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Dramatic improvements in the local recurrence rate of patients with rectal cancer have been observed after the introduction of the embriologically-based concept of Total Mesorectal Excision by Heald more than 30 years ago. During the last decades, advances in multimodal treatment have further contributed to improve outcomes, but surgery still play...
Context in source publication
Context 1
... layout and arm positioning for vascular control are shown in Figure 4. Transverse mesocolon is pulled up to exligament is sectioned, the posterior peritoneal layer of the lesser sac is incised 1 cm caudal to the inferior border of the pancreas in order to expose the Gerota's fascia. The tranverse mesocolon is separated from the inferior border of the pancreas and the dissection proceeds in order to fully mobilize the splenic flexure and a portion of the descending colon, separating the Gerota's fascia from the Toldt's one or the two layers of the Toldt's fascia ( Figure 3). After having pulled up the greater omentum, the transverse mesocolon is opened from its inferior aspect just above the body of the pancreas to enter the lesser sac. ...
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Background
Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation o...
Purpose Robotic surgery has shown promising outcomes in colorectal cancer treatment but is limited by its high cost. In response, the ArtiSential system, an articulated handheld laparoscopic instrument, has emerged as an alternative. This study aimed to assess the learning curve associated with ArtiSential during low anterior resection (LAR) of col...
Surgical resection with total mesorectal excision (TME) represents a crucial milestone in the treatment of rectal cancer. Conventional open procedures have been gradually replaced by minimally invasive techniques. To date, laparoscopic and robotic resection associated with neoadjuvant chemo-radiotherapy, represent the gold standard for rectal malig...
Introduction
Lateral pelvic node dissection (LPND) poses significant technical challenges. Despite the advent of robotic surgery, determining the optimal minimally invasive approach remains a topic of debate. This study aimed to compare postoperative outcomes between robotic total mesorectal excision with LPND (R-LPND) and laparoscopic total mesore...
Objective:
The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center.
Summary background data:
The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pe...
Citations
... The Toldt-Gerota plane previously developed and the IMV are identified. The transverse colon is lifted up with a R1-grasper and the lesser sac is opened through the incision of the transverse mesocolic root at the level of the anterior pancreatic border, gaining access to the lesser sac (one-inch one-inch bottom-up approach) [30,31] (Figure 5). The assistant keeps holding the transverse colon and the R1 grabs the posterior side of the stomach to achieve optimal exposure. ...
The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.
... Robotic technology is becoming dominant for major oncological procedures. Apart from technical difficulties, increased economic burden and steep learning curve are the 2 most salient drawbacks of the robotic procedures 31,32 . Though the expenses for the procedure are high, overall hospital and health care cost can be less when compared to open and laparoscopic procedures 33,34 . ...
Case:
Two male patients aged 37 years and 39 years, diagnosed with sacral chordoma, underwent robotic-assisted preparatory adhesiolysis from the anterior aspect of the tumor, followed by posterior en-bloc partial sacrectomy. The average total operative time was 360 minutes (anterior docking + anterior console + posterior excision), and mean blood loss was 930 mL. Both patients were mobilized early, had no postoperative complications, and were free of local recurrence at 18 month of follow-up.
Conclusions:
Robotic-assisted surgery is a novel, valid, safe, and minimally invasive technique which drastically reduces the associated surgical complications of single-staged posterior sacrectomy, resulting in excellent functional and oncological outcome.
... Robotic surgery may potentially overcome these pitfalls in lower mesorectal dissection thanks to a stable three-dimensional camera platform, Endowrist™ technology, tremor filtering and motion scaling. Several retrospective case-series and comparative studies have demonstrated the feasibility and safety of robotic low and ultralow anterior resection [24,25], even with intersphincteric resection and coloanal anastomosis. Moreover, preliminary results of the randomized controlled ROLARR (Robotic Versus Laparoscopic Resection for Rectal Cancer) Trial are encouraging: a potential reduction of the conversion rates in low anterior resection, obese and male patients (though not statistically significant) and the high oncological safety and quality of robotic mesorectal excision (with a very low percentage of CRM involvement -5.1% in the robotic group and 6.3% in the laparoscopic group -among a group of surgeons with low experience in robotic TME and a mean number of only 25 procedures performed per each prior to enrollment vs 91.5 performed with the laparoscopic approach) are the main consistent findings. ...
In 1908, Sir Ernest Miles reported his first attempt to develop a radical operation for rectal cancer, publishing his experience with abdominoperineal resection (APR). The introduction of the embriologically based concept of total mesorectal excision (TME) and the increasing use of intersphincteric resection in combination with neoadjuvant chemoradiotherapy have further contributed to improve oncological outcomes and have significantly reduced the need of APR even for low rectal cancers. Nevertheless, APR is still strictly indicated in patients with type IV low rectal cancer (<6 cm from the anal verge), defined as transanal tumors with external anal sphincter or levator ani muscle invasion. Though randomized trials have shown that minimally invasive TME is oncologically as safe as open surgery, it is technically a demanding procedure and has a steep learning curve. Robotic surgery, thanks to its technological advantages, may potentially overcome these limitations especially in lower mesorectal dissection and, potentially, in transabdominal levator ani transection. This might help to reduce CRM positivity and, ultimately, local recurrence rates for ultralow rectal cancer-requiring APR.
Colorectal cancer is the third most common cancer worldwide, and rectal cancer accounts for over one-third of cases. Surgery represents the cornerstone of colorectal cancer treatment. Anterior resection is the most common procedure for radical excision of rectal cancer and involves removal of the sigmoid colon and rectum along with total or partial excision of the mesorectum. Intestinal continuity is reestablished with a colorectal anastomosis, and a temporary diverting stoma is often performed. In selected patients in whom a standard anterior resection would not achieve an adequate distal margin, proctectomy with intersphincteric resection may be performed. This procedure involves partial or complete removal of the internal anal sphincter and coloanal anastomosis through an abdominal and perineal approach. Cancers affecting the external anal sphincter require an abdominoperineal resection, which involves complete excision of the rectum and anus by dissection through the abdomen and perineum, and permanent colostomy. Rectal surgery, especially low in a narrow pelvis, is one of the abdominal surgeries that has benefited most from the use of a robotic approach. This is mainly due to a three-dimensional magnified view, articulated instruments without tremor, and a stable camera platform. In this chapter, procedures using the da Vinci Xi platform are described.
Minimally invasive colorectal surgery offers many advantages to the patient as well as the surgeon. Despite this, its acceptance and use for low anterior resection (LAR) has been quite limited. Since 2010, much has been published regarding the safety and feasibility of robotic-assisted low anterior resection (RobLAR), including comparisons to open low anterior resection (OpenLAR) and laparoscopic-assisted low anterior resection (LapLAR). This chapter will review current data regarding LapLAR and RobLAR and compare outcomes using the two technologies. The surgeon’s learning curve for RobLAR will be discussed and guidance provided to safely and efficiently develop expertise in this procedure. Preoperative planning, operating room logistics, patient positioning, and port placement will be described in detail. Also provided are helpful information regarding instrumentation, intraoperative techniques, alternative approaches, and troubleshooting. Finally, the author’s own experience will be presented, including postoperative complications and oncologic outcomes.
Background
Colorectal cancer is the third most common cancer worldwide. Current treatment approaches are multidisciplinary, including neoadjuvant chemoradiotherapy for rectal cancer. Several studies have reported an improvement in surgical techniques and in new devices facilitating better pre- and intraoperative staging.
Objectives
Since its first application in 2002, robotic surgery has progressed steadily, offering good surgical results and better oncological outcomes. Currently, many studies and reviews have confirmed its safety and feasibility for colorectal cancer.
Materials and methods
Robotic technology simplifies surgical maneuvers thanks to the three-dimensional magnification and stable vision, convenient mobility of the robotic arms, endowrist instruments with seven degrees of freedom, ambidextrous capability, tremor filtering, and indocyanine green fluorescence imaging.
Results
Regarding the oncological outcome, the robotic technique is equivalent to the laparoscopic approach; however, a lower recurrence rate has been achieved with the robotic approach in extended lymphadenectomy as part of complete mesocolic excision for right colonic cancer and total mesorectal excision for low rectal tumors.
Conclusion
Colorectal robotic surgery has progressively improved worldwide. Its advantages are related not only to better oncological outcomes, but also to improvements in terms of detection, accurate diagnosis, and staging.
Background:
Colorectal cancer is the third most common cancer worldwide. Current treatment approaches are multidisciplinary, including neoadjuvant chemoradiotherapy for rectal cancer. Several studies have reported an improvement in surgical techniques and in new devices facilitating better pre- and intraoperative staging.
Objectives:
Since its first application in 2002, robotic surgery has progressed steadily, offering good surgical results and better oncological outcomes. Currently, many studies and reviews have confirmed its safety and feasibility for colorectal cancer.
Material and methods:
Robotic technology simplifies surgical maneuvers thanks to the three-dimensional magnification and stable vision, convenient mobility of the robotic arms, endowrist instruments with seven degrees of freedom, ambidextrous capability, tremor filtering and indocyanine green fluorescence imaging.
Results:
Regarding the oncological outcome, the robotic technique is equivalent to the laparoscopic approach; however, a lower recurrence rate has been achieved with the robotic approach in extended lymphadenectomy as part of complete mesocolic excision for right colonic cancer and total mesorectal excision for low rectal tumors.
Conclusion:
Colorectal robotic surgery has progressively improved worldwide. Its advantages are related not only to better oncological outcomes, but also to improvements in terms of detection, accurate diagnosis and staging.
Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades, thanks to its well-known advantages in short-term outcomes. Nevertheless, the penetrance of minimally invasive colorectal surgery still remains low. Few studies and metanalysis, to date, have analyzed the results of robotic versus laparoscopic colorectal surgery, often with conflicting conclusions. The robotic platform, thanks to its technological features, may potentially overcome the limitation of standard laparoscopy, especially when performing a complete mesocolic excision resection and an intracorporeal anastomosis. Robotic surgery could also shorten the learning curve of young novice surgeons, provided that strict protocols of structured training are applied. This paper is an update on the current available outcomes of robotic vs laparoscopic surgery in right colectomy.
