Laparoscopic or Robotic Rectal Cancer Surgery: Where are We Right Now?/Laparoskopik ya da Robotik Rektal Kanser Cerrahisi: Su Anda Hangi Noktadayiz?
Following the technologic and methodologic advances, surgical disciplines have witnessed substantial changes in the management of rectal cancer surgery within the last three decades. Introduction of total mesorectal excision and chemoradiation had a considerable impact on survival rates. Performing a complete resection of rectum and mesorectum necessitates a meticulous dissection within the embryologic planes, where rectum is closely located to vital vessels, nerves and adjacent organs. Since its first definition in 1982 by Heald et al., (1) total mesorectal excision has become the mainstay of the treatment in rectal cancer surgery. Implementation of laparoscopy ignited a global curiosity toward minimizing the overall trauma while sustaining the oncologic principles of the rectal cancer surgery. Transition to minimally invasive surgery has provided substantial advantages over conventional laparotomy by decreasing postoperative pain, length of hospital stay and intraoperative blood loss. (2) Nevertheless, complete adoption of novel techniques has always been a challenging progress, since most of the surgeons experience certain drawbacks due to technical difficulties. First reports pointed to various merits of laparoscopic surgery, and it has gained broader popularity after the comparison of open versus laparoscopic surgery for mid or low Rectal cancer After Neoadjuvant (COREAN) chemoradiotherapy and Colon carcinoma Laparoscopic or Open Resection (COLOR II) randomized controlled trials, in which authors compared open and laparoscopic rectal cancer surgery. (3,4) Initially, Medical Research Council CLASICC trial assessed laparoscopy against open surgery for both colon and rectal etiologies and their result supported the use of laparoscopy since it was as effective as open surgery. (5) The COLOR II trial addressed the same comparison in which they compared 699 laparoscopic cases to 345 open rectal cancer surgeries. They stated that laparoscopic surgery had less blood loss during the surgery (median 200 vs. 400 mL), earlier recovery of bowel function (2 days vs. 3 days), and shorter hospital stay (8 days vs. 9 days) whereas operation time was longer in the laparoscopic group (240 minutes vs. 180 minutes). Similarly, the COREAN trial included 340 patients dispersed in 1:1 fashion to open and laparoscopic arms, and the authors stated that three-year survival rates did not differ between both groups. These two studies granted a more extensive appliance for the laparoscopic technique in selected patients with rectal cancer. On the other hand, more recent Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) and American College of Surgeons Oncology Group (ACOSOG) Z6051 trials failed to reproduce similar results and failed to show noninferiority of the laparoscopic technique against laparotomy. (6,7) The ALaCaRT study randomized 238 laparoscopic cases and 235 open cases to evaluate whether the laparoscopic approach is sound in oncological basis and they concluded that even though laparoscopic surgery offers an increased quality of surgery, its role in the rectal cancer surgery still cannot be standardized. In conclusion, there seems to be skepticism about the laparoscopic surgery and its long-term oncologic outcomes in rectal cancer as both ACOSOG and ALaCaRT studies present early pathologic results, but increased quality of life after surgery remains as a huge attraction. All of these limitations have led to further discoveries to enhance the minimally invasive surgery, especially the instrumentation-related restrictions. At this standpoint, robotic surgery has emerged as an alternative for the laparoscopy, by providing three-dimensional and high definition vision, increased articulation by endo-wristed equipment, enhanced surgeon comfort and stable retraction. Adorned with an increased range of motion and wrist-like movements, robotic surgery is thought to be superior to laparoscopy especially in male and obese patients, where surgical exposition of the deep pelvis is more strenuous in these patients. (8) Robotic surgery can overcome the difficulties of the inline, rigid instruments of the laparoscopy to perform total mesorectal excision, and has potential to confer advantages in terms of oncological safety. Early studies indicated fewer complications, earlier recoveries, lower visual analog scale scores and most significantly fewer conversions to open surgery compared to laparoscopy. (9,10,11,12,13,14) Kang et al. (15) analyzed the outcomes of the robotic, laparoscopic and open surgery in a propensity score case-matched patient population for rectal cancer, and concluded that the robotic surgery is associated with earlier soft diet resumption, lower visual analog scale scores and shorter length of stay than laparoscopic surgery, as well as less voiding problems and circumferential resection margin involvement. Furthermore, Memon et al. (16) compared robotic surgery and laparoscopic surgery in their meta-analysis, and stated that conversion rate was significantly lower in robotic group. Eventually, robotic surgery was correlated with lower conversion rates to open in these nonrandomized studies, as one might expect, since dissection in the deep pelvis was more comfortable than that of laparoscopy with endo-wristed equipment. Besides its virtues, concerns have been raised about robotic surgery due to worse financial outcomes and longer operative times than laparoscopy. (17) There is a vast preponderance of reports in the literature indicating the cost of robotic surgery is higher than other methods in the rectal cancer surgery, which makes a technique inevitably "financially vain" since money is a variable that attains great importance. The prolonged operative time, thought to be one of the contributors of the higher costs, is also a drawback for the surgeons, although robotic surgery offers better ergonomics. Therefore robotic surgery contains some essential problems, and these problems are yet to be addressed. Most concrete evidence in robotic surgery has appeared in late 2017, an eagerly awaited study Robotic versus Laparoscopic Resection for Rectal Cancer (ROLARR) randomized trial assessed the implementation of da Vinci robotic platform (Intuitive Inc. Sunnyvale, CA). Two hundred and thirty-seven robotic-assisted cases were compared with 234 laparoscopic counterparts. (18) They reported no difference concerning conversion to open, circumferential resection margin positivity, intraoperative complications, postoperative complications and quality of life parameters (bladder dysfunction, sexual dysfunction). In conjunction with longer operative time, as expected, economic outcomes of the robotic surgery were significantly worse than laparoscopy, by adding an average of 1132$ per patient. (18) Nevertheless, the ROLARR trial still implies that robotic surgery can be beneficial in male patients. Furthermore, minimally invasive surgery was tailored to give rise to single-incision surgery and natural orifice transanal endolumenal surgery, where the invasiveness is even more minimized. Decreasing the port numbers and using natural orifices as introduction sites subsequently increased the cosmetic outcomes, but brought technical challenges due to crowding especially with the inline, rigid instruments of the laparoscopy. With combination of these two techniques, a new "bottom-to-up" transanal total mesorectal excision technique has been proposed to aim low lying rectal lesions, where transabdominal approaches fail to provide an optimal exposure. (19) Features of the robotics are magnified in this transanal technique, since the breadth is narrower than the abdomen and high maneuverability is extremely warranted. (20,21,22) Even though the transanal total mesorectal excision is itself a new entity, robotics carry potential to create a new facet for this technique after careful vetting. In conclusion, robotic technology brings ample opportunities to develop and modify the surgical experience, but further investigations are warranted to reveal its possible advantages. For now, the touted features of the robotic surgery are not enough to justify the global use of robotics in light of its financial burden. Future of the robotic surgery depends on the competition in the market, which would decrease the per capita costs and provide better economic results. As technology advances to produce novel robotic systems and as new generation surgeons utilize these robots more efficiently, we may rationalize the implementation of robotic platforms in the colorectal surgery settings.
Peer-review: Internally peer-reviewed.
Surgical and Medical Practices: E.G., Concept: T.B.C., E.G., Design: T.B.C., E.G., Data Collection or Processing: T.B.C., E.G., Analysis or Interpretation: T.B.C., E.G., Literature Search: T.B.C., E.G., Writing: T.B.C., E.G.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
(1.) Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence? Br J Surg 1982;69:613-616.
(2.) Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM; MRC CLASICC trial group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718-1726.
(3.) Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014;15:767-774.
(4.) van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ; COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 2013;14:210-218.
(5.) Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM; MRC CLASICC trial group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718-1726.
(6.) Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Davies L, Wilson K, Hague W, Simes J; ALaCaRT Investigators. Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer. JAMA 2015;314:1356-1363.
(7.) Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, Peters WR Jr, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren SM, Pisters PW, Nelson H. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes. JAMA 2015;314:1346-1355.
(8.) Gorgun E, Ozben V, Costedio M, Stocchi L, Kalady M, Remzi F. Robotic versus conventional laparoscopic rectal cancer surgery in obese patients. Colorectal Dis 2016;18:1063-1071.
(9.) Barnajian M, Pettet D, Kazi E, Foppa C, Bergamaschi R. Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases. Colorectal Dis 2014;16:603-609.
(10.) Cho MS, Baek SJ, Hur H, Min BS, Baik SH, Lee KY, Kim NK. Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study. Medicine (Baltimore) 2015;94:e522.
(11.) Kim JC, Yu CS, Lim SB, Park IJ, Kim CW, Yoon YS. Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients. Int J Colorectal Dis 2016;31:1179-1187.
(12.) Allemann P, Duvoisin C, Di Mare L, Hubner M, Demartines N, Hahnloser D. Robotic-Assisted Surgery Improves the Quality of Total Mesorectal Excision for Rectal Cancer Compared to Laparoscopy: Results of a Case-Controlled Analysis. World J Surg 2016;40:1010-1016.
(13.) Feroci F, Vannucchi A, Bianchi PP, Cantafio S, Garzi A, Formisano G, Scatizzi M. Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery. World J Gastroenterol 2016;22:3602-3610.
(14.) Ramji KM, Cleghorn MC, Josse JM, MacNeill A, O'Brien C, Urbach D, Quereshy FA. Comparison of clinical and economic outcomes between robotic, laparoscopic, and open rectal cancer surgery: early experience at a tertiary care center. Surg Endosc 2016;30:1337-1343.
(15.) Kang J, Yoon KJ, Min BS, Hur H, Baik SH, Kim NK, Lee KY. The impact of robotic surgery for mid and low rectal cancer: A case-matched analysis of a 3-arm comparison - Open, laparoscopic, and robotic surgery. Ann Surg 2013;257:95-101.
(16.) Memon S, Heriot AG, Murphy DG, Bressel M, Lynch AC. Robotic versus Laparoscopic Proctectomy for Rectal Cancer: A Meta-analysis. Ann Surg Oncol 2012;19:2095-2101.
(17.) Silva-Velazco J, Dietz DW, Stocchi L, Costedio M, Gorgun E, Kalady MF, Kessler H, Lavery IC, Remzi FH. Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy. Ann Surg 2017;265:960-968.
(18.) Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J. Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer. JAMA 2017;318:1569-1580.
(19.) Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 2010;24:1205-1210.
(20.) Atallah SB, Albert MR, deBeche-Adams TH, Larach SW. Robotic transanal minimally invasive surgery in a cadaveric model. Tech Coloproctol 2011;15:461-464.
(21.) Hompes R, Rauh SM, Ris F, Tuynman JB, Mortensen NJ. Robotic transanal minimally invasive surgery for local excision of rectal neoplasms. Br J Surg 2014;101:578-581.
(22.) Atallah S, Nassif G, Polavarapu H, deBeche-Adams T, Ouyang J, Albert M, Larach S. Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration. Tech Coloproctol 2013;17:441-447.
Turgut Bora Cengiz, Emre Gorgun
Cleveland Clinic, Department of Colorectal Surgery, Cleveland, USA
Address for Correspondence/Yazisma Adresi: Emre Gorgun MD
Cleveland Clinic, Department of Colorectal Surgery, Cleveland, USA
Phone: +90 216 444 12 44 E-mail: email@example.com ORCID ID: orcid.org/0000-0001-7725-3522
Received/Gelis Tarihi: 28.05.2018 Accepted/Kabul Tarihi: 29.05.2018
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|Author:||Cengiz, Turgut Bora; Gorgun, Emre|
|Publication:||Turkish Journal of Colorectal Disease|
|Date:||Sep 1, 2018|
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