
N=486, ‘08-‘13, RCT: lap vs.
open TME for stage II/III rectal
CA
N=475, ‘10-‘14 RCT: lap vs.
open TME for stage I–III rectal
CA
N=340, ‘06-‘09. RCT: lap vs.
open TME for stage II/III rectal
CA
N=340, ‘06’09. RCT: lap vs.
open TME for stage II/III rectal
CA (COREAN trial f/u: 3YS)
N=486, ‘08-‘13, RCT: lap vs.
open TME for stage II/III rectal
CA (ACOSOG Z6051 trial f/u:
median 48months)
Successful resection (neg CRM/distal
margin, complete/near complete
TME), 81.7% vs. 86.9% (p 0.41 for
noninferiority)
Successful resection (neg CRM/
distal margin, TME completeness),
82% vs. 89% (p=0.38 for
noninferiority)
NS: involvement of CRM, TME
specimen, #LNs harvested
NS: 3Y DFS (79.2% vs 72.5%),
p<0.0001 for noninferiority
NS: 2Y DFS (79.5% vs 83.2%),
locoregional (4.6% vs. 4.5%) or
distant (14.6% vs. 16.7%) recurrence
a
a
a
23 Laparoscopic Low Anterior Resection forRectal Cancer: TME Planes andSurgery…
369
completeness of the TME specimen. The burden of proof was to determine that a
laparoscopic approach was noninferior to open TME, which could not be demonstrated in two of the three major trials [2, 3]. Although results of long-term survival
are eagerly awaited, the most recent publications on short-term oncologic outcomes including disease-free survival rates from two of the trials suggests oncologic equivalence [10, 11].
Conclusions
Laparoscopic low anterior resection with a mesenteric-specic tumor resection
allows for functionally acceptable outcome while preserving minimizing morbidity.
However, performing these procedures safely requires a thorough understanding of
the relevant anatomic landmarks, knowledge about intraoperative pitfalls and how
to avoid them, and are best performed by surgeons experienced in minimally invasive techniques. Although early randomized trial results suggest probable oncologic
equivalence, ongoing controversy about the oncologic inferiority of minimally invasive TME and potential ramications on long-term survival should be approached
with thoughtful consideration by all rectal cancer surgeons when deciding on surgical approach and individualized based on patient and tumor factors.
References
1. Taylor F, Quirke P, Heald R, Moran B, Blomqvist L, Swift I, etal. Preoperative high-resolution
magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best
managed by surgery alone. Ann Surg. 2011;253(4):711–9.
2. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of
laparoscopic- assisted resection vs open resection of stage II or III rectal cancer on pathologic
outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314(13):1346–55.
3. Stevenson ARL, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, etal. Effect of
laparoscopic-assisted resection of open resection on pathological outcomes in rectal cancer:
the ALACART trial. JAMA. 2015;314(13):1356–63.
4. https://www.Facs.org/Quality-Programs/Cancer/Naprc/Standards.
5. Matsuda K, Yokoyama S, Hotta T, Hakifuji K, Watanabe T, Tamura K, etal. Oncological out-
comes following rectal cancer surgery with high or low ligation of the inferior mesenteric
artery. Gastrointest Tumors. 2017;4(1–2):45–52.
6. Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Watanabe T, etal. Randomized clinical
trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery. Br J Surg. 2015;102(5):501–8.
7. Fujii S, Ishibe A, Ota M, Watanabe K, Watanabe J, Kunisaki C, et al. Randomized clinical
trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal
cancer. BJS Open. 2018;2(4):195–202.
8. Mari GM, Crippa J, Cocozza E, Berselli M, Livraghi L, Carzaniga P, etal. Low ligation of infe-
rior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary
dysfunction. Ann Surg. 2018; https://doi.org/10.1097/SLA.0000000000002947. [Epub ahead
of print]
9. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, etal. Open versus laparoscopic
surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN
370
trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol.
2010;11(7):637–45.
10. Fleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA, etal. Disease-free
survival and local recurrence for laparoscopic resection compared with open reseciton fo stage
II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial.
Ann Surg. 2019;269(4):589–95.
11. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al. Open versus laparoscopic
surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN
trial): survival outcomes of an open-label, noninferiority, randomized controlled trial. Lancet
Oncol. 2014;15(7):767–74.
E. M. Haas and A. V. Hayman
Robotic Low Anterior Resection: Unique
Considerations andOptimal Setup
SlawomirMarecik, JohnJ.Park, andKunalKochar
Introduction andRationale
The objective of robotic assistance has always been to facilitate completion of
complex laparoscopic procedures [1–7], which is particularly crucial during total
mesorectal excision (TME). No randomized study has yet demonstrated the superiority of the robotic technique over laparoscopy for rectal cancer resections, but surgeons have consistently reported advantages of the robotic approach with respect to
the ease of dissection, control of the operating eld, and the ergonomics during
these demanding cases [1, 2].
At the end of 2018, there are more than 40 companies actively developing new
surgical robots. At least two of these companies offer integrated transabdominal
platforms pending FDA approval. The cost of these emerging technologies remains
the main point of contention and will need to be addressed [8, 9].
When examining robotics from a purely technical standpoint, and in the context
of pelvic dissection, there are several inherent features of the robotic system that
make it more advantageous to use when compared with laparoscopic, transanal
minimally invasive, and open techniques. First, the robotic platform allows the
24
S. Marecik (*) · K. Kochar
Advocate Lutheran General Hospital, Division of Colorectal Surgery, Park Ridge, IL, USA
University of Illinois at Chicago, Chicago, IL, USA
e-mail: smarecik@uic.edu
J. J. Park
Advocate Lutheran General Hospital, Division of Colorectal Surgery, Park Ridge, IL, USA
Chicago Medical School, Chicago, IL, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_24
371
372
primary surgeon to control the camera in a very stable way, allowing for constant
operator-friendly adjustments, as well as “freezing” of the entire operating eld.
This, together with simultaneous control of three working articulating wrist instruments (often supported by two additional instruments controlled by the bedside
assistant), gives the primary surgeon the ability to completely control the operating
eld. This is essential when working with obese patients, bulky tumors, or narrow
pelvic connes.
While other chapters will detail the principles of rectal cancer management as
well as the technique of laparoscopic LAR, this will review robotic techniques for
low anterior resection with special emphasis on optimal robotic setup and best
practices.
S. Marecik et al.
Indications andContraindications ofApproach
There are currently no strict guidelines with regard to which patients with rectal
cancer are appropriate candidates for robotic low anterior resection (rLAR). As a
general principle, however, candidates for a laparoscopic approach can also be
operated with robotic assistance. Patients with previous abdominal surgeries
should be carefully selected. The most difcult cases to include mid and low rectal cancers, bulky tumors, high body mass index (BMI), male patients, and
abdominoperineal resections may be easier with the robotic approach. Surgeons
still early along their robotic learning curve should not proceed with these complex cases without assistance by a proctor or an experienced co-surgeon.
Conversion rates have been used as surrogate parameter for failure to pursue a
minimally invasive approach [3].
Principles andQuality Benchmarks
The main objective of any emerging surgical technique is to perform a safe and
controlled operation to the benet of the patient. The robotic surgeon should have
sufcient laparoscopic and open experience to complete the procedure [10, 11].
Good clinical judgment is crucial to determine the appropriate technique
(laparoscopic, robotic, transanal, or open) for a particular patient while considering
value- based outcomes [8].
The main principle of rectal dissection for cancer is the universal concept of total
(or tumor-specic) mesorectal excision [12], i.e., to resect the necessary mesorectum with an intact mesorectal fascia (>90% of cases), low rate of positive circumferential and distal resection margins (<5%), and a low anastomotic leak rate (<5%)
[3, 4, 13]. Total mesorectal excision (TME) requires an adequate knowledge of the
pelvic anatomy and specialized training in this technique in order to perform an
oncological, technically safe operation with good functional outcomes. When the
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
373
anatomical landmarks are difcult to identify, the surgeon should look for the
roundness and symmetry of the mesorectal compartment.
rLAR can be performed as a pure robotic technique or as hybrid approach
(withtraditional laparoscopy) [14, 15]. The latter is recommended at the beginning
of the learning curve, in order to keep the procedures as short and easy as possible.
Astepwise approach, i.e., adding robotically performed parts of the procedure with
increasing robotic experience, will eventually enable the surgeon to convert to a
fully robotic procedure (if appropriate) while considering each individual surgeon’s
learning curve [14, 16].
The fourth-generation system (da Vinci Xi®) from Intuitive Surgical®
(Sunnyvale, CA, USA) is more versatile and allows a wider reach of the arms with
less chance for external collisions. This makes it more suitable for multi-quadrant
surgeries such as TME, without the need to redock. Conversely, the da Vinci Si® (or
X) system will require redocking of the robot in order to complete the left colon
mobilization and perform the TME.
Preoperative Planning, Patient Workup, andOptimization
Newly diagnosed rectal cancer patient should undergo a standardized staging
workup, per the National Accreditation Program for Rectal Cancer [17]. The
results of pathology; computer tomography of the chest, abdomen, and pelvis; as
well as magnetic resonance (MRI of the pelvis, rectal cancer protocol with standardized synoptic reporting) and blood tests (CBC, CMP, CEA) are then presented
to the multidisciplinary tumor board to determine if any neoadjuvant therapy is
recommended. Digital rectal examination and exible and/or rigid sigmoidoscopy
are performed by the surgeon her/himself in order to localize the tumor and assess
its relationship to the anal sphincters. Video documentation of the tumor (pre and
post- neoadjuvant treatment) can be particularly helpful as it allows the surgeon to
recall specic details just before surgery. This is especially important when assessing for tumor downstaging and when surgery is delayed by weeks or months after
sigmoidoscopy.
When a plan for immediate or future LAR is made, the patient undergoes medical
optimization. The rst part involves smoking and alcohol cessation, weight loss as
needed, nutrition optimization, and prehabilitation. Patients are extensively educated
with respect to what to expect perioperatively as part of standard enhanced recovery
protocols. For more information on specic protocols, refer to Chaps. 7 and 8 on
enhanced recovery in colorectal surgery.
Most patients with tumors in the mid and lower rectum, particularly after
neoadjuvant chemoradiation, are considered for a protective diverting ileostomy,
based on the low level of the anticipated colorectal anastomosis. Some experienced
surgeons are more selective in that decision. Preoperative stoma marking should be
routinely performed by an enterostomal therapist.
374
S. Marecik et al.
Operative Setup
Positioning
The patient is placed in the modied lithotomy position with the thighs at level with
the abdomen. If available, an anti-sliding pad is used (e.g., The Pink Pad®, Xodus
Medical, New Kensington, PA, USA) with both arms tucked along the torso in a
neutral position. Care is taken to provide full access to the perineum, taking into
consideration the possibility of cephalad and caudal patient sliding during steep
Trendelenburg positioning. Bony prominences and potential nerve entrapment sides
should be secured with a protective padding to avoid neuropathy [18]. The most
common sites of potential nerve injury are the cervical portion of the brachial
plexus, the ulnar nerve at the epicondylar groove (elbow), the median nerve at the
wrist, and the peroneal nerve at the bular head. The patient is strapped to the table
at the chest, with a towel between the chest and the strap so respiratory movement
is not compromised. The shoulder brackets are then secured to avoid compression
on the brachial plexus. Before draping the patient, the bed is tilted to the extreme
positions to observe any possible patient sliding. The anesthesia equipment is
moved as far cephalad as possible to prevent contamination during robotic arm
setup and instrument exchange. The minimum amount of necessary table tilt is used
throughout the procedure.
Robotic Cart Position (Fig.24.1)
For LAR using the Si system, the cart is placed by the left hip and along the left leg
while straddling the left lower corner of the operating room base. Occasionally, the
Si (or X) system can be placed between the legs (provides excellent robotic arm
distribution for pelvic dissection). However, this position precludes easy access to
the perineum.
When using the Xi system, the cart can be brought from either side with the
exception of the right upper quadrant, which is reserved for the bedside assistant.
Arotating boom of the Xi system allows the arms to be directed toward the left
abdomen and pelvis.
Port Placement
Standard principles of safe port placement should be respected. These include
ensuring the appropriate distance between the ports and depth of port insertion. In
cases of insufcient instrument reach, which may be encountered during deep pelvic dissection, the ports and the robotic arms may need to be pushed deeper beyond
the black line marked on the port’s cannula. Additionally, attention should be given
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
Fig. 24.1 Port setup for Si
(and X)system. R1-robotic
dissecting instrument,
CP-12mm camera port
(8mm in X system),
R2-micro-retracting
bipolar grasper, R3-macroretracting grasper; assistant
ports (5mm or 6mm
AirSeal®, Conmed
System, Utica, NY, USA)
375
R3
R1
CP - Camera port 12mm
R - Robotic port 8mm
CP
- Assistant ports 5mm or 6mm
Air Seal ®
- Alternative assistant ports
R2
to the position of the robotic base (Si or X system) or the center of the rotating boom
(Xi system) in relation to the ports. The shorter distance between the ports and the
abovementioned central parts of the robotic system can result in cramming of the
external arms, with the possibility of external arm collision. The longer distance
would result in decreased reach of the instruments. During the learning curve, it is
recommended that the robotic ports be placed in the most optimal location with no
regard for a future ileostomy site, or even the extraction site. With time and experience, the ileostomy site and the extraction incision can be incorporated into the port
placement.
There are many possible ways to achieve successful port placement. There are,
however, differences between the Si and Xi systems in terms of port setup. Overall,
the Xi system provides a wider reach of the arms with less chance for external collisions. The Si (or X) system will typically require redocking of the robot in order
to complete the left colon mobilization and perform the TME.The techniques for a
completely rLAR with the Si (or X) system have been described; however, the
authors suggest using them only after obtaining sufcient experience with the
simpler techniques [14, 15, 19].
376
S. Marecik et al.
Robotic LAR withtheSi System
The technique is based on the hybrid robotic-laparoscopic technique. The robot is
used for left lower quadrant dissection, inferior mesenteric artery (IMA) control,
and TME.Standard laparoscopy is used for inferior mesenteric vein (IMV) control
and splenic exure takedown. In this technique, a 12mm camera port is placed at
the umbilicus, and an 8mm robotic port (R1) is placed in the right lower quadrant,
one third to one half of the distance from the anterior superior iliac spine to the
umbilicus. Two 5 mm assistant ports (a1 and a2) are inserted in the right upper
quadrant with a1 placed just cephalad from the horizontal umbilical line in between
the camera port and R1 and a2 placed suprapubic on the line of the future extraction
port via the Pfannenstiel incision. This four-port conguration should be sufcient
for laparoscopic splenic exure takedown and IMV control. Two additional robotic
ports are necessary for the robotic portion. The R3 is an 8mm robotic port placed
above the horizontal umbilical line, on the intersection with the anterior axillary
line. An 8mm R2 is then placed in between R3 and the camera port (Fig.24.2).
Fig. 24.2 Port setup for
Xi system. X1-macroretracting grasper for
pelvic dissection,
X2-micro- retracting
bipolar grasper for pelvic
dissection, X3–8mm
camera port, X4-robotic
dissecting instrument;
assistant ports (5mm,
6mm AirSeal®, Conmed
System, Utica, NY, USA)
CP
X1
X2
X4
CP - Camera port 8mm
(X3)
X - Robotic port 8mm
- Alternative robotic ports
(adjusted for splenic flexure access)
X3
- Assistant ports 5mm or 6mm
Air Seal ®
- Alternative assistant ports
24 Robotic Low Anterior Resection: Unique Considerations andOptimal Setup
377
During the robotic part of the procedure, R1 is used for a monopolar cautery
hook or hot shears, which are assigned to the right hand of the operator. The R2
port accommodates a bipolar grasper-type instrument, and R3 is used for a
Cadiere-type (no cautery) grasper. Both R2 and R3 ports are assigned to the left
hand of the operator. The R3 instrument is primarily responsible for stationary
retraction (macroretraction) of the rectosigmoid during posterior rectal mobilization. It is also used to retract anterior pelvic structures during anterior rectal mobilization. The left hand of the assistant (a1) controls a grasper and helps with
macro- and microretraction, while the right assistant hand (a2) is supplied with a
suction irrigator in order to actively evacuate the plume and uid from the pelvis
and to assist with retraction and exposure. Zero-degree or 30-degree down camera
is used for most of the procedure.
Robotic LAR withThis Xi System
The Xi system differentiates from the Si system by its central rotating boom and a
reverse numbering of the arms from the left to right. The 8mm Xi camera can be
placed in any robotic port. The ports are placed in an almost linear conguration
from the right lower quadrant (one third to one half of the distance between the
anterior superior iliac spine and the umbilicus) to the left upper quadrant midcostal region (Fig.24.3). Subsequently, the 8mm camera port (X3) and two additional robotic ports (X2 and X1) are placed on that line, evenly distributed.
Frequently, the camera port (X3) corresponds with the umbilicus, which is the
preferred site for the camera. The line for the port positions can be modied by
pivoting it around the X4 port (which is constant). A more vertical port placement
line brings the X1 closer to the midline and allows for more comfortable dissection
around the splenic exure and the left colon. A rotation of the port placement line
in a more horizontal direction allows for more comfortable pelvic dissection and
with better reach of the X1 and X2 instruments into the deep pelvis. The assistant
port conguration includes two ports in the right upper quadrant or one port in that
location and the other one in the suprapubic location. Alternatively, the entire
robotic port line, including the X4 port, may be moved in parallel toward the right
upper quadrant.
The assignment of the arms for the pelvic dissection is essentially the same as
in the Si technique, but for the splenic exure mobilization, the instruments can be
rearranged, including the 8mm camera, which can be placed in any robotic port. If
the assistant port is chosen to be placed in the suprapubic location, the right hand
of the assistant will have to be inserted between the robotic arm of the right lower
quadrant (R1 or X4) and the camera arm. This maneuver is not usually problematic; however, the assistant should be alert for any sudden swings of the nearby
robotic arms.
Once the rectal mobilization is complete, a robotic stapler is typically introduced
via the right lower quadrant port (R1 or X4), after upsizing of that port with a
12mm designated stapler port.