Slawomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA advances in surgical treatment of colon and rectal cancers
Robots • Are here to stay • One oftheavailable toolsin our armamentarium • Powerful tool • Massive potential
Laparoscopic TME • Technically challenging • Tumor location • Anatomic structures • Difficult retraction • Unstable camera • Poor ergonomics for surgeon UK MRC CLASICC
Advanced lesion Obese, low (male) APR LAPAROSCOPY OPEN
Major Robotic Advantages 1 2 3 Quality Of Dissection Minimally Invasive Comfort For Surgeon
Laparoscopic n=57 Robotic n=56 Mesorectal Grade Complete 43 Nearly complete 12 Incomplete 2 Mesorectal grade Complete 52 Nearly complete 4 Incomplete 0 Robotic vs. Lap Rectal Dissection Quality Of Dissection p=0.033 Baik SH. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of prospective comparative study. Ann SurgOncol. 2009
Quality Of Dissection Randomized Studies To Compare Laparoscopic vs. Robotic Resection • Pigazzi, Baek O.7 % CRM 143 pts • Kim 1.6 % CRM 59 pts • Prasad, Marecik 1 % CRM 82 pts • ROLLAR • ACOSOG • Can we reduce preoperative radiation? • Improved urogenital function?
Minimally Invasive Aspect A HybridApproach Is The Most Practical Solution At This Time • The robot is more useful in certain areas • Laparoscopy is more useful in other areas
Comfort For The Surgeon • Laparoscopic TME challenging • Difficulties with advanced disease • An increase in obese patient population
Obesity Trends* Among U.S. AdultsBRFSS,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% 25%–29% ≥30%
Robotic LAR • randomized data is lacking • ACOSOG, ROLARR pending • difficulties in adoption of Korean experience • BMI • height • splenic flexure mobilization • radiation
Comparison Robotic vs. Open TME 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 MRC CLASSIC trial conversion rate – 34% (2005)
APR (abdomino-perineal resections) cylindrical intraabdominallevator transection RILT Robotic CylindricalAbdominoperineal Resection with Intraabdominal LevatorTransection Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L Dis Colon Rectum, Oct 2011
Distal pursestring 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.
Robotic LAR ???
Conclusion • 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
Conclusion • Robotic assistance has potential to improve outcomes in obese patients and in patients with advanced disease