Robotic rectal cancer surgery

The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). However, robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) resulted in a lower percentage of overall surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life, and a better short-term postoperative functional recovery as compared to OTE. In this authoritative lecture, Dr. JP Ruurda, MD, PhD addresses his team experience with RAMIE since 2003. He goes through a review of the literature and presents a clinical case describing the operative steps of the robot-assisted minimally invasive thoracolaparoscopic esophagectomy.

Dr. Giulianotti is a pioneer in robotic surgery. In this authoritative lecture, he demonstrates the robotic approach applied to hepatobiliary surgery.

In this key lecture, Dr. Pessaux presents the first liver robotic resection guided by real time augmented reality.

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

In this key lecture, Dr. Kim highlights the factors which maximize success in difficult surgeries, and especially in robotic low anterior resection (LAR).

The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.

This is the case of a 52-year-old obese woman, with no prior surgical history, presenting with a 1.5cm tumor-like nodule in the right upper lobe which was demonstrated on PET-scan. The lesion demonstrated on PET-scan and staging work-up indicated a cT1N0M0 tumor. A wedge resection with extemporaneous biopsy is decided upon. An upper right lobectomy with lymphadenectomy using thoracoscopy with the help of the da Vinci® surgical robotic system.

This is a totally robotic Nissen fundoplication performed by an experienced laparosopic surgeon. It is detailed, commencing with robot set-up, which is done with the help of the scrubbed assistants. All the same steps of laparoscopic Nissen fundoplication are reproduced easily with robotic instruments.

Dr. Moore explains the pivotal place of laparoscopic sacrocolpopexy in the surgical treatment of pelvic organ prolapse. After a thorough review of the latest data in the literature supporting its efficiency, he exposes the key steps of the surgical technique and goes through the controversial issues surrounding sacrocolpopexy and vaginal mesh repair.

This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids.
The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy.
The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer.
Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”