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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1369_Библиотеки_им_академика_М_И_Перельмана.pdf
66
Mortality
(%) Note
– 5-year OS, R,
Complication
(%)
R, 7.5; L, 9.5
Hospital stay
(mean(±SD),
days)
R, 5.86
Conversion
rate (%)
R, 0; L, 7.1
92.8 %; L,
93.5 %
(p = 0.829);
(p = 0.602)
(1.43); L,
6.54 (2.65)
(p = 0.035)
(p = 0.003)
5-year DFS, R,
81.9 %; L,
78.7 %
(p = 0.547);
5-year
cumulative LR,
R 2.3 %; L,
1.2 %
S.-J. Baek and S.-H. Kim
(p = 0.649)
Estimated
blood loss
Operative
time
Table 6.1 (continued)
(mean(±SD),
ml)
R, 77.6
(153.2); L,
(mean(±SD),
min)
R, 205.7
(67.3); L,
217 (R,
133; L,
Comparative
analysis (robot vs.
Author
(year) Type of article Cases
Park et al.
[26] (2014)
82.3 (185.8)
(p = 0.841)
208.8 (81.2)
(p = 0.766)
84)
laparoscopy)
SD standard deviation, RCT randomized controlled trial, R robot, L laparoscopy, O open, NS not specific; NA not applicable, OS overall survival, DFS disease-
free survival, LR local recurrence
6 Robotic Low Anterior Resection of Rectal Cancer
Fig. 6.5 Port placement
for single docking method
©2015 Intuitive Surgical,
Inc. used with permission
67
• da Vinci Camera Port, 12 mm (blue): Place the port 3–4 cm to the right of and
3–4 cm above the umbilicus. Distance to symphysis pubis should be approxi-
mately 22–24 cm (Fig. 6.5).
• da Vinci Instrument Arm ① Port, 8 mm (yellow): Place the port a minimum of
8 cm from the camera port, on the right spinoumbilical line (SUL) at the crossing
of the midclavicular line (MCL). Distance to symphysis pubis should be approx-
imately 14–16 cm. Alternatively, the 13 mm stapler cannula with a 13–8 mm
reducer can be used in this port location for introduction of the linear stapler.
• da Vinci Instrument Arm ② Port, 8 mm (green): Place the port a minimum of 8 cm
from the camera port, on the left spinoumbilical line (SUL) at the crossing of the
midclavicular line (MCL). The distance to the symphysis pubis should be
approximately 14–16 cm.
• da Vinci Instrument Arm ③ Port, 8 mm (red): Place the port approximately 3 cm
below the right costal margin and approximately 2 cm medial to the right MCL.
• da Vinci Instrument Arm ②/③ Port, 8 mm (green-red): Place the port 7–8 cm
below the left costal margin, slightly medial to the left MCL. Place the port a
minimum of 8 cm from the other instrument ports and the camera port.
• Assistant Port (A1), 5 mm: Place the port 8–10 cm cephalad to the Instrument
Arm ① Port and approximately 4 cm lateral to the right MCL (a minimum of
8 cm from the camera port). This port is used for suction/irrigation, ligation, and
retraction.
Port Usage and Instrument Arm Setup per Procedure Step
• Initial procedure steps 1–3 on patient’s left side are performed in a four-arm
setup with arms 1, 2, and 3 connected (Fig. 6.6a).
68
S.-J. Baek and S.-H. Kim
Fig. 6.6 Left lateral setup (steps 1–3) (a), splenic flexure setup (step 4) (b), and pelvic setup (steps
5 and 6) (c) ©2015 Intuitive Surgical, Inc. used with permission
• Splenic flexure mobilization (step 4) is performed in a three-arm setup with only
instrument arms 1 and 3 connected to minimize external collisions (Fig. 6.6b).
• Pelvic procedure steps 5 and 6 are again performed in a four-arm setup with
instrument arms 2 and 3 reconnected in the lower and upper left da Vinci instru-
ment ports (Fig. 6.6c).
Operative Outcome
Similar to the hybrid technique, most results from totally robotic low anterior resection with single docking method were comparable or better than results from a
conventional laparoscopic or open low anterior resection (Table 6.2) [27–35].
6 Robotic Low Anterior Resection of Rectal Cancer
92.0 %;
5-year DFS,
81.7 %;
5-year local
pelvic control,
95.0 %
Mortality
(%) Note
Complication
(%)
Hospital stay
(mean(±SD),
days)
Conversion
rate (%)
(p = 0.5)
(p = 0.4)
R, 0; O, 0
R, ~ 26; L, ~
–
R, 16; L, 24
R, 0;
HAL, 0
R, 15.8; HAL,
27
O, 6.9 (1.5)
36.8
R, 7; HAL, 6
(p = 0.476)
(p = 0.308)
10.5
R, 0; SL,
5.6
R, 23.3; SL,
27.8 (p = 0.62)
(p = 0.269)
R, 8; SL, 7
(p = 0.037)
R, 5.4; SL, 0
(p = 0.29)
(p = 0.180)
69
(continued)
(p = 0.15)
Estimated
blood loss
(mean(±SD),
ml)
Operative
time
(mean(±SD),
min)
Case series 200 270 190 0 – 38.5 – 5-year OS,
Case series 50 304.8 – 0 9.2 (3.9) 18 –
Case report 2 – – – – – – First report
Hara et al.
(year) Type of article Cases
(2009) [27]
Table 6.2 Operative outcomes after robotic low anterior resection using a single docking method
Author
Choi et al.
Hellan et al.
(2014) [41]
(2009) [29]
– R, 0; L, 1 R, 6.5; L, 6
R, 240; L,
50 (R, 25;
Comparative
Bianchi
– R, 0; O, NA R, 7.1 (2.1);
R, 188 (45);
237 (p = 0.2)
200 (R,
L, 25)
Comparative
analysis (robot
vs. laparoscopy)
Kim et al.
et al. (2010)
[30]
– R, 5.3; HAL,
R, 390;
HAL, 225
O, 103 (23)
(p < 0.001)
100; O,
100)
analysis (robot
vs. open)
(2012) [31]
(p < 0.001)
38 (R, 19;
HAL, 19)
Comparative
analysis (robot
vs. HAL)
Koh et al.
(2014) [34]
R, 50; SL,
35 (p = 0.59)
R, 247; SL,
295
(p = 0.055)
92 (R, 56;
SL, 36)
Comparative
analysis (robot
vs. single-port
laparoscopy)
Levic et al.
(2014) [35]
70
95.2 %; L,
88.5 %
(p = 0.174);
3-year RFS, R,
76.7 %; L,
75.0 %
(p = 0.466)
85.0 %; O,
76.1 %
(p = 0.569);
5-year LR, R,
3.2 %; O, 16.1 %
(p = 0.024);
S.-J. Baek and S.-H. Kim
5-year DFS, R,
73.2 %; O,
69.5 %
(p = 0.734);
5-year CSS, R,
86.6 %; O,
78.3 %
(p = 0.565)
Mortality
Complication
Hospital stay
(mean(±SD),
Conversion
Estimated
blood loss
(mean(±SD),
Operative
time
(mean(±SD),
– 3-year OS, R,
(%) Note
R, 38.6; L,
26.9
(%)
L, 11.0 (6.3)
days)
– R, 11.4 (5.6);
rate (%)
R, 239.8
(278.6); L,
ml)
R, 316.4
(65.1); L,
min)
(p = 0.436)
(p = 0.509)
215.4
(247.3)
(p = 0.813)
286.8 (51.5)
(p = 0.038)
– 5-year OS, R,
R, 7.7; O, 6.4
(p = 0.764)
(p < 0.001)
R, 1.5; O, NA R, 6; O, 9
R, 0; O, 150
(p = 0.002)
R, 299.0
(58.0); O,
207.5 (56.5)
(p < 0.001)
Table 6.2 (continued)
Author
(year) Type of article Cases
70 (R, 44;
L, 26)
Comparative
analysis (ISR
only) (robot vs.
Yoo et al.
(2014) [43]
174 (R,
65; O,
109)
Comparative
analysis (robot
Ghezzi et al.
vs. open)
(2014) [42]
SD standard deviation, ISR intersphincteric resection, R robot, L laparoscopy, O open, SL single-port laparoscopy, HAL hand-assisted laparoscopy, NA not appli-
cable, OS overall survival, DFS disease-free survival, RFS recurrence-free survival, LR local recurrence, CSS cancer-specific survival
laparoscopy)
6 Robotic Low Anterior Resection of Rectal Cancer
71
Again, it was found that operative time was significantly longer than conventional
surgery. However, based on recent studies, the operative time has decreased after an
initial learning curve [36–40]. To date, favorable mid- and long-term oncologic
outcomes have been reported, and long-term outcomes for totally robotic low anterior resection with single docking method are currently being studied [41–43].
Dual Docking Method
Conventional laparoscopic splenic flexure mobilization has been reported to be
technically demanding and is associated with greater intraoperative blood loss,
complications, and a longer operative time and hospitalization period than robotic
surgery because of decreased range of motion, instrument tremors caused by a longer distance between the trocar site and the target organ, and the fulcrum effect
[44–46]. Although totally robotic technique has an advantage in splenic flexure
mobilization versus conventional laparoscopy or the hybrid technique, it is still difficult because the number of active robotic arms is decreased from three to two at
that time in order to avoid external collision (Fig. 6.6b) [27, 29, 47]. Consequently,
a modified two-stage totally robotic technique (often referred to as the dual docking
method) was proposed, which involves both redocking and reorientation during the
procedure to enable easier splenic flexure mobilization [48]. This method involves
rotating the operating table instead of moving a heavy robotic cart which is technically challenging and time-consuming and is thus more convenient and efficient
than a conventional two-stage robotic technique.
Port placement in the dual docking method is suitable for a wide range of patients
that need complete splenic mobilization and avoids external collision between the
camera and the main acting port. The current recommendation is as follows below.
Again, note that patient positioning and preparation are the same as in other techniques and robotic approach is performed in all steps (1–6).
Port Placement
All port placement measurements must be made after insufflation is achieved. Make
sure to position the remote center (thick black band) of the da Vinci cannulae at the
level of peritoneum, making the band invisible on either side of the abdominal wall.
Distance between ports should be at least 8 cm:
• da Vinci Camera Port, 12 mm (blue): Place port 2–3 cm above the umbilicus on
the midline (Fig. 6.7a, b).
• da Vinci Instrument Arm ① Port, 8 mm (yellow): Draw a line from the approxi-
mate location of the splenic flexure across the camera port down to the right
anterior superior iliac spine (ASIS). This is known as the “splenic flexure line.”
Place port approximately 2 cm inferior to this line and slightly medial to the right
midclavicular line (MCL).
72
Fig. 6.7 Port placement for dual docking method at stage 1 (colon mobilization) (a) and stage 2
(rectal dissection) (b) ©2015 Intuitive Surgical, Inc. used with permission
S.-J. Baek and S.-H. Kim
• da Vinci Instrument Arm ② Port, 8 mm (green):
– For stage 1: Place this port in the epigastric area, 2–3 cm right lateral to the
midline and just below the right costal margin. If the transverse colon needs
to be mobilized all the way to the midline, place this port even more lateral
toward the right side of the patient. This port location is used as an Assistant
Port in stage 2 (A1) (Fig. 6.7a).
– For stage 2: Place this port at the level of the umbilicus and about 3–4 cm
lateral to the left MCL (Fig. 6.7b).
• Assistant Port (A), 8 mm da Vinci Port: Place port 2–3 cm above the right ASIS
on the splenic flexure line. This port is used as the da Vinci Instrument Arm ③
Port in stage 2.
• da Vinci Instrument Arm ③ Port, 8 mm (red):
– For stage 1: Place this port just above the pubic bone, 2–3 cm to the left of the
midline. This port can be used as an Assistant Port in the second stage (A2)
for stapling the rectum and may alternatively be converted to a miniPfannenstiel incision for specimen extraction (Fig. 6.7a).
– For stage 2: dock da Vinci Instrument Arm ③ to previously placed Assistant
Port (A) utilized in stage 1 (Fig. 6.7b).
Patient Cart Positioning and Docking
• During stage 1 (colonic mobilization), the patient cart is positioned over the left
flank, approaching the patient at about 15° (Fig. 6.8a).
• To transition from stage 1 to stage 2, undock the da Vinci arms and pull the
patient cart straight back; rotate the operating room table about 60° counter-
clockwise until a 45° angle is created between the patient cart and the operating
6 Robotic Low Anterior Resection of Rectal Cancer
73
Fig. 6.8 Patient cart positioning for dual docking method at stage 1 (a), stage 2 (b), and operation
room layout (c) ©2015 Intuitive Surgical, Inc. used with permission
74
report
Mortality
(%) Note
Complication
(%)
Hospital stay
(mean(±SD), days)
Conversion
rate (%)
S.-J. Baek and S.-H. Kim
Estimated blood
loss (mean(±SD),
ml)
Operative time
(mean(±SD),
min)
61 227 20 0 7 31 0 First
Case series
(including left
colectomy)
Bae et al.
(year) Type of article Cases
(2014) [48]
SD, standard deviation
Author
Table 6.3 Operative outcomes after robotic low anterior resection using a dual docking method
6 Robotic Low Anterior Resection of Rectal Cancer
75
room table. Finally, push the patient cart back in straight and redock the da Vinci
arms. Alternatively, rotate the patient cart if the operating room table cannot be
moved; rotate the patient cart (Fig. 6.8b).
• During the transition, the angle of Trendelenburg can be increased for enhanced
exposure of the pelvis. Additionally, the right-sided patient tilt can be returned to
a flat position to reorient the pelvic anatomy.
• Ensure the patient’s right leg is positioned low enough to prevent interference
with da Vinci Instrument Arm ③.
• Position the camera arm setup joint on the opposite side of da Vinci Instrument
Arm ③.
Operative Outcome
There is one report for totally robotic low anterior resection with dual docking
method (Table 6.3) [48]. As for the other techniques, this study showed comparable
operative outcomes including operative time.
Port Placement for New Robot System
Recently, a new robot system named as da Vinci Xi® was released, which has an
entirely different surgical platform from conventional da Vinci S® or Si®. Because
da Vinci Xi® has a boom-mounted system with the flexibility of a mobile platform
and a larger range of motion of robotic arms, we are expecting better accessibility
and flexibility of cart positioning, and the development of a new port placement
protocol will be necessary.
References
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2. Spinoglio G, Summa M, Priora F, Quarati R, Testa S. Robotic colorectal surgery: first 50 cases
experience. Dis Colon Rectum. 2008;51(11):1627–32.
3. Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB. Robotic-assisted laparoscopic low anterior
resection with total mesorectal excision for rectal cancer. Surg Endosc. 2006;20(10):1521–5.
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