Robotic Rectal Surgery
Recently I had my first patient come in requesting robotic surgery. The patient had a rectosigmoid cancer and was a candidate for surgery as their initial treatment modality. I discussed with the patient that for a cancer in the rectosigmoid, there was the possibility that I could perform his procedure laparoscopically with fewer incisions, and likely more quickly than if it was done robotically. Nonetheless, he was adamant (for no particularly good reasons), and thus I concluded that for this patient requiring a low anterior resection, robotic resection was a reasonable operative approach.
I have adopted utilizing the robotic technique as another option in my armamentarium to offer patients; however, up until now, I have not had a patient specifically ask for the procedure directly. As a surgical oncologist who performs a large volume of colorectal surgery, I feel there are benefits to robotic resection in select situations. I do not feel there is a role for this technique for standard colon resections, as both right and left colectomies can be performed using standard laparoscopic or single-incision laparoscopic techniques with fewer incisions, less cost, and shorter operative times.
Unlike urologists and gynecologists, general surgeons have been slower to adopt newer technologies. Nonetheless, the robot is creeping into the general surgeon's operating room. Unlike standard laparoscopic surgery, where the surgeon is controlling the instruments with their own hands, with robotic surgery, the surgeon sits at a console with their hands controlling the three robotic arms and one laparoscopic camera. The robot instruments definitely provide increased dexterity, with increased degree of motion and articulation over standard laparoscopic instruments. The technique is ideal in fixed anatomic spaces like the pelvis for low anterior resections, abdominoperineal resections, and the upper abdomen. The improved visualization, with high definition, magnification, and improved depth of perception, is ideal in the pelvis, and I currently feel the dissection is improved over standard laparoscopy and open procedures. (Most importantly, my 5- and 7-year-old sons think it is “cool” that I use a robot at work, although they were sad that it did not talk, have a face, or a laser, although this may be in the works.)
This being said, there are, of course, limitations. With familiar operating-room staff, there is limited time wasted on positioning the robot. But it does take increased time if the surgeon needs to “redock” the robot or reposition the patient to operate in different regions of the abdomen. The cost of the entire system and proprietary instrumentation is also something I struggle with, and have limited its use to select procedures where I feel there is a true benefit. With the increasing cost of healthcare, it is still to be determined where robotic surgery will ultimately end up.
In terms of outcomes related to robotic colorectal surgery, there have been no large randomized trials to date. Currently, published research is either retrospective or prospective single-institution studies. ACOSOG Z6051, which is almost finishing accrual, will help to answer the oncologic equivalency of minimally invasive surgery (laparoscopic and robotic) for rectal cancer compared to open proctectomy. Subjectively, from my experience, I feel that the robot makes the operation easier — with the ability to better visualize the mesorectal plane, hypogastric nerves, dissect all the way down the levator muscles, and perform a total mesorectal excision. I suspect that, similar to the robotic prostatectomy, the robot will continue to clamber into general abdominal surgery, and with the promotion of the media, it will be much more common practice for patients to request these procedures in upcoming years.