Key Points

Introduction

The original application of the current robotic platform was in cardiac surgery. The robot offered increased surgeon dexterity in a small field with the added advantage of a minimally invasive approach. The creation of the robotic surgery system drastically changed the surgical management in different specialties since 2001 when the first robotic prostatectomy was performed in Germany. Many specialties were impacted by robotic technology, including urology, gynecology, and head and neck surgery. Over time, clinical data from these series matured enough to demonstrate safety, efficiency, reproducibility, and oncologic and functional outcomes comparable with its open and laparoscopic counterparts. This awareness has brought the robot to its current and most widely used application, the robotic prostatectomy. During the adoption phase of robotics into urology, minimally invasive surgical techniques were being studied in colorectal cancer surgery.

The results of the Clinical Outcomes of Surgical Therapy (COST) trial in 2004 concluded that laparoscopic approaches to colon cancer could be performed without the compromise of oncologic or quality-of-life outcomes. Worldwide, more than 1 million people develop colorectal cancer annually (with approximately 608 000 deaths), accounting for 8% of all cancer deaths, making it the fourth cause of death from all cancers. Minimally invasive approaches are rapidly gaining acceptance among colorectal and general surgeons. Recent data have shown that between 10% and 30% of colon surgeries are currently being performed using laparoscopic techniques in the United States. Barriers to the widespread adoption of laparoscopy include education and training, steep learning curve, personal experience, access to trained assistants, financial reimbursement, length of surgery, and patient availability. Surprisingly, despite these challenges, robotic approaches for the management of colon cancer are slowly gaining momentum, which brings the discussion to the topic of this article: the application of robotics to colon cancer surgery. To date, the most significant application of robotics in colorectal surgery is for rectal cancer surgery; however, increasingly surgeons are applying this technology to intra-abdominal procedures, such as colectomy. In this article, the authors review the advantages and disadvantages of robotic-assisted colectomy and the techniques, early outcomes, and future directions.

Introduction

The original application of the current robotic platform was in cardiac surgery. The robot offered increased surgeon dexterity in a small field with the added advantage of a minimally invasive approach. The creation of the robotic surgery system drastically changed the surgical management in different specialties since 2001 when the first robotic prostatectomy was performed in Germany. Many specialties were impacted by robotic technology, including urology, gynecology, and head and neck surgery. Over time, clinical data from these series matured enough to demonstrate safety, efficiency, reproducibility, and oncologic and functional outcomes comparable with its open and laparoscopic counterparts. This awareness has brought the robot to its current and most widely used application, the robotic prostatectomy. During the adoption phase of robotics into urology, minimally invasive surgical techniques were being studied in colorectal cancer surgery.

The results of the Clinical Outcomes of Surgical Therapy (COST) trial in 2004 concluded that laparoscopic approaches to colon cancer could be performed without the compromise of oncologic or quality-of-life outcomes. Worldwide, more than 1 million people develop colorectal cancer annually (with approximately 608 000 deaths), accounting for 8% of all cancer deaths, making it the fourth cause of death from all cancers. Minimally invasive approaches are rapidly gaining acceptance among colorectal and general surgeons. Recent data have shown that between 10% and 30% of colon surgeries are currently being performed using laparoscopic techniques in the United States. Barriers to the widespread adoption of laparoscopy include education and training, steep learning curve, personal experience, access to trained assistants, financial reimbursement, length of surgery, and patient availability. Surprisingly, despite these challenges, robotic approaches for the management of colon cancer are slowly gaining momentum, which brings the discussion to the topic of this article: the application of robotics to colon cancer surgery. To date, the most significant application of robotics in colorectal surgery is for rectal cancer surgery; however, increasingly surgeons are applying this technology to intra-abdominal procedures, such as colectomy. In this article, the authors review the advantages and disadvantages of robotic-assisted colectomy and the techniques, early outcomes, and future directions.

Current indications

Robotic surgery was introduced to colorectal surgery to overcome the challenges of a minimally invasive dissection in the narrow deep pelvis. Surgeons were curious to see if the system could overcome the pitfalls of laparoscopic surgery with better oncologic and functional outcomes. In the past 5 years, there have been increasing numbers of early outcome studies published on robotic-assisted rectal cancer surgery demonstrating feasibility and safety and without deterioration in oncologic and functional outcomes. Although most of the studies of robotic-assisted colorectal surgery report on early experience and lack the power of larger series, there are 2 multicenter, prospective, cooperative clinical trials underway to compare robotic assisted rectal cancer surgery with laparoscopic (robotic versus laparoscopic resection for rectal cancer [ROLLAR]) and open techniques (American College of Surgeons Oncology Group 6051). These studies have stimulated increased interest in robotic colorectal surgery, which has lead to interest in applying these very same techniques to colectomy.

Advantages of robotic surgery

The reported advantages of robotic surgery include all the advantages of minimally invasive surgery plus the following:

• •
  

  Three-dimensional (3D) HD vision: This vision is better than 2-dimensional high definition (HD), giving the surgeons the depth perception without the learning curve of adapting to it, as is the case with laparoscopy.

  
  
• •
  

  Visual magnification: The robot is capable of magnifying images 10 to 15 times normal, which is more than what is seen with standard laparoscopy and much more than the naked eye. This magnification allows the surgeon to be more selective about the dissection of critical structures by fractions of a millimeter.

  
  
• •
  

  Motion scaling: In standard laparoscopy, the distance of the tissue structure from the port site on the abdomen causes amplification of motion at the instrument tip. A small motion outside the body causes a relatively large motion on the inside. This motion can frustrate attempts to target tissues. With the surgical robot, motions are filtered and deamplified up to a scale of 5 to 1. In other words, the surgeon would have to move the manipulators up to 5 in to cause movement of only an inch on the inside of the body. This motion scaling eliminates natural hand tremor entirely, allows the surgeon to target tissues with much greater ease, and gives the surgeon a certain finesse that surpasses human capabilities in both the open and standard laparoscopic realms.

  
  
• •
  

  Ergonomics: In standard laparoscopy, the surgeon must stand, sometimes in rather awkward positions, for several hours. This position can cause fatigue and long-term disability. With the surgical robot, however, the surgeon is seated comfortably at a console. The hands are positioned in a natural forward position, and the forearms are given a rest to lean on. This configuration relieves much stress on the operating surgeon and that often translates to a better quality surgery for patients.

  
  
• •
  

  Endowrist technology (Intuitive Surgical, Inc, Sunnyvale, CA): Standard laparoscopy uses fixed instrument tips. The surgical robot, however, has instrument tips that rotate and angulate in multiple different directions. This ability allows for imitation of normal wrist and elbow motions. This technology is capable of spinning 2 full revolutions, whereas the human hand can only turn about 270°.

  
  
• •
  

  Telementoring and telesurgery: The future of surgery is to teach and operate from the distance, which will allow us to perform surgery at remote areas of the world where minimally invasive surgery is not available.

The combination of these various elements gives the surgeon a sense of total control over the operation. Together, these reported advantages can translate into the following clinical advantages: facilitating sphincter preservation in low rectal tumors, ease of intracorporeal suturing, adoption of natural orifice surgery, and the use of alternate extraction sites that may decrease the rate of abdominal wall hernias and decrease pain in the patients.

Disadvantages of robotic surgery

Despite the multiple advantages of robotic surgery, few can deny that there are educational, fiscal, and access barriers that exist to the adoption of this technology.

• •
  

  Time: Most robotic series report longer operative times when compared with multiport laparoscopy. Although this variable can be altered with the surgeon’s expertise, the most experienced surgeons are equally as efficient on both techniques. In a longer surgery, patient are under anesthesia for longer and it costs more to staff the procedure.

  
  
• •
  

  Cost: At this early stage in the technology, robotic systems are very expensive. Several early outcome studies have demonstrated increased costs with robotics when compared with open and laparoscopic techniques. Improvements in technology and more competition in the market will likely reduce costs in the future. However, current modifications, service contracts, and technological advances have driven costs up, not down, and created an ever-increasing fiscal burden on hospitals and academic institutions. Another issue with costs is the problem with upgrading the systems as they improve. Only when these systems gain more widespread multidisciplinary use, will the costs become more justified. Currently, there are no specific reimbursements for robotic-assisted colorectal procedures.

  
  
• •
  

  Difficulty approaching multi-quadrant procedures: The arms of the robot come from a center column and have a certain degree of motion related to where this column is placed. Most of the time, the column is placed in line with the area of disease or target organ. In colorectal cases involving patients with a larger body mass index, there is the need for double-docking techniques to be able to avoid collisions of the robotic arms, specifically in low anterior resection when mobilization of the splenic flexure is needed.

  
  
• •
  

  Loss of tactile or haptic sensation: This problem was one of the criticisms of laparoscopic surgery; however, this problem is further accentuated with robotics. Surgeons with experience are able to compensate by using “visual haptics” which refers to the ability to adjust tissue pressure based on visual cues.

  
  
• •
  

  Learning curve: There is a learning curve associated with robotic technology. Frustrations with equipment setup and port placement can be alleviated with experienced bedside assistants. Previous investigators have reported that surgeons skilled in laparoscopic colorectal surgery progress through 3 phases when applying robotic techniques. Using cumulative sum (CUSUM) analysis, the investigators noted that the initial phase consisted of 15 cases whereby the initial learning curve took place. Phase 2 represented a plateau phase whereby surgeons were primarily becoming more accustomed to the robotic console and gaining competence. Finally, phase 3 represented the mastery phase after 25 total cases and consisted of the adequate skills needed to perform routine cases skillfully and embark on more challenging cases.

When reviewing the disadvantages of robotic surgery, it is clear that the major obstacle to widespread use is the longer operative times (learning curve) and increased costs. It is important, however, to recognize that, for both the learning curve and the operative duration, having consistent robotic teams familiar with the robot, its setup, potential malfunctions, and operative approaches can have a significant impact on reducing the operative time and reducing surgeon frustration. This familiarity can impact patient outcomes and total costs. Advocates of robotic surgery argue that the cost of the system can be balanced when examining cost savings and the return on investment more broadly; high-volume robotic centers offset costs by increasing use, reducing the length of stay, and having less morbidity and early return to work/quality of life. This situation seems to be the case in robotic-assisted prostatectomy when compared with open prostatectomy; however, these reported cost savings have not been demonstrated in colorectal surgery to date.