Home Forums General Surgery Robotic Total Mesorectal Excision for Cancer Rectum

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    This paper was published in The Feb Issue of RSM – authors Manish Chand, Rj Heald and Amjad Parvaiz. I have tried to summarize the article.

    Surgery for Rectal Cancer has gone through huge transition during the last 100 years. Mortality figures from being 100% in the 1800s is down to less than 10% today. The main reason for this is the realisation that Total Mesorectal Excision (TME) was necessary to reduce the incidence of local recurrence rates. With meticulous pathological scrutiny of resected specimens, surgeons in good cancer centres are now able to achieve a 4% local recurrence rate.

    Use of robotics is the latest innovation in rectal cancer surgery and is the subject of much debate. The impending full results from the ROLARR trial suggest that this high-cost and time-consuming venture may not be any more superior than laparoscopic surgery, although similar scepticism was encountered during the early days of laparoscopy. It took several largescale trials to convince the surgical community that laparoscopy was safe and effective in colon cancer at least.

    Perhaps it was the unfamiliarity with the anatomical views of the laparoscope which underpinned much of the scepticism. However, if one looks at the technical aspects of laparoscopy dispassionately, one must conclude that the advantages, in the right hands, can outweigh the challenges. The surgeon can potentially identify nerves, vessels and subtle planes with far more confidence than with open surgery. Optimal TME surgery not only calls for the oncological planes of the mesorectum to be respected, but the functional consequences of pelvic surgery to be appreciated. Next, the limited space of the pelvis can be a real hindrance when attempting to mobilise the rectum. Obtaining optimal traction and counter-traction, which is essential to exploit the dissection planes, is not always straightforward in open surgery. The ability of the laparoscope to access challenging areas of the pelvis with relative ease allows the surgeon to continue to precisely excise the mesorectum with minimal trauma (to the pelvis and the surgeon!). Standardisation of technique, akin to open TME surgery, and a modular approach has made laparoscopic rectal resection more acceptable in the modern management of rectal cancer.

    So robotics may further exploit the intraoperative advantages of laparoscopic surgery with the use of a potentially ‘even more precise’ technique. If we can appreciate how laparoscopic surgery can improve the most difficult and consequential aspects of pelvic surgery, we may be able to objectively evaluate the role of the robot. Robotic techniques provide a sturdy visual platform, tremor-free approach and avoid the disadvantage of a fulcrum effect seen with ‘straight laparoscopic’ instruments. With the use of a fourth arm that is controlled by the surgeon, many of the restrictions faced by the laparoscopic surgeon are immediately overcome. Robotic instruments allow this plane to be dissected with relative ease and minimal trauma to the specimen. Furthermore, the multiarm controls allow the principal surgeon to perform the dissection without reliance on an assistant, who even when appropriately senior will still need explanation of the subtleties of the dissection the principal is aiming for. The robot extends the surgeons capabilities from two hands to four or more.

    One of the disadvantages quoted for robotic approach is lack of tactile feedback. This clearly gets compensated by the better visual feedback seen with the high-definition 3D camera system enabling surgeons to examine in detail the embryological layers of anatomy, while performing the precision surgery that remains the goal for rectal cancer resection. In addition, the use of the fourth arm helps with the principle of traction and counter-traction, while the surgical planes are exploited by the use of low-voltage monopolar diathermy which certainly still provides one of the best energy tools for pelvic surgery.

    The skill gap that currently exists can be overcome with standardisation of the technique and structured objective assessments-based training programme as run by the European Academy of Robotic Colorectal Surgery (http://www.earcs.pt). The important and measurable parts of TME surgery would include safety, good oncological margins, preservation of pelvic nerves and functional outcomes. There have now been several reports documenting the safety and efficacy of robotic TME surgery with a meta-analysis showing that patient safety and oncological outcomes are comparable to laparoscopic surgery. Indeed, more recent case-matched studies have demonstrated that short-term perioperative and oncological outcomes are certainly on par if not improved over laparoscopic surgery including those undertaken post chemoradiotherapy.

    Safety and oncological compromise are consistently cited as concerns in novel surgical techniques. However, if these have been addressed, the next challenge is technique and functional outcomes. Any novel technology should aim to ease the most challenging technical aspects of the operation. Accurately identifying and preserving the pelvic nerves has become increasingly important as we understand the functional consequences of mishandling them. D’Annibale et al.10 compared 50 robotic with 50 laparoscopic resections. In addition to showing improved rates of conversion and shorter hospital stay, they also demonstrated better functional outcomes – less erectile dysfunction at one year and less voiding disturbance.

    Apart from high cost, the availability and training of surgeons will probably be the rate-limiting step in further popularising robotic surgery for rectal cancer. A training programme, as one run by the EARCS, would certainly help deliver standardised structured training. However, with increasing patient awareness, the demand will certainly grow, and leading well-trained colorectal surgeons may hopefully demonstrate improved outcomes that will justify the investment of people, time, effort and money that will undoubtedly be needed.

    My take on this Topic: New instruments and techniques of treatment in medicine are evolving continuously. When the newer methods are introduced, the results may be no different or even worse than the previous methods used initially. It is most important that a surgeon is not allowed to perform a newer technique or use a newer instrument on a patient until he or she is fully trained and has perfected the method under the supervision of a more experienced trainer.

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