While laparoscopic colorectal surgery has become a mainstay in treating benign and malignant colorectal disease, robotic surgery within this specialty is still in its infancy — or at least its adolescence — in the United States.
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“While there’s increasing experience with robotic colorectal surgery throughout the country, the numbers are fairly limited when it comes to experienced robotic colorectal surgeons — there are still only a couple dozen of us nationally,” says I. Emre Gorgun, MD, a colorectal surgeon in Cleveland Clinic’s Digestive Disease Institute.
Hermann Kessler, MD I. Emre Gorgun, MD
However, a sea change may be ahead: the five colorectal surgeons at Cleveland Clinic who are now using the technique regularly — primarily for lower anterior resections (LAR) for rectal cancer — are finding that the approach addresses some of the inherent limitations found with conventional laparoscopy.
Expanding the surgical armamentarium
With department-wide robotic colorectal surgery experience now surpassing 150 cases, Cleveland Clinic’s surgeons have seen a significant uptick during the past six months as the approach becomes the go-to choice in appropriately selected patients. Those numbers include pure robotic surgeries as well as certain cases in which a hybrid technique of conventional laparoscopy and robotic surgery may be employed.
“The expanding robotics program here reflects a further refinement of our surgical armamentarium,” says Hermann Kessler, MD, PhD, Section Head of Minimally Invasive Surgery in the Department of Colorectal Surgery. Although numerous complex cases referred to Cleveland Clinic may not be amenable to minimally invasive surgery, when they are, robotic surgery is applied “wherever possible,” he says.
Dr. Gorgun, who has performed more than 60 robotic LARs, says: “The oncologic outcomes have been extremely satisfying — we’ve achieved good numbers of harvested lymph nodes, good distal resection margins, more sphincter-preserving operations and short lengths of hospital stay.” He adds: “All of my rectal cases are performed under the robotic approach unless there’s a contraindication for it.”
Advantages over conventional laparoscopy
Studies have found that using the robotic approach for LAR compared with conventional laparoscopy may result in a lower conversion rate to open surgery, fewer major complications, shorter hospital stays, a quicker return to normal diet, and quicker return of urinary and sexual function.
While conventional laparoscopic surgery has significantly improved colorectal surgery outcomes over the years, Dr. Kessler says the robotic approach offers advantages that take minimally invasive colorectal surgery to a new level, including improved visualization and better dexterity and retraction.
With traditional laparoscopic surgery, the surgeon only has two-dimensional visualization and is not in control of the camera because an assistant must guide it, instruments are rigid and retraction can sometimes be challenging. “Robotic technology is highly ergonomic, offering high-resolution, three-dimensional visualization and seven degrees of freedom with surgical instruments,” he says. “By using these freely articulating instruments and having direct control of the camera in a console away from the patient, we gain a much more liberal application of surgical instruments around all areas of the pelvis.”
The 3-D flexibility also facilitates intracorporeal suturing. In addition, robotic technology allows surgeons to better identify, visualize and preserve pelvic nerves that can affect sexual nerves and bladder function.
The third arm of the robot allows for easy retraction of the small bowel, uterus and intra-abdominal organs, and better exposure and counter-traction in the pelvis, particularly in obese patients.
“The robotic approach also allows us to go lower down to the pelvic floor and push the sphincter-preserving limits, especially in obese patients with difficult body habitus or in the narrow male pelvis,” Dr. Gorgun says. He is currently heading an IRB-approved, case-matched study comparing outcomes in obese patients who undergo conventional laparoscopic colorectal surgery vs. robotic surgery.
That’s not to say that robotic colorectal surgery is without disadvantages. “It’s more expensive and OR times are longer than regular laparoscopy,” Dr. Kessler says. “However, when looking at the long-term oncologic outcomes, the higher cost may be balanced by better outcomes.”
What the future holds
Sometime soon, Cleveland Clinic surgeons will be receiving a new generation robot that was introduced at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting in April. The new model will have an additional arm for surgical retraction, for a total of five arms — two for performing surgery, two for retraction and one that holds the camera.
“The additional retraction device will make new access techniques possible and we may be able to do more procedures robotically than in the past,” Dr. Kessler says. “It may decrease the number of hybrid procedures and could reduce OR time.”
Looking forward, colorectal surgeons at Cleveland Clinic are considering new fields of indication for applying robotic surgery, such as cancer of the right colon or inflammatory bowel disease. “We believe there is a broad spectrum of diseases that can benefit from this approach,” Dr. Kessler says.
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