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La TME robotica
a. coratti – m. di marino
UO Chirurgia Generale, Grosseto
Laparoscopic surgery
ADVANTAGES
DRAWBACKS
• Pain control
• Unnatural movements
• Blood losses negligible
• Poor ergonomics for the surgeon
• Immunitary system
• Reduced degrees of freedom
• Shorter ileus
• Abdominal wall
• Dissociated visual-mechanical
control
• Morbidity
• Bidimensional vision
• Post-op stay
• Limited sutures
Robotic surgery
Robotic surgery
The new system “da Vinci SI HD”
OVERCOMES LAPAROSCOPIC PITFALLS
 3D / HD vision
 Fine dissection
 Deep, small operating fields
 High precision suturing
 Easier setup
 Tutoring
Robotic surgery
ENDO-WRIST ™ SYSTEM
6 degrees of freedom


Tremor elimination

Motion scaling
Robotic surgery in Grosseto
October 2000 – September 2012
Total series
General Surgery
First period
2000 – 2007
732
General Surgery
Second period
2007 – 2012
393
Urology/gynecologist -
2007 – 2012
298
TOTAL
2000 – 2012 1423
Robotic rectal resection
Reported series
Author
Year Refer.
Pts.
Op. time
Conversion Morbidity
Mortality
(min)
D’Annibale*
2004
Dis Colon
Rectum
53
240
9.4%
15%
0
Hellan
2007
Ann Surg
Oncol
39
285
2.6%
12.1%
0
Baik
2008
Surg
Endosc
9
220.8
0
0
0
Spinoglio*
2008
Dis Colon
Rectum
50
338.8
4%
14%
0
Choi
2009
Surg
Endosc
13
260.8
0
23%
0
Luca*
2009
Ann Surg
Oncol
55
290
0
12.7%
0
* Including colonic resections
Robotic rectal resection
No randomized prospective study – 66 pts
Casciola (JSLS 2009)
Short- and medium-term outcome of robot-assisted and traditional
laparoscopic rectal resection.
Robotic rectal resection
Casciola (JSLS 2009)
Intraoperative and pathologic data
Robotic rectal resection
Casciola (JSLS 2009)
Early and long-term outcomes
Robotic rectal resection
Casciola (JSLS 2009)
Oncological results
(NS)
Local recurrence
ROB: 0
LAP: 5.4%
(NS)
Conclusions
Robot-assisted rectal surgery is a safe and
feasible procedure that facilitates
laparoscopic total mesorectal excision.
Robotic rectal resection
Retrospective multicentric study – 143 pts
Pigazzi et Al (Ann Surg Oncol 2010)
Multicentric Study on Robotic Tumor-Specific Mesorectal Excision
for the Treatment of Rectal Cancer.
Procedure
112 RAR, 31APR
Conversion (%)
4.9%
Mean blood loss
283ml
Mean op time
297min
N. harvested nodes
14.1 (± 6.5)
Distal margin
2.9cm (± 1.8)
Negative radial margin
142/143 (99.3%)
Robot-assisted rectal
surgery is a safe and
feasible procedure that
may facilitate mesorectal
3Y survival
97%
excision.
Local recurrence
0 (mean follow-up 17.4 months)
Conclusions
Experience in Grosseto
Perioperative results: 58 pts. (2001-2012)
Procedures
LAR
APR
44
14
Hybrid technique
Full robotic
33
25
Preop CHT/RT
46/58 (79,3%)
Open conversions
1/58 (1.7%)
Operative time
288min (range: 120-420)
Blood loss
Negligible
Ileostomy (LAR)
41/44(93.3%)
Morbidity
9/58 (15,5%)
Redo surgery
5/58 (8,6%)
Mortality
0
Mean hospital stay
7.9 days (range: 4-40)
Pathology
Rectal carcinoma
Large rectal adenoma
Anal carcinoma
Anal melanoma
51
3
2
2
NO intraoperative blood transfusions
Anastomotic leakage 2, pelvic abscess 1, bowel
occlusion 1, postoperative bleeding 1 (VLS redo)
Experience in Grosseto
Oncological outcomes - Rectal carcinoma
TNM of rectal
carcinomas
(51 cases)
yT0N0
Stage I
Stage II
Stage III
Stage IV
5
25
10
10
1
Retrieved
lymph nodes
11.3 (range: 5-30)
Resection margins
R0 in all cases
Mean follow-up
44.2 months (range: <1-118)
Recurrence
Local: 0
Port site: 0
Distant MTS: 6/51 (11,7%)
Related cancer
mortality
3,9% (2/51)
Liver 2, peritoneum 3, inguinal nodes 1
Experience in Grosseto
Long term survival (DFS, OS) - Rectal carcinoma
3-Years overall survival (OS)
3-Years disease free survival (DFS)
Experience in Grosseto
Functional outcomes: 58 pts. (2001-2012)
Urinary dysfunction
1.7% (1/58)
Sexual dysfunction
Males: 6.9% (2/29)
Total: 5,1% (3/58)
Faecal incontinence
5.8% (2/34; 8 pts. are waiting for closure of ileostomy)
(LAR)
Soiling
(LAR)
8.8% (3/34; 8 pts. are waiting for closure of ileostomy)
Rectal robotic surgery
Technical aspects
SURGICAL STRATEGY
Full robotic
technique
Hybrid (lap/rob)
technique
Surgical steps
Patient positioning
Robotic cart
Ports
■ ROBOTIC
■ LAPAROSCOPY
■ ROBOTIC
Docking 1
. Paziente supino
. Posizione ginecologica
. Arti super. Addotti
. Anti-trendelenburg 30 °
. Ruotato sul fianco destro
di 15 °
. Carello robotico dalla
spalla sinistra
Docking 2
. Paziente supino
. Posizione ginecologica
. Arti super. Addotti
. Trendelenburg 25 °
. Ruotato sul fianco destro
di 15 °
. Carello robotico dalla
gamba sinistra
Posizionamento dei trocars
I step
ottica
II step
ottica
R1
R2
R2
Ass
R3
R3
Ass
Ass
Ass
R1
minilaparomia
Posizionamento dei trocars
I step
ottica
II step
ottica
R1
R2
R2
Ass
R3
R3
Ass
Ass
Ass
R1
Minilaparotomia
Personal experience
Very difficult at the beginning
 Ports positioning
 Cart docking
 Pelvic exposure
 Time consuming
 Laparoscopy it’s better?
Personal experience
Very difficult at the beginning
Intermediate experience
 Switch from hybrid to full robotic
 Changing in port and cart setup
Personal experience
Very difficult at the beginning
Intermediate experience
Advanced experience
 Full robotic technique
 Starting by pelvic dissection
 Ultralow intersphyncteric dissection
 No return to laparoscopy!
Robot-assisted LAR - I step
video
Robot-assisted LAR – II step
video
Rectal robotic surgery
Technical aspects
ADVANTAGES
 3D/HD vision - Endowrist
 TME
 Nerves sparing
 Intersphynteric dissection
 Pelvic dissection (deep, narrow)
 Obese patients
 Reduction of conversions (?)
Rectal robotic surgery
Technical aspects
DRAWBACKS
 Large operating field
 Change of cart/patients positioning
 Bowel retraction
 Expert assistant surgeon
 High cost procedure
Conclusions

Robot-assisted rectal resection are feasible and safe.

The robotic technique may improve TME, nerves sparing and
intersphynteric dissection in ultralow rectal resection.

Major advantages can be appreciated in males, in narrow and deep
pelvis, and in obese patients.

The long-term functional and oncological results are very interesting.

We are waiting the ROLARR trial.
Scuola ACOI di Chirurgia Robotica
www.roboticschool.it
COURSES 2012
BASIC
May, 21-25
1st ADVANCED
(Upper GI, HPB, Endocrine)
June, 25-29
2nd ADVANCED
(Colorectal, HPB, Endocrine)
November, 26-30