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R.K. Cleary
and oncologic outcomes. Transanal minimally invasive surgery (TAMIS) is a
laparoscopic approach to transanal excision of early rectal neoplasms and has been
shown to be safe and feasible [122–124]. The “down to up” transanal approach has
also been described and developed for total mesorectal excision of rectal neoplasms.
At this time, this procedure is typically done with laparoscopic transabdominal
mobilization of the proximal colon and assistance with the proximal part of the
TME, though a completely transanal natural orifice approach has been described
[125]. The transanal laparoscopic component of these operations has the same limitations as conventional laparoscopic TME from the abdominal approach with
respect to rigid in-line instruments, nonadvantageous angles to the pelvic sidewalls,
and the difficulty with suturing a defect after excision.
The robotic version of these operations is currently under development in an
effort to take advantage of superior imaging, and articulating and wristed instruments. The transanal approach to mid and low rectal neoplasms is feasible though
docking is challenging. FDA approval of a single-incision robotic system for the
transanal approach has the potential to make this platform the procedure of choice,
in light of the robotic imaging, instrument, and ergonomic advantages. Atallah et al.
and others have reported on the feasibility of both robotic transanal excision of early
rectal neoplasms and transanal TME for more advanced neoplasia [126–129].
Cost
The cost of purchase and maintenance of the robotic system has limited widespread
application in many countries. Numerous reports show higher costs for the robot
compared to laparoscopy but there are some exceptions [62]. Rawlings et al. showed
no statistically significant difference in laparoscopic and robotic total hospital costs
for right and sigmoid colectomies. Operating room supply costs were higher for the
robotic right and sigmoid colectomies and operating room time costs were higher
for robotic right colectomies, but not for sigmoid colectomies [29].
To date, most comparative cost analyses of minimally invasive surgery examine
operative time, operating room supplies, pharmacy and anesthesia costs, and boarding costs. For the cost of the robotic approach to be comparable with respect to laparoscopic surgery, cost savings will have to be incurred by either decreasing hospital
LOS, decreasing conversions, or decreasing another parameter of cost effectiveness.
More recent comparative studies have shown hospital LOS and conversion rates
more favorable for the robotic approach when compared to laparoscopy [37]. This
includes recent analyses of large protocol-driven, externally audited, nonadministrative regional and national databases [89, 90].
Another consideration is the willingness to absorb the cost of an approach that
may be applicable to a larger number of patients, particularly for rectal cancer. It is
not clear yet what cost savings would be incurred for those patients who would
otherwise require open surgery because laparoscopic TME is not part of their
surgeon’s skill set or who are converted from laparoscopic to open. Limiting the use
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
219
of the robot to specialized centers may be another way of addressing cost, but this
would exclude a significant number of patients from access to a minimally invasive
approach. The penetration of laparoscopy in practice varies by region and many
areas of the United States are underserved and have no minimally invasive options
and are without access to surgeons with laparoscopic skill sets [108, 130]. Future
cost analyses will likely include the cost of conversion to open, hospital LOS,
Emergency Department visits, readmissions, return to health without symptoms,
and other measures of cost effectiveness [16].
Future Directions
The quality of trials evaluating minimally invasive approaches continues to advance.
Single site case series and comparative studies were followed by large database
analyses. Recent analyses of large regional and national databases have shown
advantages for robotic compared to laparoscopic colectomy with respect to conversion and hospital LOS [89, 90]. The strength of these database analyses is the source
of the data. Regional databases like the Michigan Surgical Quality Collaborative are
protocol driven and characterized by data that is entered by highly trained individuals, regularly validated, and externally audited. These database outcomes represent
surgeons of varying minimally invasive skill sets and are therefore generalizable.
They are potentially more valid with respect to outcomes when compared to databases that rely on administrative and billing information. Randomized controlled
trials comparing robotic and laparoscopic approaches followed these database analyses, and the ROLARR trial which represents surgeons with significant minimally
invasive expertise is complete [16]. These studies will likely lead to data that allows
surgeons to choose minimally invasive options based on patient characteristics and
their skill sets. These trials may also focus questions that require further study.
The Association for Program Directors in Colon and Rectal Surgery identified
the issues of fellowship training in the laparoscopic era, especially with regard to
the low penetrance of laparoscopic colorectal surgery among young fellowshiptrained Colon and Rectal Surgeons [10]. In response, this organization has sponsored the development of a standardized national robotic training curriculum to
address the challenges in fellowship training and to become proactive in training the
Colon and Rectal Surgeons of the future. Ninety-five percent of the Colon and
Rectal Surgery Fellows attended the standardized colorectal surgery robotic courses
based on this curriculum in 2014. These efforts uncovered a need to train robotic
mentors necessary to allow operative robotic educational opportunities for residents
and fellows.
Future innovations in robotic technology may include telementoring surgeons at remote locations who may benefit from expert advice, telepresence surgery with the expert performing the robotic operation from a remote location,
CT or MRI-guided robotic interventions, and other robotic-guided clinical
applications [115, 131–133].
220
R.K. Cleary
Until recently, a disadvantage to robotic colorectal surgery has been the need to
operate in multiple quadrants, sometimes requiring redocking and negotiating
external robotic arm collisions. The most recent upgrades in robotic technology
address the issues of multiple docking and transanal access. What is possible with
robotic technology is limited only by the imagination. Upgrades in minimally invasive platforms will likely result in options not yet evaluated or even considered.
Today’s robot is not yesterday’s robot, and it is likely that future minimally invasive
upgrades will allow current procedures to be done more effectively, and allow additional procedures not yet performed by a minimally invasive approach.
Conclusion
Robotic colorectal surgery was originally designed to reduce the laparoscopic limitations of decreased range of motion, instrument tremor, lack of instrument articulation, decreased depth perception, and ergonomic patient bedside disadvantages
[62]. That the laparoscopic approach is utilized in only 45 % of elective colectomies
and 10 % of elective TME in the United States is a testament to the degree of difficulty imposed by this minimally invasive option.
Studies to date comparing robotic with open and laparoscopic colorectal surgery
suggest that the technical upgrades that improve imaging, instrument angles to tissues, surgeon-controlled stable camera and 3
ergonomic appeal offer advantages, especially in the pelvis. This robotic advantage
for rectal cancer appears to be most consistent with respect to conversion rates,
hospital LOS, and may potentially affect circumferential margins and oncologic
outcomes. A larger number of patients with rectal cancer now have the opportunity
for minimally invasive surgery because of these robotic advantages in the pelvis.
Trials evaluating the role of the robotic approach for colectomy have also identified advantages to the robotic platform in this location, especially with regard to
suturing the intracorporeal anastomosis, incisional hernias, and single-incision procedures. Upgrades in technology that have resulted in sleeker, more sophisticated
robotic arms and single-incision ports will ultimately require further study. It is
possible that the continued evolution of minimally invasive robotic upgrades will
change the paradigm of minimally invasive colorectal surgery.
rd
arm for fixed retraction, and robotic
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