Managing advanced colorectal cancer with robotic surgery

In colorectal cancer, the traditional method for removing the tumour is open surgery. However, the surgical treatment landscape has evolved over the years and transitioned to embrace the utilization of minimally invasive approaches such as laparoscopic or keyhole surgery and the use of robotics.

Since the first laparoscopic colorectal operation was described in 1991, there has been continuous evolution and significant advancement of this surgical approach, together with its wide adoption as standard practice over the years. [Perm J 2008;12:27-31]

Brief background on robotic surgery

Robotics in surgery was first adopted in the fields of urology and gynaecology. [Sensors (Basel) 2023;23:7104; Ann Acad Med Singap 2023;52:331-332] The first robotic colorectal surgery was performed in 2001. [Yonsei Med J 2008;49:891-896; Curr Oncol Rep 2016;18:5] Robotic colorectal surgery for benign and malignant disease was first reported in 2002. [Dis Colon Rectum 2002;45:1689-1694; Surg Endosc 2002;16:1187-1191]

The procedure involves small incisions similar to those done in laparoscopic surgery. The specialized instruments used in the surgical field are attached to robotic arms controlled by the surgeon seated at the console.

Benefits

With the more precise dissection facilitated by the robotic platform, this approach has provided surgeons with:

·       Three-dimensional and augmented visualization

·       Enhanced manual dexterity, particularly within the constraints of a narrow pelvis

·       Multi-articulated instruments and third-arm retraction

·       Scalable mobility

For the patient, robotic surgery offers numerous benefits, such as:

·       Reduced intraoperative blood loss

·       Reduced wound complications

·       Improved surgical site infection rates

·       Reduced incisional hernia rates

·       Earlier recovery of bowel function

·       Shorter hospital stays

·       Reduced postoperative pain

·       Fewer intra-abdominal adhesions

·       Lower rate of conversion to open surgery

·       Preservation of important neurovascular structures

·       Reduced rates of urogenital and sexual dysfunction

·       Comparable oncological outcomes and overall survival rates

Robotic surgery is also beneficial for male patients or those with obesity, as the platform enables superior visualization on a stable camera platform and precise dissection with enhanced instrument manipulation (with 7 degrees of freedom) within the confines of the narrow pelvis.

Challenges

However, robotic surgery for colorectal cancer does not come without challenges. Some of the difficulties that may be encountered are:

·       Longer operative duration, with the patient in a Trendelenburg position

·       Higher costs in terms of equipment and consumables

Nonetheless, the adoption of robotics in colorectal surgery has become more widely used with expanding indications and procedures, including colectomy, total mesorectal excision, abdominoperineal resection, and rectopexy.

Overcoming the learning curve

In robotic colorectal surgery, the surgeon must first overcome the learning curve and attain the technical proficiency required to operate the robotic system, with adequate experience to deal with potential difficulties and intraoperative complications that may be encountered.

For surgeons transitioning to robotic colorectal surgery, a qualified proctor can provide onsite immediate feedback and support. This enables the surgeon to adapt and refine his technique, including complex manoeuvres and decision-making skills specific to robotic surgery, and accelerate the learning process.

Secondly, advanced low rectal cancers located deep in the narrow pelvis may pose a technical challenge during the resection. For obese patients undergoing robotic surgery, some potential difficulties include reduced field of view due to the presence of increased mesenteric fat and limited operative space. There is also a possible higher risk of bleeding with friable fatty tissue and technical difficulties during dissection. Preoperative planning using up-to-date imaging of the surgical anatomy is crucial for determining the surgical plan and anticipating possible intraoperative challenges.

Furthermore, each robotic operation has unique considerations, difficulties, learning, and discussion points. Therefore, regular review of operative videos is invaluable for learning and mastering the robotic surgical technique.

Subsequent postoperative care and patient follow-up enable the surgeon to ensure continuity of care and derive further insights into the benefits and implications of robotic colorectal surgery.

Further trials warranted

However, the clinical value of the routine use of robotic surgery for colorectal cancer remains controversial.

In the ROLARR trial, robotic surgery was associated with lower circumferential resection margin positivity rates than laparoscopic surgery, but the difference fell short of statistical significance (5.1 percent vs 6.3 percent; adjusted odds ratio, 0.78; p=0.56). [JAMA 2017;318:1569-1580] In rectal cancer, a positive circumferential resection margin correlates with a high rate of local recurrence and poor morbidity and mortality. [Ann Surg 2015;262:891-898]

Nonetheless, there is increasing acceptance and adoption of robotic surgery for rectal cancers and tumours located in the middle and lower thirds of the rectum.

In the REAL trial, patients with middle and low rectal cancer who underwent robotic surgery had shorter postoperative hospital stay (median 7 vs 8 days; p=0.0001), fewer abdominoperineal resections (16.9 percent vs 22.7 percent) and conversions to open surgery (1.7 percent vs 3.9 percent; p=0.021), less estimated blood loss (median 40 vs 50 mL; p<0.0001), and fewer intraoperative complications (5.5 percent vs 8.7 percent; p=0.030) than those who had laparoscopic surgery. [Lancet Gastroenterol Hepatol 2022;7:991-1004]

With the growing adoption of and advancement in robotic colorectal surgical techniques, future studies and emerging evidence are awaited to validate its role in the clinical setting.

Takeaways

The field of robotic colorectal surgery is dynamic and evolving, particularly with wider recognition of the numerous potential benefits that this approach offers to both the surgeon and the patient.

It is thus timely to underscore the need to prioritize patient safety and operative outcomes. Strict and meticulous attention to detail and adherence to established protocols are vital in minimizing risks and reducing complications. Strong fundamental laparoscopic competency and mentorship with an experienced robotic surgical mentor are important.