Giuseppe Spinoglio, MD, Luca Lenti, PhD, Giampaolo Formisano, MD, Alessandra Marano, MD, Marco Lodin, MD. Department of General and Oncologic Surgery, SS. Antonio e Biagio Hospital, Alessandria, Italy.
The robotic colorectal surgery enhances the advantages of laparoscopy providing a three-dimensional view, ambidextrous capability, tremor elimination and instruments with multiple hand-like degrees of freedom (Endowrist® technology). The robotic technique is a gold standard for prostatectomy and is gaining worldwide acceptance for rectal cancer since the narrow pelvis is the same operative field of the rectal dissection. Therefore, in 2005, we started our robotic experience in colorectal surgery and we introduced the new four-arm DaVinci® Si HD in 2010 to perform low anterior resections (LAR) for rectal cancer with our current and standardized full-robotic single-docking technique.
Methods and procedures
From March 2010 to September 2013, we performed 88 robotic LAR for cancer. Our standardized full-robotic single docking technique starts from splenic flexure mobilization and takedown and continues with the vascular control of the inferior mesenteric vessels and total mesorectal excision (TME). Bowel continuity was restored with transanal stapled end-to-end or end-to-side anastomosis in 74 patients and with manual coloanal anastomosis for ultralow anterior resections in 14 patients. A diverting loop ileostomy was performed in 69 out of 88 patients (78.4%). Since the introduction of the integrated near-infrared (NIR) fluorescence imaging system in 2011, evaluation of bowel stump perfusion with intravenously injected indocyanine green was carried out in 28 patients.
Full-robotic LAR was performed in 80 out of 88 patients (conversion rate: 9%). No intraoperative complications were observed. Mean age was 66.9 ±9.6 years (37-87). Mean operative time was 399.6 ± 97.8 minutes (245-780). Mean distal resection margins were 3.64 ± 1.85 cm (0.5-10) and two specimens (2.3%) showed circumferential resection margins involvement. All patients were submitted to a perioperative fast-track program. The mean hospital stay was 10.1 ± 5.4 days (4-37). Fluorescence imaging allowed clear visualization of bowel stump perfusion in all cases (100%).
Low anterior resection for rectal cancer with full-robotic single-docking technique is safe and feasible. Moreover, since surgeons lack predictive accuracy for anastomotic leakage, fluorescence imaging system is the only tool to evaluate bowel stump perfusion objectively and might be the way to go in the next future. Larger sample sizes and further studies are needed to confirm its role.