The advantages of robotic low anterior resection

Report
Slawomir Marecik, MD, FACS
Advocate Lutheran General Hospital, Park Ridge, IL
Clinical Assistant Professor
University of Illinois, Chicago, USA
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Are here to stay
One of the available tools in our armamentarium
Powerful tool
Massive potential
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Technically challenging
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Tumor location
Anatomic structures
Difficult retraction
Unstable camera
Poor ergonomics for surgeon
UK MRC CLASICC
Advanced lesion
Obese, low (male)
APR
1
Quality Of Dissection
2
Minimally Invasive
3
Comfort For Surgeon
Quality Of Dissection
Quality Of Dissection
Robotic n=56
Laparoscopic n=57
Mesorectal grade
Complete
Mesorectal Grade
52
p=0.033
Complete
43
12
Nearly complete
4
Nearly complete
Incomplete
0
Incomplete
Baik SH. Robotic versus laparoscopic low anterior resection of
rectal cancer: short-term outcome of prospective comparative
study.
Ann Surg Oncol. 2009
2
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Pigazzi, Baek
Kim
Prasad, Marecik
ROLLAR
ACOSOG
O.7 % CRM
1.6 % CRM
1 % CRM
143 pts
59 pts
82 pts
Randomized Studies To Compare
Laparoscopic vs. Robotic Resection
Can we reduce preoperative radiation?
Improved urogenital function?
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The robot is more useful in certain areas
Laparoscopy is more useful in other areas
A Hybrid Approach Is The Most
Practical Solution At This Time
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Laparoscopic TME challenging
Difficulties with advanced disease
An increase in obese patient population
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
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randomized data is lacking
 ACOSOG, ROLARR pending
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difficulties in adoption of Korean experience
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BMI
height
splenic flexure mobilization
radiation
DCR 2010
Open/HALS (=46)
Robotic (n= 36)
P value
Mid and low rectal
tumors
47.8%
80.5%
.006
OR time (min)
273.8
337.9
.003
EBL (mL)
273.8
187.5
.036
Postoperative
complications, n (%)
15 (32.6)
11 (30.6)
.84
Length of stay (days)
7.3
7.0
.74
Distal margin
positive, n (%)
0 (0)
1 (2.8)
.44
Radial margin
positive, n (%)
3 (6.5)
0
NS
Lymph nodes
16.8
15
.26
deSouza AL, Prasad LM , Marecik SJ et al.
Comparison of Open and Robotic Total Mesorectal Excision for Rectal
Adenocarcinoma;
Dis Colon Rectum, 2011
Robotic TME
Laparoscopy for rectal cancer – conversion rates
Author
No. of Pts
Conversion
rate
Mean BMI
Laparoscopic
Mean BMI
Converted
P value
Yamamoto S
Japan (2009)
1073
(Lap)
7.3%
22.7
(13.7-36.7)
24.6
(16.6-34.8)
<0.0001
Agha A
Germany (2008)
300
(Lap)
8.6%
26.2
(16.7-37.5)
29.0
(22.6-43.9)
0.002
Rottoli M
Italy (2009)
173
(Lap)
15%
24.9 ±3.2
27.3±2.9
<0.001
deSouza
2010*
44
(Robotic)
4.5%
28.2
(17.6-43)
41.5
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MRC CLASSIC trial conversion rate – 34% (2005)
Colorectal Dis 2011
APR (abdomino-perineal resections)
cylindrical intraabdominal levator transection
Robotic Cylindrical Abdominoperineal Resection with Intraabdominal LevatorTransection
Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L
Dis Colon Rectum, Oct 2011
Prasad LM, deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in
low anterior resection. Dis Colon Rectum. 2010 Feb;53(2):230-4.
upper rectum
easy, thin patient
Laparoscopic TME
Mini-laparotomy
lower rectum
difficult, obese patient
Robotic
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Robotic assistance in low anterior resection
decreases conversion rates when compared to
laparoscopy
Mesorectal quality grade is higher in robotic
technique, which may translate into better
oncological outcomes
Robotic system allows for a very precise work in
deep pelvis making intersphincteric dissection
easier, distal pursestring application possible and
transanal specimen extraction more common
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Robotic assistance has potential to improve
outcomes in obese patients and in patients with
advanced disease

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